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PARRIS N. GLENDENING, Governor
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S.B. 190
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panel who is a licensed dentist, who shall consult with a dentist who is board certified
or eligible in the same specialty as the service under review.
(4) in the event a patient or health care provider, including a physician,
intermediate care facility described in § 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:
(i) be stated in writing and provide an explanation of the reason for
the adverse decision; and
(ii) reference the specific criteria and standards, including
interpretive guidelines, upon which the adverse decision is based.
(b) A private review agent may not charge a fee to a patient or health care
provider for an appeal of an adverse decision.
(c) (1) Except as provided in paragraph (2) of this subsection, if a course of
treatment has been preauthorized or approved for a patient, a private review agent
may not retrospectively render an adverse decision regarding the preauthorized or
approved services delivered to that patient.
(2) A private review agent may retrospectively render an adverse
decision regarding preauthorized or approved services delivered to a patient if:
(i) the information submitted to the private review agent
regarding the services to be delivered to the patient was fraudulent or intentionally
misrepresentative or critical information requested by the private review agent
regarding services to be delivered to the patient was omitted such that the private
review agent's determination would have been different had it known the critical
information; or
(ii) the planned course of treatment for the patient that was
approved by the private review agent was not substantially followed by the provider.]
15-10B-07.
(A) (1) EXCEPT AS PROVIDED FOR IN PARAGRAPHS (2) AND (3) OF THIS
SUBSECTION, ALL ADVERSE DECISIONS SHALL BE MADE BY A PHYSICIAN, OR A
PANEL OF OTHER APPROPRIATE HEALTH CARE SERVICE REVIEWERS WITH AT LEAST
ONE PHYSICIAN ON THE PANEL WHO IS BOARD CERTIFIED OR ELIGIBLE IN THE SAME
SPECIALTY AS THE TREATMENT UNDER REVIEW.
(2) WHEN THE HEALTH CARE SERVICE UNDER REVIEW IS A MENTAL
HEALTH OR SUBSTANCE ABUSE SERVICE, THE ADVERSE DECISION SHALL BE MADE
BY A PHYSICIAN, OR A PANEL OF OTHER APPROPRIATE HEALTH CARE SERVICE
REVIEWERS WITH AT LEAST ONE PHYSICIAN, SELECTED BY THE PRIVATE REVIEW
AGENT WHO:
(I) IS BOARD CERTIFIED OR ELIGIBLE IN THE SAME SPECIALTY AS
THE TREATMENT UNDER REVIEW; OR
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- 3761 -
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