31.10.18.02

.02 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 which would otherwise be covered under the member's contract is not or was not medically necessary, appropriate, or efficient; and

(ii) May result in noncoverage of the health care service.

(b) "Adverse decision" does not include a decision concerning a person's status as a member.

(2) "Carrier" has the meaning stated in Insurance Article, §15-10A-01, Annotated Code of Maryland.

(3) "Complaint" means a protest filed with the Commissioner involving an adverse decision or grievance decision concerning a member.

(4) "Emergency case" means a case involving an adverse decision for which an expedited review is required under Regulation .05 of this chapter.

(5) "Filing date" means the earlier of:

(a) 5 days after the date of mailing; or

(b) The date of receipt.

(6) "Grievance" means a protest filed by a member, a member’s representative, or a health care provider on behalf of a member with a carrier through the carrier's internal grievance process regarding an adverse decision concerning the member.

(7) "Grievance decision" means a final determination by a carrier that arises from a grievance filed with the carrier under its internal grievance process regarding an adverse decision concerning a member.

(8) "Health Advocacy Unit" means the Health Education and Advocacy Unit in the Division of Consumer Protection of the Office of the Attorney General established under Commercial Law Article, Title 13, Subtitle 4A, Annotated Code of Maryland.

(9) "Health care provider" means:

(a) An individual who is:

(i) Licensed or otherwise authorized in this State to provide health care services in the ordinary course of business or practice of a profession, and

(ii) A treating provider of a member; or

(b) A hospital, as defined in Health-General Article, §19-301, Annotated Code of Maryland.

(10) "Health care service" has the meaning stated in Insurance Article, §15-10A-01, Annotated Code of Maryland.

(11) Member.

(a) "Member" means a person entitled to health care benefits under a policy, plan, or certificate issued or delivered in the State by a carrier.

(b) "Member" includes:

(i) A subscriber; and

(ii) Unless preempted by federal law, a Medicare recipient.

(c) "Member" does not include a Medicaid recipient.

(12) “Member’s representative” has the meaning stated in Insurance Article, §15-10A-01, Annotated Code of Maryland.

(13) "Private review agent" has the meaning stated in Insurance Article, §15-10B-01, Annotated Code of Maryland.