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 […]
Section 15-10B-11 – Private Review Agent — Prohibitions
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 […]
Section 15-10B-12 – Private Review Agent — Penalties
(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 […]
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.