Section 15-10B-19 – Examination by Commissioner
(a) Whenever the Commissioner considers it advisable, the Commissioner shall examine the affairs, transactions, accounts, records, and assets of each private review agent at least once every 5 years. (b) The Commissioner shall examine the affairs, transactions, accounts, records, and assets of each private review agent that applies for a certificate of registration under § 15-10B-03 of […]
Section 15-10B-20 – Examination by Commissioner — Pharmacy Benefit Manager
(a) In addition to the requirements under § 15-10B-19 of this subtitle, the Commissioner shall conduct an examination of any pharmacy benefit manager registered as a private review agent to determine whether the pharmacy benefit manager is acting in compliance with this subtitle. (b) The examination shall be conducted: (1) in accordance with § 2-207 of this article; […]
Section 15-10B-04 – Certificates — Application; Fees
(a) An applicant for a certificate shall: (1) submit an application to the Commissioner; and (2) pay to the Commissioner the application fee established by the Commissioner through regulation. (b) The application shall: (1) be on a form and accompanied by any supporting documentation that the Commissioner requires; and (2) be signed and verified by the applicant. (c) The fees required under […]
Section 15-10B-05 – Certificates — Additional Information
(a) In conjunction with the application, the private review agent shall submit information that the Commissioner requires including: (1) a utilization review plan that includes: (i) the specific criteria and standards to be used in conducting utilization review of proposed or delivered health care services; (ii) those circumstances, if any, under which utilization review may be delegated to a […]
Section 15-10B-06 – Determinations by Private Review Agent
(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 […]
Section 15-10B-07 – Adverse Decisions by Private Review Agent
(a) (1) Except as provided 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 […]
Section 15-10B-08 – Requirements of Internal Grievance Process
(a) If a carrier delegates its internal grievance process to a private review agent, the private review agent shall establish an internal grievance process for its patients and health care providers acting on behalf of a patient. (b) A private review agent’s internal grievance process shall meet the same requirements established under §§ 15-10A-02 through 15-10A-05 of […]
Section 15-10B-09 – Requirements of Internal Grievance Process — Maternity and Newborn Care
(a) In this section, “attending provider” means an obstetrician, pediatrician, or other physician or certified nurse midwife or pediatric nurse practitioner attending the mother or newborn child. (b) Except as provided in subsections (c) and (d) of this section, the criteria and standards used by a private review agent or health maintenance organization in performing utilization review […]
Section 15-10B-09.1 – Requirements of Grievance Decision
A grievance decision shall be made based on the professional judgment of: (1) (i) a physician who is board certified or eligible in the same specialty as the treatment under review; or (ii) 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 […]
Section 15-10B-10 – Certificates — Expiration; Renewal
(a) A certificate expires on the second anniversary of its effective date unless the certificate is renewed for a 2-year term as provided in this section. (b) Before the certificate expires, a certificate may be renewed for an additional 2-year term if the applicant: (1) otherwise is entitled to the certificate; (2) pays to the Commissioner the renewal fee […]