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 expert shall have a quality assurance mechanism in place that assures the:

(1) Timeliness and quality of the reviews;

(2) Qualifications and independence of the expert reviewers and the independent review organization, or the medical expert; and

(3) Confidentiality of medical records and review materials, consistent with federal and State laws.

C. An independent review organization seeking to contract with the Commissioner shall submit to the Commissioner a copy of the accreditation certificate issued by a nationally recognized private accrediting organization.

D. An independent review organization designated by the Commissioner to review an adverse decision shall have the authority and powers as delegated by the Commissioner for the following functions related to conducting an independent review:

(1) Obtaining all information relative to the complaint from the carrier, the provider, the member, and the memberís representative;

(2) Assigning the expert reviewer for review of an adverse decision; and

(3) Performing conflicts checks relative to the independent review organization and the expert reviewer assigned to review the adverse decision.

E. A medical expert designated by the Commissioner to review an adverse decision shall have the authority and powers, as delegated by the Commissioner, for obtaining all information relative to the complaint from the:

(1) Carrier;

(2) Provider;

(3) Member; and

(4) Memberís representative.