ROBERT L. EHRLICH, JR., Governor                            Ch. 415

(ii) a panel of other appropriate health care service reviewers with
at least one physician on the panel who is board certified or eligible in the same
specialty as the treatment under review;

(2) when the grievance decision involves a dental service, a licensed
dentist, or a panel of appropriate health care service reviewers with at least one
dentist on the panel who is a licensed dentist, who shall consult with a dentist who is
board certified or eligible in the same specialty as the service under review; or

(3) when the grievance decision involves a mental health or substance
abuse service:

(i) a licensed physician who:

1. is board certified or eligible in the same specialty as the
treatment under review; or

2. is actively practicing or has demonstrated expertise in the
substance abuse or mental health service or treatment under review; or

(ii) a panel of other appropriate health care service reviewers with
at least one physician, selected by the private review agent who:

1. is board certified or eligible in the same specialty as the
treatment under review; or

2. is actively practicing or has demonstrated expertise in the
substance abuse or mental health service or treatment under review.

(B) A GRIEVANCE DECISION MAY NOT BE MADE BY A PHYSICIAN OR OTHER
HEALTH CARE SERVICE REVIEWER WHO:

(1) WAS CONSULTED IN CONNECTION WITH THE ADVERSE DECISION
FOR THE SAME HEALTH CARE SERVICE; OR

(2) IS A SUBORDINATE OF THE PHYSICIAN OR OTHER HEALTH CARE
SERVICE REVIEWER WHO MADE THE ADVERSE DECISION FOR THE SAME HEALTH
CARE SERVICE.

15-10D-01.

(a) In this subtitle the following words have the meanings indicated.

(b) "Appeal" means a protest filed by a member or [a health care provider] AN
AUTHORIZED REPRESENTATIVE with a carrier under its internal appeal process
regarding a coverage decision concerning a member.

(e) "Appeal decision" means a final determination by a carrier that arises
from an appeal filed with the carrier under its appeal process regarding a coverage
decision concerning a member.

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

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