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Ch. 123
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PARRIS N. GLENDENING, Governor
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(4) flexible enough to allow deviations from norms when justified on a
case by case basis.]
A PRIVATE REVIEW AGENT SHALL ADVISE THE COMMISSIONER, IN WRITING, OF
A CHANGE IN:
(1) CORPORATE OWNERSHIP, MEDICAL DIRECTOR OR CHIEF EXECUTIVE
OFFICER AT LEAST 60 DAYS BEFORE WITHIN 30 DAYS OF THE DATE OF THE CHANGE;
(2) THE NAME, ADDRESS, OR TELEPHONE NUMBER OF THE PRIVATE
REVIEW AGENT WITHIN 30 DAYS OF THE DATE OF THE CHANGE; OR
(3) THE PRIVATE REVIEW AGENT'S SCOPE OF RESPONSIBILITY UNDER A
CONTRACT.
15-10B-06.
[(a) In this section, "utilization review" means a system for reviewing the
appropriate and efficient allocation of health care resources and services given or
proposed to be given to a patient or group of patients by a health care provider,
including a hospital or an intermediate care facility described under § 8-403(e) of the
Health - General Article.
(b) In addition to any other requirements under this subtitle, a private review
agent performing utilization review of services related to the treatment of alcoholism,
drug abuse, or mental illness shall meet the requirements of this section.
(c) All adverse decisions shall be made by a physician, or a panel of other
appropriate health care providers with at least 1 physician, selected by the private
review agent who is:
(1) (i) board certified or eligible in the same specialty as the treatment
under review; or
(ii) actively practicing, or has demonstrated expertise, in the
alcohol, drug abuse, or mental health service or treatment under review; and
(2) not compensated by the private review agent in a manner that
provides a financial incentive directly or indirectly to deny or reduce coverage.
(d) If a course of treatment has been preauthorized or approved for a patient,
a private review agent may not revise or modify the specific criteria or standards used
for the utilization review to make an adverse decision regarding the services delivered
to that patient.
(e) (1) In the event a patient or health care provider, including a physician,
intermediate care facility described under § 8-403(e) of the Health - General Article,
or hospital seeks reconsideration or appeal of an adverse decision by a private review
agent, the final determination of the appeal of the adverse decision shall be made
based on the professional judgment of a physician, or a panel of other appropriate
health care providers with at least 1 physician, selected by the private review agent
who is:
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- 753 -
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