Ch. 35

1997 LAWS OF MARYLAND

(B) IN GENERAL.

EACH ENTITY SUBJECT TO THIS SECTION SHALL:

(1) HAVE A CERTIFICATE ISSUED UNDER TITLE 19, SUBTITLE 13 OF THE
HEALTH - GENERAL ARTICLE;

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

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

(C) DISPUTED CLAIMS.

NOTWITHSTANDING ANY OTHER PROVISION OF THIS ARTICLE, IF THE
MEDICAL NECESSITY OF PROVIDING A COVERED BENEFIT IS DISPUTED, AN ENTITY
SUBJECT TO THIS SECTION THAT DOES NOT MEET THE REQUIREMENTS OF
SUBSECTION (B) OF THIS SECTION SHALL PAY ANY PERSON 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 § 19-319(D) OF THE
HEALTH - GENERAL ARTICLE.

REVISOR'S NOTE: This section is new language derived without substantive
change from former Art. 48A, §§ 354HH, 470Y, and 477-11.

In subsection (a) of this section, the reference to insurers and nonprofit health
service plans that propose to issue or deliver "individual" health insurance
policies or contracts in the State is added to clarify the applicability of this
section.

Also in subsection (a) of this section, the former reference to a "health"
insurer is deleted as unnecessary in light of the reference to insurers that issue
or deliver "health insurance" policies or contracts.

In subsection (b)(1) and (2) of this section, the references to having a
certificate "issued under" Title 19, Subtitle 13 of the Health - General Article
are substituted for the former references to having a certificate "in accordance
with" Title 19, Subtitle 13 of the Health - General Article for clarity.

In subsection (b)(3) of this section, the reference to delegating "utilization
review" to a hospital utilization review program is added for clarity.

In subsection (c) of this section, the reference to an "entity subject to this
section" is substituted for the former references to a "nonprofit health service
plan", an "insurer", and a "health insurer" in light of subsection (a) of this
section.

Also in subsection (c) of this section, the former phrase "for claims" is deleted
as surplusage.

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