(a) In this subtitle the following words have the meanings indicated. (b) (1) “Adverse decision” means a utilization review determination made by a private review agent that a proposed or delivered health care service: (i) is or was not medically necessary, appropriate, or efficient; and (ii) may result in noncoverage of the health care service. (2) “Adverse decision” does not include […]
The purpose of this subtitle is to: (1) promote the delivery of quality health care in a cost effective manner; (2) foster greater coordination between payors and providers conducting utilization review activities; (3) protect patients, business, and providers by ensuring that private review agents are qualified to perform utilization review activities and to make informed decisions on the […]
(a) A private review agent may not conduct utilization review in this State unless the Commissioner has granted the private review agent a certificate. (b) The Commissioner shall issue a certificate to an applicant that has met all the requirements of this subtitle and all applicable regulations of the Commissioner. (c) A certificate issued under this subtitle is […]
(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 […]
(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 […]
(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 […]
(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 […]
(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 […]
(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 […]
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 […]
(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 […]
A private review agent may not: (1) violate any provision of this subtitle or any rule or regulation adopted under this subtitle; (2) fail to meet the requirements for certification under this subtitle; (3) obtain or attempt to obtain certification based on inaccurate information; (4) fraudulently or deceptively obtain or use a certificate; (5) fail to make available the services […]
(a) (1) A person who violates any provision of § 15-10B-11 of this subtitle is guilty of a misdemeanor and on conviction is subject to a penalty not exceeding $1,000. (2) Each day a violation is continued after the first conviction is a separate offense. (b) In addition to the provisions of subsection (a) of this section, if any […]
Any person aggrieved by an order of the Commissioner under this subtitle has the right to a hearing and the right to appeal from the action of the Commissioner in accordance with §§ 2-210 through 2-215 of this article.
The Commissioner may waive the requirements of this subtitle for a private review agent that operates solely under contract with the federal government for utilization review of patients eligible for hospital services under Title XVIII of the Social Security Act.
The Commissioner shall periodically provide a list of private review agents issued certificates and the renewal date for those certificates to any person on request.
The Commissioner may establish reporting requirements to: (1) evaluate the effectiveness of private review agents; and (2) determine if the utilization review programs are in compliance with the provisions of this section and applicable regulations.
(a) (1) Except as provided in paragraph (2) of this subsection, this section does not apply to: (i) a private review agent referring an individual to a health care provider or facility that participates in a health maintenance organization; (ii) a preferred provider organization network of participating health care providers or facilities to which the individual would otherwise be […]
(a) A private review agent shall advise the Commissioner, in writing, of its intention to withdraw its certificate within 60 days of intention to cease operations as a private review agent. (b) A private review agent shall submit its certificate to the administration within 30 days after the date that the private review agent ceased operations.
(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 […]
