10.07.01.17

.17 Exemptions from Hospital Utilization Review.

A. A hospital shall be exempt from carrying out utilization review procedures for a given patient if the:

(1) Person, corporate entity, or insurance plan paying for the patient's hospitalization has a utilization review program that is determined by the Insurance Commissioner and the Secretary to substantially meet the minimum standards described in these regulations, including the reporting requirements detailed in Regulation .19 of this chapter, those programs and amendments to them having been submitted to the Commissioner for approval;

(2) Patient is a subscriber or a member of a health maintenance organization as defined in Health-General Article, §19-701, Annotated Code of Maryland; or

(3) Patient is a Medicare or Maryland Medical Assistance Program beneficiary, and the services rendered at the hospital are within the scope of coverage provided by the relevant program.

B. The Secretary will issue yearly lists of third-party payers known to have utilization review plans that qualify for the exemption described in this regulation.