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

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

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

(2) "Affiliate" means a person who directly or indirectly, through one or more intermediaries, controls, is controlled by, or is under common control with another person.

(3) "Carrier" means:

(a) An insurer that offers health insurance other than long-term care insurance or disability insurance;

(b) A nonprofit health service plan;

(c) A health maintenance organization;

(d) A dental plan organization; or

(e) Any other person that provides health benefit plans subject to regulation by the State.

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

(5) "Emergency case" means a case involving an adverse decision for which an expedited review is required under COMAR 31.10.18.05.

(6) "Expert reviewer" means a physician or other appropriate health care provider who contracts with or is retained by an independent review organization to conduct external review of a carrier's adverse decision pursuant to Insurance Article, §15-10A-05, Annotated Code of Maryland.

(7) "Health care provider" means:

(a) An individual who is:

(i) Licensed under the Health Occupations Article, Annotated Code of Maryland, or holds a nonrestricted license in a state of the United States to provide health care services in the ordinary course of business or practice of a profession, and

(ii) A treating provider of the member; or

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

(8) "Health care service" means a health or medical care procedure or service rendered by a health care provider including:

(a) Testing, diagnosis, or treatment of a human disease or dysfunction;

(b) Dispensing of drugs, medical devices, medical appliances, or medical goods for the treatment of a human disease or dysfunction; and

(c) Any other care, service, or treatment of disease or injury, the correction of defects, or the maintenance of the physical and mental well-being of human beings.

(9) "Independent review organization" means an entity that contracts with the Commissioner to conduct independent review of a carrier's adverse decision pursuant to Insurance Article, §15-10A-05, Annotated Code of Maryland.

(10) "Medical expert" means a physician or other appropriate health care provider who contracts with the Commissioner to conduct external review of a carrier's adverse decision pursuant to Insurance Article, §15-10A-05, Annotated Code of Maryland.

(11) "Medical record" has the meaning stated in Health-General Article, §4-301, Annotated Code of Maryland.

(12) 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.

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

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