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S.B. 190
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VETOES
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proposed to be given to a patient or group of patients by a health care provider,
including a hospital or an intermediate care facility described under § 8-403(e) of the
Health - General Article.
(b) In addition to any other requirements under this subtitle, a private review
agent performing utilization review of services related to the treatment of alcoholism,
drug abuse, or mental illness shall meet the requirements of this section.
(c) All adverse decisions shall be made by a physician, or a panel of other
appropriate health care providers with at least 1 physician, selected by the private
review agent who is:
(1) (i) board certified or eligible in the same specialty as the treatment
under review; or
(ii) actively practicing, or has demonstrated expertise, in the
alcohol, drug abuse, or mental health service or treatment under review; and
(2) not compensated by the private review agent in a manner that
provides a financial incentive directly or indirectly to deny or reduce coverage.
(d) If a course of treatment has been preauthorized or approved for a patient,
a private review agent may not revise or modify the specific criteria or standards used
for the utilization review to make an adverse decision regarding the services delivered
to that patient.
(e) (1) In the event a patient or health care provider, including a physician,
intermediate care facility described under § 8-403(e) of the Health - General Article,
or hospital seeks reconsideration or appeal of an adverse decision by a private review
agent, the final determination of the appeal of the adverse decision shall be made
based on the professional judgment of a physician, or a panel of other appropriate
health care providers with at least 1 physician, selected by the private review agent
who is:
(i) 1. board certified or eligible in the same specialty as the
treatment under review; or
2. actively practicing or has demonstrated expertise in the
alcohol, drug abuse, or mental health service or treatment under review; and
(ii) not compensated by the .private review agent in a manner that
provides a financial incentive directly or indirectly to deny or reduce coverage.
(2) In the event a patient or health care provider, including a physician,
intermediate care facility described under § 8-403(e) of the Health - General Article,
or hospital seeks reconsideration or appeal of an adverse decision by a private review
agent, the final determination of the appeal of the adverse decision shall be stated in
writing and shall reference the specific criteria and standards, including interpretive
guidelines, upon which the denial or reduction in coverage is based.
(f) A private review agent may not charge a fee to a patient or health care
provider for an appeal of an adverse decision.]
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- 3758 -
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