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PARRIS N. GLENDENING, Governor Ch. 359
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(4) "Provider panel" means those providers with which a carrier
contracts to provide services to its members.
(5) "Specialist" means a physician who is certified or trained to practice
in a specified field of medicine and who is not designated as a primary care provider
by the carrier.
(b) (1) [Each] SUBJECT TO SUBSECTION (C) OF THIS SECTION, EACH carrier
that does not allow direct access to specialists shall establish and implement a
procedure by which a member may receive a standing referral to a specialist in
accordance with this subsection.
(2) The procedure shall provide for a standing referral to a specialist if:
(i) the primary care physician of the member determines, in
consultation with the specialist, that the member needs continuing care from the
specialist;
(ii) the member has a condition or disease that:
1. is life threatening, degenerative, chronic, or disabling; and
2. requires specialized medical care; and
(iii) the specialist:
1. has expertise in treating the life-threatening,
degenerative, chronic, or disabling disease or condition; and
2. is part of the carrier's provider panel.
(3) A EXCEPT AS PROVIDED IN SUBSECTION (C) OF THIS SECTION, A
standing referral shall be made in accordance with a written treatment plan for a
covered service developed by:
(i) the primary care physician;
(ii) the specialist; and
(iii) the member.
(4) A treatment plan may:
(i) limit the number of visits to the specialist;
(ii) limit the period of time in which visits to the specialist are
authorized; and
(iii) require the specialist to communicate regularly with the
primary care physician regarding the treatment and health status of the member.
(5) The procedure by which a member may receive a standing referral to
a specialist may not include a requirement that a member see a provider in addition
to the primary care physician before the standing referral is granted.
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- 2055 -
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