WILLIAM DONALD SCHAEFER, Governor                   Ch. 703

(3) CONTRACT WITH OR DELEGATE TO A HOSPITAL
UTILIZATION REVIEW PROGRAM APPROVED UNDER § 19-319(D) OF THE
HEALTH - GENERAL ARTICLE.

(B) NOTWITHSTANDING ANY OTHER PROVISION OF THIS ARTICLE,
FOR CLAIMS WHERE THE MEDICAL NECESSITY OF THE PROVISION OF A
COVERED BENEFIT IS DISPUTED, AN INSURER THAT DOES NOT MEET THE
REQUIREMENTS OF SUBSECTION (A) OF THIS SECTION SHALL PAY ANY
PERSON OR HOSPITAL ENTITLED TO REIMBURSEMENT UNDER THE POLICY,
CONTRACT, OR CERTIFICATE IN ACCORDANCE WITH THE DETERMINATION OF
MEDICAL NECESSITY BY THE HOSPITAL UTILIZATION REVIEW PROGRAM
APPROVED UNDER SECTION 19-319(D) OF THE HEALTH - GENERAL ARTICLE.

477-11.

(A)  EVERY HEALTH INSURER PROPOSING TO ISSUE OR DELIVER IN
THIS STATE A GROUP OR BLANKET HEALTH INSURANCE POLICY OR
ADMINISTER A HEALTH BENEFIT PROGRAM WHICH PROVIDES FOR THE
COVERAGE OF HOSPITAL BENEFITS AND THE UTILIZATION REVIEW OF SUCH
BENEFITS SHALL: MEET THE REQUIREMENTS OF SUBTITLE 13 OF TITLE 19
OF THE HEALTH - GENERAL ARTICLE.

(1) HAVE A CERTIFICATE IN ACCORDANCE WITH SUBTITLE 13
OF TITLE 19 OF THE HEALTH - GENERAL ARTICLE;

(2) CONTRACT WITH A PRIVATE REVIEW AGENT THAT HAS A
CERTIFICATE IN ACCORDANCE WITH SUBTITLE 13 OF TITLE 19 OF THE
HEALTH - GENERAL ARTICLE; OR

(3) CONTRACT WITH OR DELEGATE TO A HOSPITAL
UTILIZATION REVIEW PROGRAM APPROVED UNDER § 19-319(D) OF THE
HEALTH - GENERAL ARTICLE.

(B)  NOTWITHSTANDING ANY OTHER PROVISION OF THIS ARTICLE,
FOR CLAIMS WHERE THE MEDICAL NECESSITY OF THE PROVISION OF A
COVERED BENEFIT IS DISPUTED, A HEALTH INSURER THAT DOES NOT MEET
THE REQUIREMENTS OF SUBSECTION (A) OF THIS SECTION SHALL PAY ANY
PERSON OR HOSPITAL ENTITLED TO REIMBURSEMENT UNDER THE POLICY,
CONTRACT, OR CERTIFICATE IN ACCORDANCE WITH THE DETERMINATION OF
MEDICAL NECESSITY BY THE HOSPITAL UTILIZATION REVIEW PROGRAM
APPROVED UNDER SECTION 19-319(D) OF THE HEALTH - GENERAL ARTICLE.

SECTION 2. AND BE IT FURTHER ENACTED, That the Department
of Health and Mental Hygiene report to the General Assembly by
November 1, 1988 and each year thereafter on the number of
private review agents conducting utilization review, and the type
of criteria used to perform utilization review, the feasibility
of adopting uniform standards for one or more aspects of
utilization review including standardized forms for data
collection and the medical procedures for which preauthorization
and second surgical opinions would be required.

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