PARRIS N. GLENDENING, Governor

Ch. 332

(2) AFFECT THE RIGHT OF AN ENROLLEE TO APPEAL ANY ADVERSE
DECISION BY A CARRIER THROUGH THE CARRIER'S APPEAL PROCESS.

(D) (1) EACH CARRIER SHALL DISCLOSE TO PROVIDERS, ENROLLEES, AND
PROSPECTIVE ENROLLEES PROVIDERS AND ENROLLEES THE CARRIER'S
DEFINITION OF "EXPERIMENTAL MEDICAL CARE".

(2) THE CARRIER SHALL DISCLOSE THE DEFINITION IN:

(I) CONTRACTS OFFERED TO PROVIDERS THAT MAY RENDER
DIRECT HEALTH CARE SERVICES TO THE ENROLLEES OF THE CARRIER; AND

(II) MARKETING MATERIALS AND ENROLLMENT MATERIALS OF
THE CARRIER THAT ARE PROVIDED TO CURRENT ENROLLEES AND PROSPECTIVE
ENROLLEES, AS APPROPRIATE.

(3) THE DEFINITION:

(I) SHALL INCLUDE THE GENERAL CRITERIA AND PROCESS THAT
THE CARRIER FOLLOWS FOR INDIVIDUAL ENROLLEES OR FOR THE ENTIRE
ENROLLED POPULATION IN EVALUATING WHETHER AN EMERGING MEDICAL OR
SURGICAL TREATMENT WILL BE COVERED BY THE CARRIER; AND

(II) SHALL BE BINDING ON THE CARRIER, ENROLLEES, AND
PROVIDERS FOR THE PURPOSE OF RESOLVING DISPUTES THAT ARISE OVER
WHETHER A MEDICAL OR SURGICAL TREATMENT IS OR IS NOT EXPERIMENTAL,
AND THEREFORE, COVERED BY THE CARRIER.

(E) (1) EACH CARRIER SHALL ESTABLISH A SYSTEMATIC, SCIENTIFIC
PROCESS TO FOLLOW FOR EVALUATING EMERGING MEDICAL AND SURGICAL
TREATMENTS TO ENSURE THAT PROVIDERS AND ENROLLEES HAVE ACCESS TO THE
LATEST APPROPRIATE TREATMENTS.

(2) THE PROCESS SHALL INCLUDE:

(I) ONGOING ANALYSES BY THE MEDICAL DIRECTOR OF THE
CARRIER AND THE MEDICAL POLICY STAFF OF THE CARRIER OF PUBLISHED,
PEER RENEWED MEDICAL LITERATURE, AND THE FINDINGS AND PUBLICATIONS
OF STATE AND FEDERAL AGENCIES; AND

(II) ONGOING DIALOGUE WITH OTHER CLINICAL EXPERTS IN THE
MEDICAL COMMUNITY FOR THE PURPOSE OF EVALUATING WHETHER EMERGING
MEDICAL OR SURGICAL TREATMENTS HAVE BECOME AN APPROPRIATE STANDARD
OF CARE FOR SPECIFIED HUMAN DISEASES OR DISORDERS.

(3) THE CARRIER SHALL IDENTIFY LEADING CLINICAL EXPERTS IN
RECOGNIZED MEDICAL AND SURGICAL SPECIALITIES AND SUBSPECIALTIES FOR
THE PURPOSE OF HAVING THE CLINICAL EXPERTS PROVIDE THE CARRIER WITH
DIALOGUE ON AND ANALYSES OF THE STATUS OF EMERGING MEDICAL AND
SURGICAL TREATMENTS.

(4) THE CLINICAL EXPERTS IDENTIFIED BY THE CARRIER:

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