31.10.19.05

.05 Independent Review.

A. In conducting a review of an adverse decision, each independent review organization or medical expert shall, after reviewing all relevant medical and contractual information, advise the Commissioner in writing on whether the service was medically necessary.

B. The advice to the Commissioner shall state in writing the specific factual bases for the decision of the expert reviewer or the medical expert and reference the specific criteria and standards, including interpretive guidelines, on which the expert reviewer's or the medical expert's decision was based.

C. The Commissioner shall preserve the confidentiality of commercial information and a member's medical records and personal records in accordance with:

(1) State Government Article, §10-611 et seq., Annotated Code of Maryland;

(2) Health-General Article, §4-301, Annotated Code of Maryland; and

(3) Any pertinent federal laws.