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2006 LAWS OF MARYLAND
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Ch. 331
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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, physicians, or
hospitals 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;
(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;
[(5)] (6) the policies and procedures to ensure that all applicable State
and federal laws to protect the confidentiality of individual medical records are
followed;
[(6)] (7) a copy of the materials designed to inform applicable patients
and providers of the requirements of the utilization review plan;
[(7)] (8) a list of the third party payors for which the private review
agent is performing utilization review in this State;
[(8)] (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;
[(9)] (10) a list of the persons involved in establishing the specific criteria
and standards to be used in conducting utilization review; and
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