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S.B. 190
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VETOES
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delivered health care services.] "ADVERSE DECISION" DOES NOT INCLUDE A
DECISION CONCERNING A SUBSCRIBER'S STATUS AS A MEMBER
(c) "Certificate" means a certificate of registration granted by the
Commissioner to a private review agent.
(d) (1) "Employee assistance program" means a health care service plan
that, in accordance with a contract with an employer or labor union:
(i) consults with employees or members of an employee's family or
both to:
1. identify the employee's or the employee's family member's
mental health, alcohol, or substance abuse problems; and
2. refer the employee or the employee's family member to
[health care providers] A PHYSICIAN OR PROVIDER LICENSED OR AUTHORIZED TO
PROVIDE HEALTH CARE SERVICES or other community resources for counseling,
therapy, or treatment; and
(ii) performs utilization review for the purpose of making claims or
payment decisions on behalf of the employer's or labor union's health insurance or
health benefit plan.
(2) "Employee assistance program" does not include a health care service
plan operated by a hospital solely for employees, or members of an employee's family,
of that hospital.
(E) (1) "GRIEVANCE" MEANS A PROTEST FILED BY A PATIENT OR A HEALTH
CARE PROVIDER ON BEHALF OF A PATIENT WITH A PRIVATE REVIEW AGENT
THROUGH THE PRIVATE REVIEW AGENT'S INTERNAL GRIEVANCE PROCESS
REGARDING AN ADVERSE DECISION CONCERNING A PATIENT.
(2) "GRIEVANCE" DOES NOT INCLUDE A VERBAL REQUEST FOR
RECONSIDERATION OF A UTILIZATION REVIEW DETERMINATION.
(F) "GRIEVANCE DECISION" MEANS A FINAL DETERMINATION BY A PRIVATE
REVIEW AGENT THAT ARISES FROM A GRIEVANCE FILED WITH THE PRIVATE REVIEW
AGENT UNDER ITS INTERNAL GRIEVANCE PROCESS REGARDING AN ADVERSE
DECISION CONCERNING A PATIENT.
[(e)] (G) "Health care facility" means:
(1) a hospital as defined in § 19-301 of the Health - General Article;
(2) a related institution as defined in § 19-301 of the Health - General
Article;
(3) an ambulatory surgical facility or center which is any entity or part
thereof that operates primarily for the purpose of providing surgical services to
patients not requiring hospitalization and seeks reimbursement from third party
payors as an ambulatory surgical facility or center;
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- 3752 -
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