Maryland § 15-10B-05

§ 15-10B-05.

    (a)    In conjunction with the application, the private review agent shall submit information that the Commissioner requires including:

        (1)    a utilization review plan that includes:

            (i)    the specific criteria and standards to be used in conducting utilization review of proposed or delivered health care services;

            (ii)    those circumstances, if any, under which utilization review may be delegated to a hospital utilization review program; and

            (iii)    if applicable, any provisions by which patients or physicians, hospitals, or other health care providers may seek reconsideration;

        (2)    the type and qualifications of the personnel either employed or under contract to perform the utilization review;

        (3)    a copy of the private review agent’s internal grievance process if a carrier delegates its internal grievance process to the private review agent in accordance with § 15–10A–02(l) of this title;

        (4)    the procedures and policies to ensure that a representative of the private review agent is reasonably accessible to patients and health care providers 7 days a week, 24 hours a day in this State including having a direct telephone number and monitored e–mail address as required in subsection (e) of this section;

        (5)    if applicable, the procedures and policies to ensure that a representative of the private review agent is accessible to health care providers to make all determinations on whether to authorize or certify an emergency inpatient admission, or an admission for residential crisis services as defined in § 15–840 of this title, for the treatment of a mental, emotional, or substance abuse disorder within 2 hours after receipt of the information necessary to make the determination;

        (6)    the policies and procedures to ensure that all applicable State and federal laws to protect the confidentiality of individual medical records are followed;

        (7)    a copy of the materials designed to inform applicable patients and providers of the requirements of the utilization review plan;

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

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

        (10)    a list of the persons involved in establishing the specific criteria and standards to be used in conducting utilization review, including each person’s board certification or practice specialty, licensure category, and title within the person’s organization; and

        (11)    certification by the private review agent that the criteria and standards to be used in conducting utilization review are generally recognized by health care providers practicing in the relevant clinical specialties and are:

            (i)    objective;

            (ii)    clinically valid;

            (iii)    reflected in published peer–reviewed scientific studies and medical literature;

            (iv)    developed by:

                1.    a nonprofit health care provider professional medical or clinical specialty society, including through the use of patient placement criteria and clinical practice guidelines; or

                2.    for criteria not within the scope of a nonprofit health care provider professional medical or clinical specialty society, an organization that works directly with health care providers in the same specialty for the designated criteria who are employed or engaged within the organization or outside the organization to develop the clinical criteria, if the organization:

                A.    does not receive direct payments based on the outcome of the utilization review; and

                B.    demonstrates that its clinical criteria are consistent with criteria and standards generally recognized by health care providers practicing in the relevant clinical specialties;

            (v)    recommended by federal agencies;

            (vi)    approved by the federal Food and Drug Administration as part of drug labeling;

            (vii)    taking into account the needs of atypical patient populations and diagnoses, including the unique needs of children and adolescents;

            (viii)    sufficiently flexible to allow deviations from norms when justified on a case–by–case basis, including the need to use an off–label prescription drug;

            (ix)    ensuring quality of care of health care services;

            (x)    reviewed, evaluated, and updated at least annually and as necessary to reflect any changes; and

            (xi)    in compliance with any other criteria and standards required for coverage under this title, including compliance with § 15–802(d) of this title for the treatment of substance use disorders.

    (b)    The private review agent shall:

        (1)    post on the member’s and provider’s pages of its website or the carrier’s website the specific criteria and standards to be used in conducting utilization review of proposed or delivered services and any subsequent revisions, modifications, or additions to the specific criteria and standards to be used in conducting utilization review of proposed or delivered services; and

        (2)    on the request of a person, including a health care facility, provide a copy of the information specified under item (1) of this subsection to the person making the request.

    (c)    The private review agent may charge a reasonable fee for a hard copy of the specific criteria and standards or any subsequent revisions, modifications, or additions to the specific criteria to any person or health care facility requesting a copy under subsection (b)(2) of this section.

    (d)    A private review agent shall advise the Commissioner, in writing, of a change in:

        (1)    ownership, medical director, or chief executive officer within 30 days of the date of the change;

        (2)    the name, address, or telephone number of the private review agent within 30 days of the date of the change; or

        (3)    the private review agent’s scope of responsibility under a contract.

    (e)    (1)    A private review agent shall:

            (i)    have available the following dedicated to utilization review:

                1.    a direct telephone number that is not the general customer call number; and

                2.    a monitored e–mail address; and

            (ii)    except where a shorter time period is otherwise required under this title, respond to voicemails or e–mails within 2 business days after receipt of the voicemail or e–mail.

        (2)    The telephone number and e–mail address shall be prominently displayed on the notices required under § 15–10A–02(f) and (i) of this title.