Annotated Code of Maryland

(1996 Volume and 1998 Supplement)

SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF
MARYLAND, That the Laws of Maryland read as follows:

Article - Insurance

15-303.

(F) EACH POLICY OF GROUP HEALTH INSURANCE SHALL CONTAIN A
PROVISION THAT REQUIRES THE EMPLOYER LABOR UNION, ASSOCIATION, OR
OTHER ENTITY TO WHICH A POLICY OF GROUP HEALTH INSURANCE HAS BEEN
ISSUED TO CONTINUE TO PAY THE PREMIUM FOR AN EMPLOYEE, MEMBER OR
DEPENDENT UNDER THE POLICY UNTIL NOTICE OF TERMINATION OF COVERAGE
HAS BEEN RECEIVED BY THE INSURER

15-10B-07.

(c) (1) Except as provided in paragraph (2) of this subsection, if a course of
treatment has been preauthorized or approved for a patient, a private review agent
may not retrospectively render an adverse decision regarding the preauthorized or
approved services delivered to that patient.

(2) A private review agent may retrospectively render an adverse
decision regarding preauthorized or approved services delivered to a patient if:

(i) [the patient, on the date the services were rendered, was not
insured by or an enrollee, subscriber, or member of the entity that the private review
agent is affiliated with, under contract with, or acting on behalf of;

(ii)] the information submitted to the private review agent
regarding the services to be delivered to the patient was fraudulent or intentionally
misrepresentative or critical information requested by the private review agent
regarding services to be delivered to the patient was omitted such that the private
review agent's determination would have been different had it known the critical
information; OR

[(iii) except for determinations of appropriateness or medical
necessity of the covered services that were preauthorized, the services would not be
covered in whole or in part under the policy or contract; or

(iv)] (II) the planned course of treatment for the patient that was
approved by the private review agent was not substantially followed by the provider.

Article - Health - General

19-706.

(FF) THE PROVISIONS OF § 15-303(F) OF THE INSURANCE ARTICLE APPLY TO
HEALTH MAINTENANCE ORGANIZATIONS.

SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect
October 1, 1999.