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31.10.21.00.htm 31.10.21.00. Title 31 MARYLAND INSURANCE ADMINISTRATION Subtitle 10 HEALTH INSURANCE ― GENERAL Chapter 21 Private Review Agents Authority: Insurance Article, §2-109(a)1) and 15-10B-03(h) Annotated Code of Maryland
31.10.21.01.htm 31.10.21.01. 01 Definitions.. A. In this chapter, the following terms have the meanings indicated.. B. Terms Defined.. 1) "Accrediting organization" means an entity that accredits or certifies the utilization management activities of a private review agent.2) "Administration" means the Maryland Insurance Administration.. 3) Adverse Decision.. a) "Adverse decision" means a utilization review determination made by a private review agent that a proposed or delivered health care service that is
31.10.21.02.htm 31.10.21.02. 02 Certification.. A. A private review agent shall hold a certificate from the Commissioner to conduct utilization review in this State.B. A private review agent shall submit to the Commissioner the contact information of one person who will be available to respond to inquiries from the Maryland Insurance Administration. If the contact information for the designated person changes, the private review agent shall:1) Notify the Commissioner in writing within 30 days; and.
31.10.21.02-1.htm 31.10.21.02-1. 02-1 Uniform Treatment Plan.. A. Scope. This regulation does not apply to a person that uses a treatment plan form solely for internal purposes, unless the private review agent requires the information to authorize treatment.B. Form Required. If a private review agent requires a health care provider to submit a treatment plan or telephonically provide the information requested on the uniform treatment plan, to enable the private review agent to conduct utilization review
31.10.21.03.htm 31.10.21.03. 03 Specific Criteria and Standards.. A. Required Copies. Upon the written request of a person or health care facility, a private reviewagent shall provide one copy of the specific criteria and standards to be used in conducting utilization review of proposed or delivered services and any subsequent revisions or modifications to the specific criteria and standards.B. Fee for Copy. A private review agent shall:. 1) Make available a copy of specific criteria and
31.10.21.04.htm 31.10.21.04. 04 Determinations.. A. Nonemergency Treatment. A private review agent shall make all initial determinations on whether to authorize or certify a nonemergency course of treatment for a patient within the time period specified in Insurance Article, §15-10B-06, Annotated Code of Maryland.B. Extended Stays or Additional Health Care Services. A private review agent shall make all determinations on whether to authorize or certify an extended stay in a health care facility or additional h
31.10.21.05.htm 31.10.21.05. 05 Patient Referrals by Private Review Agents.. A. Except as provided in §B of this regulation, this regulation does not apply to:. 1) A private review agent referring an individual to a health care provider or facility that participates in a health maintenance organization;2) A preferred provider organization network of participating health care providers or facilities to which the individual would otherwise be referred as part of the individual's membership or insuranc
31.10.21.06.htm 31.10.21.06. 06 Denial or Revocation of Certification.. A. The Commissioner shall deny a certificate to an applicant if the Administration finds that the initial application does not include all requirements of Regulation .02 of this chapter.B. The Commissioner may revoke the certification of a private review agent:. 1) That violates any provision of this chapter;. 2) That fraudulently or deceptively obtains, attempts to obtain, or uses a certificate;.
31.10.21.07.htm 31.10.21.07. 07 Term of Certification and Recertification.. A. A certificate of registration:. 1) Is not transferable; and. 2) Expires on the second anniversary of its effective date unless certification has been renewed for another 2-year term.B. Before certification expires, a private review agent may renew its certification if the certified private review agent:1) Otherwise is entitled to be certified;. 2) Pays to the Commissioner the nonrefundable renewal fee of $1,500; and.
31.10.21.08.htm 31.10.21.08. 08 Penalties.. A. Criminal Penalty. A person who violates a provision of this chapter shall be guilty of a misdemeanor, and on conviction is subject to a penalty not exceeding $1,000. Each day a violation is continued after the first conviction is a separate offense.B. Administrative Penalty. In addition to, or instead of, the criminal penalty described in §A of this regulation, the Commissioner may impose an administrative penalty not to exceed $5,000 for violat
31.10.21.09.htm 31.10.21.09. 09 Hearings and Appeals.. A private review agent subject to an administrative penalty, or to denial or revocation of certification, has the right to a hearing and the right to appeal from an action of the Commissioner in accordance with Insurance Article, §2-210―2-215, Annotated Code of Maryland.
31.10.21.10.htm 31.10.21.10. 10 Exemptions.. The Commissioner may waive the requirements of this chapter 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.
31.10.21.11.htm 31.10.21.11. 11 Accredited Private Review Agents and Filing Requirement Waivers.. A. Determination of Approved Accrediting Organization.. 1) An accrediting organization is not an approved accrediting organization until the Commissioner issues a letter of approval to the accrediting organization.2) For the purpose of determining which entities are approved accrediting organizations, the Commissioner shall consider whether:a) Some or all of the accreditation standards required to be met for accred
31.10.21.9999.htm 31.10.21.9999. Administrative History Effective date: June 6, 1994 (21:11 Md. R. 951). Chapter revised and recodified from COMAR 10.07.19 to COMAR 31.10.21 as an emergency provision effective January 1, 1999 (26:2 Md. R. 104) amended and recodified permanently effective March 22, 1999 (26:6 Md. R. 491)Regulation .02-1 adopted effective August 21, 2000 (27:16 Md. R. 1526) ―. Chapter revised effective April 12, 2004 (31:7 Md. R. 587).
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