Section 15-10B-13 – Right to Hearing and Appeal From Action of Commissioner
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.
Section 15-10B-14 – Waiver of Requirements for Review of Certain Patients
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.
Section 15-10B-15 – List of Private Review Agents
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.
Section 15-10B-01 – Definitions
(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 […]
Section 15-10B-16 – Reporting Requirements
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.
Section 15-10B-02 – Purpose of Subtitle
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 […]
Section 15-10B-17 – Patient Referrals by Private Review Agents
(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 […]
Section 15-10B-03 – Certificates — Required; Issuance; Transferability; Regulations; Uniform Treatment Plan Form
(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 […]
Section 15-10B-18 – Withdrawal and Submission of Certificate
(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.
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 […]