Ch. 332

1997 LAWS OF MARYLAND

SHALL BE ACTIVELY INVOLVED IN THE PROVISION OF DIRECT
HEALTH CARE SERVICES TO PATIENTS WITH THE HUMAN DISEASES OR DISORDERS
BEING EVALUATED, WHETHER OR NOT THE PATIENTS ROUTINELY TREATED BY
THE PROVIDER ARE ENROLLEES OF THE CARRIER;

(II) MAY NOT BE AN EMPLOYEE OF THE CARRIER;

(III) SHALL BE BOARD CERTIFIED IN THE PERTINENT OR
APPROPRIATE SPECIALTY OR SUBSPECIALTY AREA; AND

(IV) SHALL BE GENERALLY RECOGNIZED BY THEIR PEERS TO BE
AUTHORITATIVE RESOURCES IN THE CLINICAL AREA BEING EVALUATED, AS
EVIDENCED BY:

1. FACULTY APPOINTMENTS;

2. AUTHORSHIP OF A SIGNIFICANT BODY OF

PEER-REVIEWED CLINICAL LITERATURE IN THE RELEVANT SPECIALITY AREA; AND

3. A DEMONSTRATED HISTORY OF LEADERSHIP IN LOCAL
STATE, AND NATIONAL PROFESSIONAL ASSOCIATIONS AND NONPROFIT PATIENT
AND COMMUNITY ADVOCACY ORGANIZATIONS THAT ADDRESS THE DISEASES AND
SPECIALTY AREAS IN QUESTION.

(5) EACH CARRIER SILALL FILE ANNUALLY WITH THE COMMISSIONER
THE CREDENTIALING CRITERIA THE CARRIER HAS UTILIZED IN SELECTING THE
CLINICAL EXPERTS AND OTHER SOURCES UTILIZED BY THE CARRIER IN
EVALUATING A DIAGNOSTIC OR THERAPEUTIC SERVICE THAT IS PART OF AN
EMERGING MEDICAL OR SURGICAL TREATMENT.

(F) A CARRIER'S DECISION TO PROVIDE COVERAGE FOR AN EMERGING
MEDICAL OR SURGICAL TREATMENT SHALL RESULT FROM THE CONSENSUS OF
OPINION FROM ITS OWN ANALYSIS AND THE KNOWLEDGE PROVIDED TO THE
CARRIER FROM THE CLINICAL EXPERTS IDENTIFIED BY THE CARRIER UNDER
SUBSECTION (E)(3) OF THIS SECTION.

(G) (1) EACH CARRIER, IN CONSULTATION WITH TILE CLINICAL EXPERTS
IDENTIFIED BY THE CARRIER UNDER SUBSECTION (E)(3) OF THIS SECTION, SHALL
DECIDE THE APPROPRIATE PATIENT SELECTION CRITERIA FOR AN EMERGING
MEDICAL OR SURGICAL TREATMENT FOR THE CARRIER'S AND THE CLINICAL
EXPERT'S REVIEW AND FOR WHICH COVERAGE BY THE CARRIER IS TO BE
EXTENDED.

(2) A CARRIER MAY USE THE PATIENT SELECTION CRITERIA AND
OTHER GUIDELINES AGREED ON WITH THE CLINICAL EXPERTS TO APPROVE OR
DENY COVERAGE FOR EMERGING MEDICAL AND SURGICAL TREATMENTS FOR ITS
ENROLLEES:

(H) (1) A CARRIER'S MEDICAL DIRECTOR AND MEDICAL POLICY STAFF
MAY NOT MAKE COVERAGE DECISIONS ON LIFESAVING EMERGING MEDICAL OR
SURGICAL TREATMENTS WITHOUT FIRST CONSULTING THE CLINICAL EXPERTS
IDENTIFIED BY THE CARRIER UNDER SUBSECTION (E)(3) OF THIS SECTION.

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