31.10.20.04

.04 Denial or Revocation of Certification.

A. The Commissioner shall deny a certificate to an applicant if the Commissioner finds that the initial application does not meet the requirements of this chapter.

B. The Commissioner may revoke the certification of a medical director:

(1) Who violates any provision of this chapter;

(2) Who fails to meet the requirements for certification under Regulation .04B of this chapter;

(3) Who obtains certification based on inaccurate information;

(4) Who fraudulently or deceptively obtains, attempts to obtain, or uses a certificate; or

(5) If the Commissioner finds a pattern that the utilization management procedures and policies used by the medical director in making utilization review decisions or used by a private review agent employed by or under contract with the health maintenance organization over whose utilization review decisions the medical director has responsibility are not:

(a) Objective;

(b) Clinically valid;

(c) Compatible with established principles of health care; or

(d) Flexible enough to allow deviations from the norms when justified on a case by case basis.

C. Before denying an initial application for certification or revoking an issued certificate, the Commissioner shall provide the applicant or certificate holder with:

(1) Reasonable time to supply additional information which demonstrates compliance with the requirements of this chapter and the opportunity to request a hearing;

(2) Written notice of the reasons for the denial or revocation; and

(3) 30 days in which to request a hearing in accordance with State Government Article, Title 10, Subtitle 2, Annotated Code of Maryland.