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Ch. 123
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2000 LAWS OF MARYLAND
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(i) 1. board certified or eligible in the same specialty as the
treatment under review; or
2. actively practicing or has demonstrated expertise in the
alcohol, drug abuse, or mental health service or treatment under review; and
(ii) not compensated by the private review agent in a manner that
provides a financial incentive directly or indirectly to deny or reduce coverage.
(2) 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 stated in
writing and shall reference the specific criteria and standards, including interpretive
guidelines, upon which the denial or reduction in coverage is based.
(f) A private review agent may not charge a fee to a patient or health care
provider for an appeal of an adverse decision.]
(A) (1) A PRIVATE REVIEW AGENT SHALL:
(I) MAKE ALL INITIAL DETERMINATIONS ON WHETHER TO
AUTHORIZE OR CERTIFY A NONEMERGENCY COURSE OF TREATMENT FOR A PATIENT
WITHIN 2 WORKING DAYS AFTER RECEIPT OF THE INFORMATION NECESSARY TO
MAKE THE DETERMINATION;
(II) MAKE ALL DETERMINATIONS ON WHETHER TO AUTHORIZE OR
CERTIFY AN EXTENDED STAY IN A HEALTH CARE FACILITY OR ADDITIONAL HEALTH
CARE SERVICES WITHIN 1 WORKING DAY AFTER RECEIPT OF THE INFORMATION
NECESSARY TO MAKE THE DETERMINATION; AND
(III) PROMPTLY NOTIFY THE HEALTH CARE PROVIDER OF THE
DETERMINATION.
(2) IF WITHIN 3 CALENDAR DAYS AFTER RECEIPT OF THE INITIAL
REQUEST FOR HEALTH CARE SERVICES THE PRIVATE REVIEW AGENT DOES NOT
HAVE SUFFICIENT INFORMATION TO MAKE A DETERMINATION, THE PRIVATE
REVIEW AGENT SHALL INFORM THE HEALTH CARE PROVIDER THAT ADDITIONAL
INFORMATION MUST BE PROVIDED.
(B) IF AN INITIAL DETERMINATION IS MADE BY A PRIVATE REVIEW AGENT
NOT TO AUTHORIZE OR CERTIFY A HEALTH CARE SERVICE AND THE HEALTH CARE
PROVIDER BELIEVES THE DETERMINATION WARRANTS AN IMMEDIATE
RECONSIDERATION, A PRIVATE REVIEW AGENT SHALL MAY PROVIDE THE HEALTH
CARE PROVIDER THE OPPORTUNITY TO SPEAK WITH THE PHYSICIAN THAT
RENDERED THE DETERMINATION, BY TELEPHONE ON AN EXPEDITED BASIS, WITHIN
A PERIOD OF TIME NOT TO EXCEED 24 HOURS OF THE HEALTH CARE PROVIDER
SEEKING THE RECONSIDERATION.
(C) FOR EMERGENCY INPATIENT ADMISSIONS, A PRIVATE REVIEW AGENT
MAY NOT RENDER AN ADVERSE DECISION SOLELY BECAUSE THE HOSPITAL DID NOT
NOTIFY THE PRIVATE REVIEW AGENT OF THE EMERGENCY ADMISSION WITHIN 24
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- 754 -
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