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Ch. 123
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PARRIS N. GLENDENING, Governor
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15-10B-07.
(A) (1) EXCEPT AS PROVIDED FOR IN PARAGRAPHS (2) AND (3) OF THIS
SUBSECTION, ALL ADVERSE DECISIONS SHALL BE MADE BY A PHYSICIAN, OR A
PANEL OF OTHER APPROPRIATE HEALTH CARE SERVICE REVIEWERS WITH AT LEAST
ONE PHYSICIAN ON THE PANEL WHO IS BOARD CERTIFIED OR ELIGIBLE IN THE SAME
SPECIALTY AS THE TREATMENT UNDER REVIEW.
(2) WHEN THE HEALTH CARE SERVICE UNDER REVIEW IS A MENTAL
HEALTH OR SUBSTANCE ABUSE SERVICE, THE ADVERSE DECISION SHALL BE MADE
BY A PHYSICIAN, OR A PANEL OF OTHER APPROPRIATE HEALTH CARE SERVICE
REVIEWERS WITH AT LEAST ONE PHYSICIAN, SELECTED BY THE PRIVATE REVIEW
AGENT WHO:
(I) IS BOARD CERTIFIED OR ELIGIBLE IN THE SAME SPECIALTY AS
THE TREATMENT UNDER REVIEW; OR
(II) IS ACTIVELY PRACTICING OR HAS DEMONSTRATED EXPERTISE
IN THE SUBSTANCE ABUSE OR MENTAL HEALTH SERVICE OR TREATMENT UNDER
REVIEW.
(3) WHEN THE HEALTH CARE SERVICE UNDER REVIEW IS A DENTAL
SERVICE, THE ADVERSE DECISION SHALL BE MADE BY A LICENSED DENTIST, OR A
PANEL OF OTHER APPROPRIATE HEALTH CARE SERVICE REVIEWERS WITH AT LEAST
ONE LICENSED DENTIST ON THE PANEL.
(B) ALL ADVERSE DECISIONS SHALL BE MADE BY A PHYSICIAN OR A PANEL OF
OTHER APPROPRIATE HEALTH CARE SERVICE REVIEWERS WHO ARE NOT
COMPENSATED BY THE PRIVATE REVIEW AGENT IN A MANNER THAT VIOLATES §
19-705.1 OF THE HEALTH - GENERAL ARTICLE OR THAT DETERS THE DELIVERY OF
MEDICALLY APPROPRIATE CARE.
(C) EXCEPT AS PROVIDED IN SUBSECTION (D) OF THIS SECTION, IF A COURSE
OF TREATMENT HAS BEEN PREAUTHORIZED OR APPROVED FOR A PATIENT, A
PRIVATE REVIEW AGENT MAY NOT RETROSPECTIVELY RENDER AN ADVERSE
DECISION REGARDING THE PREAUTHORIZED OR APPROVED SERVICES DELIVERED
TO THAT PATIENT.
(D) A PRIVATE REVIEW AGENT MAY RETROSPECTIVELY RENDER AN ADVERSE
DECISION REGARDING PREAUTHORIZED OR APPROVED SERVICES DELIVERED TO A
PATIENT IF:
(1) THE INFORMATION SUBMITTED TO THE PRIVATE REVIEW AGENT
REGARDING THE SERVICES TO BE DELIVERED TO THE PATIENT WAS FRAUDULENT
OR INTENTIONALLY MISREPRESENTATIVE;
(2) CRITICAL INFORMATION REQUESTED BY THE PRIVATE REVIEW
AGENT REGARDING SERVICES TO BE DELIVERED TO THE PATIENT WAS OMITTED
SUCH THAT THE PRIVATE REVIEW AGENT'S DETERMINATION WOULD HAVE BEEN
DIFFERENT HAD THE AGENT KNOWN THE CRITICAL INFORMATION; OR
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- 757 -
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