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Ch. 142
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2007 Laws of Maryland
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(d) (1) Each carrier shall establish and implement a procedure by which a
member may request a referral to a specialist OR NONPHYSICIAN SPECIALIST who is
not part of the carrier's provider panel in accordance with this subsection.
(2) The procedure shall provide for a referral to a specialist OR
NONPHYSICIAN SPECIALIST who is not part of the carrier's provider panel if:
(i) the member is diagnosed with a condition or disease that
requires specialized HEALTH CARE SERVICES OR medical care; and
(ii) 1. the carrier does not have in its provider panel a
specialist OR NONPHYSICIAN SPECIALIST with the professional training and
expertise to treat OR PROVIDE HEALTH CARE SERVICES FOR the condition or
disease; or
2. the carrier cannot provide reasonable access to a
specialist OR NONPHYSICIAN SPECIALIST with the professional training and
expertise to treat OR PROVIDE HEALTH CARE SERVICES FOR the condition or
disease without unreasonable delay or travel.
(e) For purposes of calculating any deductible, copayment amount, or
coinsurance payable by the member, a carrier shall treat services received in
accordance with subsection (d) of this section as if the service was provided by a
provider on the carrier's provider panel.
(f) A decision by a carrier not to provide access to or coverage of treatment
OR HEALTH CARE SERVICES by a specialist OR NONPHYSICIAN SPECIALIST in
accordance with this section constitutes an adverse decision as defined under Subtitle
10A of this title if the decision is based on a finding that the proposed service is not
medically necessary, appropriate, or efficient.
(g) Each carrier shall file with the Commissioner a copy of each of the
procedures required under this section.
SECTION 2. AND BE IT FURTHER ENACTED. That this Act shall apply to
all policies, contracts, and health benefit plans issued, delivered, or renewed in the
State on or after October 1, 2007.
SECTION 2. 3. AND BE IT FURTHER ENACTED, That this Act shall take
effect October 1, 2007.
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Approved by the Governor, April 24, 2007.
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- 1218 -
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