|
Ch. 604
1995 LAWS OF MARYLAND
(IV) A DENTAL PLAN ORGANIZATION; OR
(V) ANY PERSON ACTING AS A THIRD PARTY ADMINISTRATOR.
(3) "CRITERIA" MEANS A SYSTEM, PLAN, METHODOLOGY, PROVIDER
PROFILE, OR STANDARD USED BY A CARRIER TO SELECT OR DENY PROVIDERS
THAT HAVE APPLIED TO BECOME MEMBERS OF THE CARRIER'S PROVIDER PANEL.
(4) "ENROLLEE" MEANS ANY PERSON ENTITLED TO HEALTH CARE
BENEFITS FROM A CARRIER.
(5) "PARTICIPATING PROVIDER" MEANS ANY PROVIDER THAT HAS
ENTERED INTO A WRITTEN PROVIDER SERVICE CONTRACT WITH A CARRIER TO
PROVIDE: SERVICES UNDER THE CARRIER'S HEALTH BENEFIT PLAN.
(6) (I) "PROVIDER" MEANS A PERSON LICENSED, CERTIFIED, OR
OTHERWISE AUTHORIZED UNDER THE HEALTH OCCUPATIONS ARTICLE TO
PROVIDE HEALTH CARE SERVICES.
(II) "PROVIDER" INCLUDES A HEALTH CARE FACILITY,
PHARMACY, PROFESSIONAL. SERVICE CORPORATION, PARTNERSHIP, LIMITED
LIABILITY COMPANY, PROFESSIONAL OFFICE, OR ANY OTHER ENTITY LICENSED OR
AUTHORIZED BY LAW TO PROVIDE. OR DELIVER PROFESSIONAL SERVICES
THROUGH OR ON BEHALF OF A PROVIDER.
(7) "PROVIDER PANEL" MEANS A GROUP OF PROVIDERS THAT HAVE
ENTERED INTO A WRITTEN PROVIDER SERVICE CONTRACT WITH A CARRIER TO
PROVIDE SERVICES UNDER THE CARRIER'S HEALTH BENEFIT PLAN.
(B) A CARRIER SHALL PROVIDE HEALTH CARE SERVICES TO ENROLLEES IN
ACCORDANCE WITH THE PROVISIONS OF § 657 OF THIS ARTICLE.
(C) (1) A CARRIER THAT USES A PROVIDER PANEL SHALL:
(I) ESTABLISH REASONABLE CRITERIA FOR PARTICIPATION ON
THE CARRIER'S PROVIDER PANEL;
(II) ESTABLISH REASONABLE PROCEDURES FOR THE REVIEW OF
APPLICATIONS FOR MEMBERSHIP ON THE CARRIER'S PROVIDER PANEL;
(III) REVIEW APPLICATIONS SUBMITTED TO PROVIDERS APPLYING
FOR MEMBERSHIP OR CONTINUED MEMBERSHIP ON A CARRIER'S PROVIDER PANEL
IN ACCORDANCE WITH THIS SECTION; AND
(IV) MAINTAIN THE CRITERIA AND PROCEDURES AT A LOCATION
IN THE STATE AND MAKE THE CRITERIA AVAILABLE TO THE PUBLIC UPON
REQUEST.
(2) (I) THE COMMISSIONER AND THE SECRETARY OF HEALTH AND
MENTAL HYGIENE JOINTLY SHALL ADOPT REGULATIONS FOR;
1. THE FILING OF CRITERIA AND PROCEDURES WITH THE
STATE; AND
- 3434 -
|
