31.10.21.06

.06 Denial or Revocation of Certification.

A. The Commissioner shall deny a certificate to an applicant if the Administration finds that the initial application does not include all requirements of Regulation .02 of this chapter.

B. The Commissioner may revoke the certification of a private review agent:

(1) That violates any provision of this chapter;

(2) That fraudulently or deceptively obtains, attempts to obtain, or uses a certificate;

(3) That fails to meet the requirements for certification under Regulation .02B of this chapter;

(4) That obtains certification based on inaccurate information; or

(5) If the Commissioner finds a pattern that the utilization management procedures and policies used by a private review agent 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.