31.10.19.04

.04 Assignment of an Independent Review Organization or Medical Expert.

A. Concurrently with the assignment of a complaint to an independent review organization or a medical expert, the Commissioner shall notify the member, memberís representative, or health care provider acting on behalf of the member, and the carrier of the assignment.

B. If the complaint is assigned to an independent review organization, the independent review organization shall screen its expert reviewer for potential material conflicts of interest.

C. The Commissioner shall have the discretion to determine whether a material conflict of interest exists for the expert reviewer of an independent review organization or the medical experts subject to this regulation and as provided by Insurance Article, §15-10A-05, Annotated Code of Maryland.

D. An expert reviewer or medical expert shall:

(1) Be an expert in the treatment of the member's specific medical condition;

(2) Be knowledgeable about the recommended health care service or treatment through actual clinical experience as determined by the Commissioner based on the period of time:

(a) Actually treating patients with the same or similar specific medical condition, and

(b) That has elapsed between the clinical experience and the present;

(3) Hold:

(a) A nonrestricted license as a physician or other appropriate health care provider in a state of the United States; and

(b) For physicians, a current certification by a recognized American Medical Specialty Board in the area appropriate to the subject of review;

(4) Be licensed in the same health care occupation as the health care provider who considers the health care service that is the subject of the carrier's adverse decision to be medically necessary, appropriate, or efficient; and

(5) Have no history of disciplinary investigations, actions, or sanctions, including loss of staff privileges or participation restrictions that have been taken or are pending by any hospital, governmental agency or unit, or regulatory body, that raises a substantial question as to the expert reviewer's or medical expert's physical, mental or professional competence or moral character as determined by the Commissioner.

E. To allow the Commissioner to determine whether an expert reviewer assigned by the independent review organization or a medical expert has a history of disciplinary investigations, actions, or sanctions that raises a substantial question as to the expert reviewer's or medical expert's physical, mental, or professional competence or moral character, the independent review organization or medical expert shall disclose to the Commissioner any:

(1) Pending investigation or action against the expert reviewer or medical expert relating to health care of which the expert reviewer or medical expert has notice, and the nature of the action;

(2) Civil or criminal investigation or action against the expert reviewer or medical expert relating to health care, and the nature of the action; and

(3) Investigation, conviction, or plea of guilty or nolo contendere with respect to a crime of moral turpitude against the expert reviewer or medical expert, regardless of whether any appeal or other proceeding is pending to have the conviction or plea set aside.

F. The information relevant to the consideration by the Commissioner of whether the expert reviewer or medical expert meets the requirements of this regulation will be handled in accordance with State Government Article, §10-618, Annotated Code of Maryland.