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S.B. 190
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VETOES
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(II) IS ACTIVELY PRACTICING OR HAS DEMONSTRATED EXPERTISE
IN THE SUBSTANCE ABUSE OR MENTAL HEALTH SERVICE OR TREATMENT UNDER
REVIEW.
(3) 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 SERVICE REVIEWERS WITH AT LEAST
ONE LICENSED DENTIST ON THE PANEL.
(B) ALL ADVERSE DECISIONS SHALL BE MADE BY A PHYSICIAN OR A PANEL OF
OTHER APPROPRIATE HEALTH CARE SERVICE REVIEWERS WHO ARE NOT
COMPENSATED BY THE PRIVATE REVIEW AGENT IN A MANNER THAT VIOLATES §
19-705.1 OF THE HEALTH - GENERAL ARTICLE OR THAT DETERS THE DELIVERY OF
MEDICALLY APPROPRIATE CARE.
(C) EXCEPT AS PROVIDED IN SUBSECTION (D) OF THIS SECTION, 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.
(D) A PRIVATE REVIEW AGENT MAY RETROSPECTIVELY RENDER AN ADVERSE
DECISION REGARDING PREAUTHORIZED OR APPROVED SERVICES DELIVERED TO A
PATIENT IF;
(1) THE INFORMATION SUBMITTED TO THE PRIVATE REVIEW AGENT
REGARDING THE SERVICES TO BE DELIVERED TO THE PATIENT WAS FRAUDULENT
OR INTENTIONALLY MISREPRESENTATIVE;
(2) 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 THE AGENT KNOWN THE CRITICAL INFORMATION; OR
(3) THE PLANNED COURSE OF TREATMENT FOR THE PATIENT THAT WAS
APPROVED BY THE PRIVATE REVIEW AGENT WAS NOT SUBSTANTIALLY FOLLOWED
BY THE PROVIDER
(E) IF A COURSE OF TREATMENT HAS BEEN PREAUTHORIZED OR APPROVED
FOR A PATIENT, A PRIVATE REVIEW AGENT MAY NOT REVISE OR MODIFY THE
SPECIFIC CRITERIA OR STANDARDS USED FOR THE UTILIZATION REVIEW TO MAKE
AN ADVERSE DECISION REGARDING THE SERVICES DELIVERED TO THAT PATIENT.
[15-10B-08.
(a) Except as provided in subsection (b) of this section, a private review agent
shall:
(1) make all initial determinations on whether to authorize or certify a
nonemergency course of treatment for a patient within 2 working days of receipt of
the information necessary to make the determination; and
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- 3762 -
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