WILLIAM DONALD SCHAEFER, Governor

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 TITLE 19, SUBTITLE 13 OF THE HEALTH - GENERAL
ARTICLE.

Article - Health - General

19-710.

(j) (1) With the approval of the Department, the health
maintenance organization shall provide continuous internal peer
review for monitoring and evaluating patient records for:

[(l)] (I) Quality of care; and

[(2)] (II) Over use and under use of provider care.

(2) THE HEALTH MAINTENANCE ORGANIZATION SHALL MEET
THE REQUIREMENTS OF SUBTITLE 13 OF THIS TITLE FOR THE PERFORMANCE
OF UTILIZATION REVIEW.

SUBTITLE 13. PRIVATE REVIEW AGENTS

19-1301.

(A)  IN THIS SUBTITLE THE FOLLOWING WORDS HAVE THE MEANINGS
INDICATED.

(B)  "UTILIZATION REVIEW" MEANS A SYSTEM FOR REVIEWING THE
APPROPRIATE AND EFFICIENT ALLOCATION OF HOSPITAL RESOURCES AND
SERVICES GIVEN OR PROPOSED TO BE GIVEN TO A PATIENT OR GROUP OF
PATIENTS.

(C)  "PRIVATE REVIEW AGENT" MEANS A NONHOSPITAL-AFFILIATED
PERSON OR ENTITY PERFORMING UTILIZATION REVIEW THAT IS EITHER
AFFILIATED WITH, UNDER CONTRACT WITH, OR ACTING ON BEHALF OF: A

BUSINESS ENTITY, HEALTH MAINTENANCE ORGANIZATION, PREFERRED

PROVIDER ORGANIZATION, HEALTH INSURER, NONPROFIT HEALTH SERVICE
PLAN, HEALTH INSURANCE SERVICE ORGANIZATION, OR OTHER THIRD PARTY
PAYOR.

(1)  A MARYLAND BUSINESS ENTITY; OR

(2)  A THIRD PARTY PAYOR WHICH PROVIDES OR ADMINISTERS
HOSPITAL BENEFITS TO CITIZENS OF THIS STATE INCLUDING;

(I) A HEALTH MAINTENANCE ORGANIZATION ISSUED A
CERTIFICATE OF AUTHORITY IN ACCORDANCE WITH SUBTITLE 7 OF THIS
TITLE; OR

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