Ch. 604

1995 LAWS OF MARYLAND

(6) EXCEPT IN A SITUATION WHERE ONLY ONE PROVIDER CLASS IS
LICENSED TO PROVIDE A PARTICULAR SERVICE, A CARRIER MAY NOT LIMIT A
PROVIDER PANEL EXCLUSIVELY TO A SPECIFIC PROVIDER CLASS.

(7) (I) A CARRIER MAY RESTRICT PARTICIPATION IN ITS PROVIDER
PANEL ON THE BASIS THAT IT HAS A SUFFICIENT NUMBER OF PROVIDERS ONLY IF
THE CARRIER DEMONSTRATES TO THE SATISFACTION OF THE SECRETARY OF
HEALTH AND MENTAL HYGIENE THAT WITH SUCH A PROVIDER LIMITATION THE
CARRIER IS ABLE TO ADEQUATELY ADDRESS THE HEALTH CARE NEEDS OF
ENROLLEES IN A TIMELY MANNER.

(II) AN ENROLLEE MAY FILE A COMPLAINT WITH THE SECRETARY
OF HEALTH AND MENTAL HYGIENE CONCERNING THE ADEQUACY AND TIMELINESS
OF THE DELIVERY OF CARE BY A PROVIDER PANEL THAT RESTRICTS
PARTICIPATION UNDER SUBPARAGRAPH (I) OF THIS PARAGRAPH.

(E)     (1) (I) EACH CARRIER SUBJECT TO THIS SECTION SHALL PROVIDE AN
INTERNAL MECHANISM THROUGH WHICH A PROVIDER WHO IS REFUSED
PARTICIPATION IN A PROVIDER PANEL OR TERMINATED FROM PARTICIPATION IN A
PROVIDER PANEL MAY, ON THE PROVIDER'S WRITTEN REQUEST, OBTAIN A REVIEW
OF THE MANNER IN WHICH THE CARRIER'S CRITERIA HAVE BEEN APPLIED IN
CONNECTION WITH THE PROVIDER.

(II) A REVIEW UNDER SUBPARAGRAPH (I) OF THIS PARAGRAPH
SHALL BE PROVIDED BY A COMMITTEE THAT SHALL INCLUDE A MAJORITY OF
PROVIDERS WHO ARE ACTIVELY ENGAGED IN THE PRACTICE OF THE SPECIALTY OF
THE PROVIDER.

(III) A CARRIER SHALL PROVIDE A REVIEW UNDER

SUBPARAGRAPH (I) OF THIS PARAGRAPH WITHIN 30 DAYS AFTER THE REQUEST IS
MADE.

(2) THE FAILURE OF A CARRIER TO PROVIDE THE REVIEW WITHIN 30
DAYS AFTER THE REQUEST IS MADE SHALL BE DEEMED AN ACCEPTANCE BY THE
CARRIER OF THE PROVIDER ON THE CARRIER'S PROVIDER PANEL.

(3) A WRITTEN NOTICE OF THE COMMITTEE'S DECISION SHALL BE
GIVEN TO THE PROVIDER WITHIN 15 DAYS OF THE REVIEW HEARING.

(F)     THIS SECTION DOES NOT PROHIBIT A CARRIER FROM:

(1) REQUIRING PREAUTHORIZATION OR UTILIZATION REVIEW; OR

(2) ESTABLISHING REASONABLE PROFESSIONAL QUALIFICATIONS
APPLICABLE TO ALL PROVIDERS OF THE SAME TYPE, PROFESSION, AND SPECIALTY.

(G)     (1) THE MARKETING MATERIALS OF A CARRIER SHALL LIST MEMBERS OF
THIS PROVIDER PANEL AND SHALL BE UPDATED IMMEDIATELY PRIOR TO THE
DISTRIBUTION OF MARKETING MATERIALS FOR AN OPEN ENROLLMENT PERIOD,
BUT AT LEAST ONCE A YEAR.

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