(4) flexible enough to allow deviations from norms when justified on a
case by case basis.

DRAFTER'S NOTE:

Error: Incomplete reference in § 15-10B-05(e) of the Insurance Article.

Occurred: Ch. 112, Acts of 1998. Correction by the publisher of the
Annotated Code in the 1998 Supplement of the Insurance Article is
validated by this Act.

15-10B-07.

(a) Except as specifically provided in § 15-10B-06 of this subtitle:

(1) except as provided in paragraph (2) of this subsection, all adverse
decisions shall be made by a physician or a panel of other appropriate health care
providers with at least 1 physician on the panel.

(2) when the health care service under review is a dental service, the
adverse decision shall be made by a licensed dentist or a panel of other appropriate
health care providers with at least 1 licensed dentist on the panel.

(3) in the event a patient or health care provider, including a physician,
intermediate care facility described in § 8-403(e) of the Health - General Article, or
hospital seeks reconsideration or appeal of an adverse decision by a private review
agent, the final determination of the appeal of the adverse decision shall be made
based on the professional judgment of:

(i) a physician or a panel of other appropriate health care
providers with at least 1 physician on the panel who is board certified or eligible in
the same specialty as the treatment under review; or

(ii) when the adverse decision involves a dental service, a licensed
dentist, or a panel of appropriate health care providers with at least 1 dentist on the
panel who is a licensed dentist, who shall consult with a dentist who is board certified
or eligible in the same specialty as the service under review.

(4) in the event a patient or health care provider, including a physician,
intermediate care facility described in § 8-403(e) of the Health - General Article, or
hospital seeks reconsideration or appeal of an adverse decision by a private review
agent, the final determination of the appeal of the adverse decision shall:

(i) be stated in writing and provide an explanation of the reason for
the adverse decision; and

(ii) reference the specific criteria and standards, including
interpretive guidelines, upon which the adverse decision is based.

DRAFTER'S NOTE:

Error: Stylistic error in § 15-10B-07(a)(3)(i) of the Insurance Article.