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Ch. 123
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2000 LAWS OF MARYLAND
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(3) THE PLANNED COURSE OF TREATMENT FOR THE PATIENT THAT WAS
APPROVED BY THE PRIVATE REVIEW AGENT WAS NOT SUBSTANTIALLY FOLLOWED
BY THE PROVIDER
(E) 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.
[15-10B-08.
(a) Except as provided in subsection (b) of this section, a private review agent
shall:
(1) make all initial determinations on whether to authorize or certify a
nonemergency course of treatment for a patient within 2 working days of receipt of
the information necessary to make the determination; and
(2) promptly notify the attending health care provider and patient of the
determination.
(b) A private review agent shall:
(1) 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 of receipt of the information necessary to make the determination; and
(2) promptly notify the attending health care provider of the
determination.
(c) If an initial determination is made by the private review agent not to
authorize or certify a course of treatment, an extended stay in a health care facility, or
additional health care services and the attending health care provider believes the
determination warrants an immediate reconsideration, the private review agent shall
provide the attending health care provider an opportunity to seek a reconsideration of
that determination by telephone on an expedited basis not to exceed 24 hours of the
health care provider seeking the reconsideration.
(d) For emergency inpatient admissions, a private review agent may not
render an adverse decision or deny coverage for medically necessary covered services
solely because the hospital did not notify the private review agent of the emergency
admission within 24 hours or other prescribed period of time after that admission if
the patient's medical condition prevented the hospital from determining:
(1) the patient's insurance status; and
(2) the private review agent's emergency admission notification
requirements.
(e) For an involuntary or voluntary inpatient admission of a patient
determined by the patient's physician or psychologist in conjunction with a member of
the medical staff of the hospital who has privileges to admit patients to be in
imminent danger to self or others, a private review agent may not render an adverse
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- 758 -
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