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PARRIS N. GLENDENING, Governor
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S.B. 190
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(5) EXCEPT FOR A MANAGED CARE ORGANIZATION AS DEFINED IN TITLE
15, SUBTITLE 1 OF THE HEALTH - GENERAL ARTICLE, ANY OTHER PERSON THAT
PROVIDES HEALTH BENEFIT PLANS SUBJECT TO REGULATION BY THE STATE.
(b) (1) [Each] SUBJECT TO PARAGRAPH (2) OF THIS SUBSECTION, EACH
entity subject to this section shall:
[(1)] (I) have a certificate issued under Subtitle 10B of this title; OR
[(2)] (II) contract with a private review agent that has a certificate
issued under Subtitle 10B of this title[; or].
[(3)] (2) FOR HOSPITAL SERVICES, EACH ENTITY SUBJECT TO THIS
SECTION MAY contract with or delegate utilization review to a hospital utilization
review program approved under § 19-319(d) of the Health - General Article.
(c) Notwithstanding any other provision of this article, if the medical
necessity of providing a covered benefit is disputed, an entity subject to this section
that does not meet the requirements of subsection (b) of this section shall pay any
person entitled to reimbursement under the policy[, contract, or certificate] OR
CONTRACT in accordance with the determination of medical necessity by [the
hospital utilization review program approved under § 19-319(d) of the Health -
General Article]:
(1) THE TREATING PROVIDER; OR
(2) WHEN HOSPITAL SERVICES ARE PROVIDED, THE HOSPITAL
UTILIZATION REVIEW PROGRAM APPROVED UNDER § 19-319(D) OF THE HEALTH -
GENERAL ARTICLE.
(D) AN ENTITY SUBJECT TO THIS SECTION MAY NOT:
(1) ACT AS A PRIVATE REVIEW AGENT WITHOUT HOLDING A
CERTIFICATE ISSUED UNDER SUBTITLE 10B OF THIS TITLE; OR
(2) USE A PRIVATE REVIEW AGENT THAT DOES NOT HOLD A
CERTIFICATE ISSUED UNDER SUBTITLE 10B OF THIS TITLE.
(E) AN ENTITY THAT VIOLATES ANY PROVISION OF THIS SECTION IS SUBJECT
TO THE PENALTIES PROVIDED UNDER § 15-10B-12 OF THIS TITLE.
15-10B-01.
(a) In this subtitle the following words have the meanings indicated.
(b) (1) "Adverse decision" means a utilization review determination made by
a private review agent that a proposed or delivered health care service:
(i) is or was not medically necessary, appropriate, or efficient; and
(ii) may result in noncoverage of the health care service.
(2) [There is no adverse decision if the private review agent and the
health care provider on behalf of the patient reach an agreement on the proposed or
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- 3751 -
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