31.10.21.02

.02 Certification.

A. A private review agent shall hold a certificate from the Commissioner to conduct utilization review in this State.

B. A private review agent shall submit to the Commissioner the contact information of one person who will be available to respond to inquiries from the Maryland Insurance Administration. If the contact information for the designated person changes, the private review agent shall:

(1) Notify the Commissioner in writing within 30 days; and

(2) Provide new contact information.

C. A private review agent seeking certification shall submit to the Commissioner an application for certification on a form specified by the Commissioner so that the Commissioner can determine whether the private review agent meets the requirements of this regulation. The private review agent shall attach the following additional information to the application:

(1) A utilization review plan which includes the following:

(a) Types of reviews performed and a written protocol describing each type of review, including:

(i) Preauthorization;

(ii) Preadmission;

(iii) Admission;

(iv) Emergency admission;

(v) Second surgical opinion;

(vi) Discharge planning;

(vii) Concurrent; or

(viii) Retrospective;

(b) Copies of specific criteria and standards to be used in conducting utilization reviews of proposed or delivered health care services, including:

(i) A list of the interpretive guidelines used by the private review agent that identifies the title, author, publisher, and edition of the guidelines; and

(ii) Copies of interpretive guidelines for which there are no applicable copyright laws;

(c) Forms that are completed during the review;

(d) Specified time frames in which the private review agent makes determinations to authorize or certify services;

(e) A written protocol describing the following:

(i) The grievance procedure by which a patient, a patient's representative, or a patient's health care provider may file a grievance with a private review agent;

(ii) The grievance procedure for receipt of an emergency case, including the initial acceptance of a verbal grievance by a patient, a patient's representative, or a patient's health care provider; and

(iii) Any procedures for handling a verbal request for reconsideration of a utilization review determination;

(f) Forms to be completed by a private review agent, a patient, or a patient's representative, including a health care provider, during the grievance procedure;

(g) Specified time frames in which a private review agent shall make a final grievance decision in writing;

(h) Qualifications of the personnel making the final grievance determinations; and

(i) The circumstances, if any, under which utilization review may be delegated to a hospital utilization review program and, if applicable, a list of the carriers for whom the private review agent:

(i) Is performing utilization review; and

(ii) Has been delegated the internal grievance process pursuant to Insurance Article, Title 15, Subtitle 10A, Annotated Code of Maryland;

(2) Type and qualifications of the personnel either employed or under contract to perform utilization review which includes:

(a) Registered nurses;

(b) Medical records technicians or similar personnel supported and supervised by physicians as may be required;

(c) Physicians; or

(d) Other appropriate health care providers;

(3) Policies and procedures to ensure that a representative of a private review agent is reasonably accessible to patients and providers 7 days a week, 24 hours a day in this State;

(4) Policies and procedures to ensure that all applicable State and federal laws protecting the confidentiality of individual medical records are followed;

(5) A copy of materials designed to inform patients and providers of requirements of the utilization review plan;

(6) A list of third-party payors for which a private review agent is performing utilization review in this State;

(7) Policies and procedures to ensure that a private review agent has a formal program for the effective orientation and training of the personnel either employed or under contract to perform utilization review;

(8) An outline of the training program which includes content and schedule of presentation;

(9) Qualifications of health care providers involved in establishing the specific criteria and standards to be used in conducting utilization review if nationally recognized criteria are not used;

(10) Certification by a private review agent that the criteria and standards to be used in conducting utilization review are:

(a) Objective;

(b) Clinically valid;

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

(d) Flexible enough to allow deviations from norms when justified on a case-by-case basis; and

(11) A nonrefundable application fee of $1,500.