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31.10.19.00.htm 31.10.19.00. Title 31 MARYLAND INSURANCE ADMINISTRATION Subtitle 10 HEALTH INSURANCE ― GENERAL Chapter 19 Independent Review Organizations and Medical Experts Authority: Insurance Article, §2-109, 15-10A-05, and 15-10A-09, Annotated Code of Maryland
31.10.19.01.htm 31.10.19.01. 01 Definitions.. A. In this chapter, the following terms have the meanings indicated.. B. Terms Defined.. 1) Adverse Decision.. a) "Adverse decision" means a utilization review determination by a private review agent, a carrier, or a health care provider acting on behalf of a carrier that:i) A proposed or delivered health care service that is otherwise covered under the member's contract is not or was not medically necessary, appropriate, or efficient; and
31.10.19.02.htm 31.10.19.02. 02 Use of Independent Review Organizations and Medical Experts.. A. In cases considered appropriate by the Commissioner, the Commissioner shall seek advice concerning adverse decisions from an independent review organization or medical expert, as provided in Insurance Article, §15-10A-05, Annotated Code of Maryland.B. For any independent review organization or medical expert that contracts with the Commissioner, the independent review organization or medical expe
31.10.19.03.htm 31.10.19.03. 03 Conflicts of Interest Standards for Independent Review Organizations and Medical Experts.. A. An independent review organization or medical expert may not be an affiliate of a trade association of:1) Health benefit plans; or. 2) Health care providers.. B. The independent review organization shall provide to the Commissioner the following:. 1) The name and biographical information for each director, officer, and management employee of the independent review organi
31.10.19.04.htm 31.10.19.04. 04 Assignment of an Independent Review Organization or Medical Expert.. A. Concurrently with the assignment of a complaint to an independent review organization or a medical expert, the Commissioner shall notify the member, member’s representative, or health care provider acting on behalf of the member, and the carrier of the assignment.B. If the complaint is assigned to an independent review organization, the independent review organization shall screen its e
31.10.19.05.htm 31.10.19.05. 05 Independent Review.. A. In conducting a review of an adverse decision, each independent review organization or medical expert shall, after reviewing all relevant medical and contractual information, advise the Commissioner in writing on whether the service was medically necessary.B. The advice to the Commissioner shall state in writing the specific factual bases for the decision of the expert reviewer or the medical expert and reference the specific criteria and standards, inc
31.10.19.06.htm 31.10.19.06. 06 Payment of Fees.. A. The carrier that is the subject of the complaint is responsible for paying the reasonable expenses for the complaint under review by the independent review organization or medical expert selected by the Commissioner.B. The independent review organization or medical expert for each complaint under review shall:. 1) Present to the carrier:. a) An invoice detailing the expenses incurred by the independent review organization or medical expe
31.10.19.07.htm 31.10.19.07. 07 Time for Rendering Final Decisions on Complaints.. A. Except for an emergency case as provided in COMAR 31.10.18.05 or as provided in §B of this regulation, the Commissioner shall make a final written decision on a complaint within 45 days after a complaint is filed.B. The Commissioner may extend the period within which a final written decision is to be made under §A of this regulation for up to an additional 30 working days if the:
31.10.19.9999.htm 31.10.19.9999. Administrative History Effective date:. Regulations .01―07 adopted as an emergency provision effective January 1, 1999 (25:26 Md. R. 1917) adopted permanently effective February 22, 1999 (26:4 Md. R. 274)Regulation .01B amended effective April 16, 2012 (39:7 Md. R. 496). Regulation .02 amended effective April 16, 2012 (39:7 Md. R. 496). Regulation .04A, D amended effective April 16, 2012 (39:7 Md. R. 496). Regulation .06C amended effective April 16, 2012 (39:7 Md. R. 496).
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