Ch. 415                                    2004 LAWS OF MARYLAND

2. for a health maintenance organization, under the Health -
General Article or under this article.

(3) In addition to paragraph (1) of this subsection, it is a violation of this
subtitle, if the Commissioner, in consultation with an independent review
organization, medical expert, the Department, or other appropriate entity, determines
that the criteria and standards used by a health maintenance organization to conduct
utilization review are not:

(i) objective;

(ii) clinically valid;

(iii) compatible with established principles of health care; or

(iv) flexible enough to allow deviations from norms when justified
on a case by case basis.

[(d)](E) The Commissioner may refer complaints not within the
Commissioner's jurisdiction to the Health Advocacy Unit or any other appropriate
federal or State government agency or unit for disposition or resolution.

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) "Adverse decision" does not include a decision concerning a
subscriber's status as a member.

(C) "AUTHORIZED REPRESENTATIVE" MEANS A PERSON, INCLUDING A
HEALTH CARE PROVIDER, AUTHORIZED BY THE PATIENT TO ACT ON BEHALF OF THE
PATIENT.

[(c)](D) "Certificate" means a certificate of registration granted by the
Commissioner to a private review agent.

[(d)] (E) (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 or other community resources for counseling, therapy, or
treatment; and

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