31.10.20.01

.01 Definitions.

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

(1) "Administration" means the Maryland Insurance Administration.

(2) "Board" means the State Board of Physician Quality Assurance established under Health Occupations Article, Title 14, Annotated Code of Maryland.

(3) "Certificate" means a certificate, issued by the Commissioner under this chapter, to act as a medical director.

(4) "Commissioner" means the State Insurance Commissioner.

(5) “Contact information” means an individual’s name, job title and department, address, telephone number, facsimile number, and email address.

(6) "Department" means the Maryland Department of Health.

(7) "Governing authority" means the person or persons designated in the bylaws with the responsibility for operating the health maintenance organization.

(8) "Health maintenance organization" has the meaning stated in Health-General Article, §19-701, Annotated Code of Maryland.

(9) Medical Director.

(a) "Medical director" means a physician employed by or under contract with a health maintenance organization who is responsible for:

(i) The establishment or maintenance of the policies and procedures at the health maintenance organization for quality assurance and utilization management;

(ii) Compliance with the quality assurance and utilization management policies and procedures of the health maintenance organization; and

(iii) Oversight of utilization review decisions of private review agents employed by or under contract with the health maintenance organization.

(b) "Medical director" includes an associate medical director or an assistant medical director who has been delegated any of the functions of a medical director.

(10) "Quality assurance" means a formal set of activities to review the quality of medical services provided to those persons covered by the health maintenance organization including implementation of corrective actions to address any deficiencies identified in the care and services provided to those persons covered by the health maintenance organization.

(11) "Utilization management" means the process of evaluating and determining the appropriateness of the utilization of covered medical services, including prior authorization, concurrent review, retrospective review, discharge planning, and case management.