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S.B. 190
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PARRIS N. GLENDENING, Governor
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(A) (1) A PRIVATE REVIEW AGENT SHALL:
(I) MAKE ALL INITIAL DETERMINATIONS ON WHETHER TO
AUTHORIZE OR CERTIFY A NONEMERGENCY COURSE OF TREATMENT FOR A PATIENT
WITHIN 2 WORKING DAYS AFTER RECEIPT OF THE INFORMATION NECESSARY TO
MAKE THE DETERMINATION;
(II) MAKE ALL DETERMINATIONS ON WHETHER TO AUTHORIZE OR
CERTIFY AN EXTENDED STAY IN A HEALTH CARE FACILITY OR ADDITIONAL HEALTH
CARE SERVICES WITHIN 1 WORKING DAY AFTER RECEIPT OF THE INFORMATION
NECESSARY TO MAKE THE DETERMINATION; AND
(III) PROMPTLY NOTIFY THE HEALTH CARE PROVIDER OF THE
DETERMINATION.
(2) IF WITHIN 3 CALENDAR DAYS AFTER RECEIPT OF THE INITIAL
REQUEST FOR HEALTH CARE SERVICES THE PRIVATE REVIEW AGENT DOES NOT
HAVE SUFFICIENT INFORMATION TO MAKE A DETERMINATION, THE PRIVATE
REVIEW AGENT SHALL INFORM THE HEALTH CARE PROVIDER THAT ADDITIONAL
INFORMATION MUST BE PROVIDED.
(B) IF AN INITIAL DETERMINATION IS MADE BY A PRIVATE REVIEW AGENT
NOT TO AUTHORIZE OR CERTIFY A HEALTH CARE SERVICE AND THE HEALTH CARE
PROVIDER BELIEVES THE DETERMINATION WARRANTS AN IMMEDIATE
RECONSIDERATION, A PRIVATE REVIEW AGENT SHALL MAY PROVIDE THE HEALTH
CARE PROVIDER THE OPPORTUNITY TO SPEAK WITH THE PHYSICIAN THAT
RENDERED THE DETERMINATION, BY TELEPHONE ON AN EXPEDITED BASIS, WITHIN
A PERIOD OF TIME NOT TO EXCEED 24 HOURS OF THE HEALTH CARE PROVIDER
SEEKING THE RECONSIDERATION.
(C) FOR EMERGENCY INPATIENT ADMISSIONS, A PRIVATE REVIEW AGENT
MAY NOT RENDER AN ADVERSE DECISION SOLELY BECAUSE THE HOSPITAL DID NOT
NOTIFY THE PRIVATE REVIEW AGENT OF THE EMERGENCY ADMISSION WITHIN 24
HOURS OR OTHER PRESCRIBED PERIOD OF TIME AFTER THAT ADMISSION IF THE
PATIENT'S MEDICAL CONDITION PREVENTED THE HOSPITAL FROM DETERMINING:
(1) THE PATIENTS INSURANCE STATUS; AND
(2) IF APPLICABLE, THE PRIVATE REVIEW AGENTS EMERGENCY
ADMISSION NOTIFICATION REQUIREMENTS.
(D) A PRIVATE REVIEW AGENT MAY NOT RENDER AN ADVERSE DECISION AS
TO AN ADMISSION OF A PATIENT DURING THE FIRST 24 HOURS AFTER ADMISSION
WHEN:
(1) THE ADMISSION IS BASED ON A DETERMINATION THAT THE PATIENT
IS IN IMMINENT DANGER TO SELF OR OTHERS;
(2) THE DETERMINATION HAS BEEN MADE BY THE PATIENT'S
PHYSICIAN OR PSYCHOLOGIST IN CONJUNCTION WITH A MEMBER OF THE MEDICAL
STAFF OF THE FACILITY WHO HAS PRIVILEGES TO MAKE THE ADMISSION; AND
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- 3759 -
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