reglab/housing_qa huggingface dataset:
MD. Insurance Code Ann. §  15-1009 (2021)
2021 Maryland Statutes|Insurance|Title 15 - Health Insurance|Subtitle 10 - Claims and Utilization Review|Section 15-1009 - "Carrier" Defined; Reimbursement for Preauthorized Care; Payment of Claims

    (a)    In this section, “carrier” means:        (1)    an insurer;        (2)    a nonprofit health service plan;        (3)    a health maintenance organization;        (4)    a dental plan organization; or        (5)    any other person that provides health benefit plans subject to regulation by the State.    (b)    If a health care service for a patient has been preauthorized or approved by a carrier or the carrier’s private review agent, the carrier may not deny reimbursement to a health care provider for the preauthorized or approved service delivered to that patient unless:        (1)    the information submitted to the carrier regarding the service to be delivered to the patient was fraudulent or intentionally misrepresentative;        (2)    critical information requested by the carrier regarding the service to be delivered to the patient was omitted such that the carrier’s determination would have been different had it known the critical information;        (3)    a planned course of treatment for the patient that was approved by the carrier was not substantially followed by the health care provider; or        (4)    on the date the preauthorized or approved service was delivered:            (i)    the patient was not covered by the carrier;            (ii)    the carrier maintained an automated eligibility verification system that was available to the contracting provider by telephone or via the Internet; and            (iii)    according to the verification system, the patient was not covered by the carrier.    (c)    Notwithstanding subsection (b) of this section, a carrier may suspend review of a claim for reimbursement of a preauthorized or approved health care service if:        (1)    the patient is in the second or third month of a grace period under 45 C.F.R. § 156.270(d);        (2)    the carrier maintains an automated eligibility verification system that was available to the health care provider by telephone or via the Internet at the time the health care service was provided;        (3)    according to the verification system, the provider is informed that:            (i)    the patient is in the second or third month of a grace period and review of a claim for reimbursement may be suspended; and            (ii)    a carrier is not prohibited from denying a claim for reimbursement of a suspended claim; and        (4)    the carrier complies with the notice and claim payment requirements under § 15–1005 of this subtitle.    (d)    A carrier shall pay a claim for a preauthorized or approved covered health care service in accordance with §§ 15–1005 and 15–1008 of this subtitle.
MD. Insurance Code Ann. §  15-1010 (2021)
2021 Maryland Statutes|Insurance|Title 15 - Health Insurance|Subtitle 10 - Claims and Utilization Review|Section 15-1010 - "Disability Benefit" and "Adverse Benefit Determination" Defined; Regulations

    (a)    (1)    In this section the following words have the meanings indicated.        (2)    “Adverse benefit determination” means:            (i)    a denial, reduction, or termination of a disability benefit;            (ii)    a failure to provide or make payment, in whole or in part, for a disability benefit; or            (iii)    any denial, reduction, termination, or failure to provide or make payment that is based on a determination of an individual’s eligibility for coverage of a disability benefit.        (3)    (i)    “Disability benefit” means a benefit that is payable based on the disability of a covered individual.            (ii)    “Disability benefit” does not include:                1.    long–term care insurance;                2.    a benefit that is payable based solely on a dismemberment of a covered individual;                3.    benefits in a life insurance policy that operate to safeguard the contract from lapse or to provide a special surrender value, special benefit, or annuity in the event of total and permanent disability; or                4.    benefits in a health insurance policy that operate to safeguard the contract from lapse due to disability.    (b)    (1)    The Commissioner shall adopt regulations that establish standards governing the processing of claims by an insurer that:            (i)    issues or delivers individual policies in the State that include a disability benefit; or            (ii)    issues or delivers group policies in the State that include a disability benefit.        (2)    The regulations adopted under this subsection shall establish and maintain reasonable claims procedures governing the filing of disability benefit claims, including:            (i)    notification of an adverse benefit determination; and            (ii)    an appeal by an insured or the insured’s authorized representative of an insurer’s adverse benefit determination.        (3)    The claims procedures established for both individual and group policies under this subsection shall be consistent with the provisions of the Department of Labor’s regulation entitled “Employee Retirement Income Security Act of 1974, Rules and Regulations for Administration and Enforcement; Claims Procedure; Final Rule” (29 C.F.R. 2560).
MD. Insurance Code Ann. §  15-1011 (2021)
2021 Maryland Statutes|Insurance|Title 15 - Health Insurance|Subtitle 10 - Claims and Utilization Review|Section 15-1011 - Expense Reimbursement Claims Forms -- Methods for Submission

    (a)    (1)    This section applies to:            (i)    insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and            (ii)    health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.        (2)    This section does not apply to claims for reimbursement:            (i)    for services received under Medicare supplemental policies or contracts; or            (ii)    for pharmaceutical or vision services.    (b)    An entity subject to this section shall permit an insured, a subscriber, or a member seeking reimbursement for expenses incurred by the insured, subscriber, or member, in connection with a covered service provided in the United States, to submit a claim for reimbursement:        (1)    by first–class mail; and        (2)    at the election of the entity:            (i)    by facsimile transmission; or            (ii)    through a Web site that allows for the secure transmission of information.    (c)    An entity subject to this section annually shall provide:        (1)    a notice that a claims form may be submitted:            (i)    by first–class mail; and            (ii)    at the election of the entity:                1.    by facsimile transmission; or                2.    through a Web site that allows for the secure transmission of information; and        (2)    instructions on how to submit a claim by facsimile transmission or through a secure Web site.
MD. Insurance Code Ann. §  15-10A-01.1 (2021)
2021 Maryland Statutes|Insurance|Title 15 - Health Insurance|Subtitle 10A - Complaint Process for Adverse Decisions or Grievances|Section 15-10A-01.1 - Applicability

    This subtitle applies to a health benefit plan that:         (1)    is delivered or issued in the State; or        (2)    covers individuals who reside or work in the State if the health benefit plan is delivered or issued in a state that the Commissioner determines does not have an external complaint process for adverse decisions or grievances comparable to the complaint process established in this subtitle.
MD. Insurance Code Ann. §  15-10A-06 (2021)
2021 Maryland Statutes|Insurance|Title 15 - Health Insurance|Subtitle 10A - Complaint Process for Adverse Decisions or Grievances|Section 15-10A-06 - Quarterly Reports by Carrier to Commissioner; Annual Summary Report by Commissioner

    (a)    On a quarterly basis, each carrier shall submit to the Commissioner, on the form the Commissioner requires, a report that describes:        (1)    the activities of the carrier under this subtitle, including:            (i)    the outcome of each grievance filed with the carrier;            (ii)    the number and outcomes of cases that were considered emergency cases under § 15-10A-02(b)(2)(i) of this subtitle;            (iii)    the time within which the carrier made a grievance decision on each emergency case;            (iv)    the time within which the carrier made a grievance decision on all other cases that were not considered emergency cases;            (v)    the number of grievances filed with the carrier that resulted from an adverse decision involving length of stay for inpatient hospitalization as related to the medical procedure involved; and            (vi)    the number of adverse decisions issued by the carrier under § 15-10A-02(f) of this subtitle and the type of service at issue in the adverse decisions; and        (2)    the number and outcome of all other cases that are not subject to activities of the carrier under this subtitle that resulted from an adverse decision involving the length of stay for inpatient hospitalization as related to the medical procedure involved.    (b)    The Commissioner shall:        (1)    compile an annual summary report based on the information provided:            (i)    under subsection (a) of this section; and            (ii)    by the Secretary under § 19-705.2(e) of the Health - General Article; and        (2)    provide copies of the summary report to the Governor and, subject to § 2-1257 of the State Government Article, to the General Assembly.
MD. Insurance Code Ann. §  15-10A-07 (2021)
2021 Maryland Statutes|Insurance|Title 15 - Health Insurance|Subtitle 10A - Complaint Process for Adverse Decisions or Grievances|Section 15-10A-07 - Quarterly Report to Commissioner by Health Advocacy Unit

    On a quarterly basis, the Health Advocacy Unit shall submit a report to the Commissioner that:         (1)    describes activities it performed on behalf of members that have participated in an internal grievance process of a carrier established under this subtitle;        (2)    describes its efforts to mediate cases that involve an adverse decision;        (3)    names each carrier involved in the cases described in the report;        (4)    states the number and outcome of each grievance considered an emergency case under § 15-10A-02(b)(2)(i) of this subtitle described in the report, including the time within which the carrier made a grievance decision on each emergency case; and        (5)    states the number and outcome of each case described in the report that was not considered an emergency case, including the time within which the carrier made a grievance decision on the case.
MD. Insurance Code Ann. §  15-10A-08 (2021)
2021 Maryland Statutes|Insurance|Title 15 - Health Insurance|Subtitle 10A - Complaint Process for Adverse Decisions or Grievances|Section 15-10A-08 - Annual Summary Report by Health Advocacy Unit

    (a)    On or before November 1, 1999, and each November 1 thereafter, the Health Advocacy Unit shall publish an annual summary report and provide copies of the report to the Governor and, subject to § 2-1257 of the State Government Article, the General Assembly.    (b)    (1)    The annual summary report required under subsection (a) of this section shall be on the grievances and complaints filed with or referred to a carrier, the Commissioner, the Health Advocacy Unit, or any other federal or State government agency or unit under this subtitle during the previous fiscal year.        (2)    In consultation with the Commissioner and any affected State government agency or unit, the Health Advocacy Unit shall:            (i)    evaluate the effectiveness of the internal grievance process and complaint process available to members; and            (ii)    include in the annual summary report the results of the evaluation and any proposed changes that it considers necessary.
MD. Insurance Code Ann. §  15-10A-09 (2021)
2021 Maryland Statutes|Insurance|Title 15 - Health Insurance|Subtitle 10A - Complaint Process for Adverse Decisions or Grievances|Section 15-10A-09 - Regulations; Right to Challenge Decision Resulting in Nonpayment

    (a)    The Commissioner shall adopt regulations to carry out this subtitle.    (b)    In addition to the requirements of subsection (a) of this section, the Commissioner shall adopt by regulation a requirement that each carrier provide a mechanism in a form and manner that the Commissioner may require to enable a member to:        (1)    be informed of the member’s right to challenge a decision made by a carrier that resulted in the nonpayment of a health care service; and        (2)    access the Consumer Education and Advocacy Program in the Administration.
MD. Insurance Code Ann. §  15-10A-10 (2021)
2021 Maryland Statutes|Insurance|Title 15 - Health Insurance|Subtitle 10A - Complaint Process for Adverse Decisions or Grievances|Section 15-10A-10 - Requirements of Notice by Carrier

    A carrier shall provide the notices required to be provided to members under this subtitle in a culturally and linguistically appropriate manner as described in the Affordable Care Act.
MD. Insurance Code Ann. §  15-10B-02 (2021)
2021 Maryland Statutes|Insurance|Title 15 - Health Insurance|Subtitle 10B - Private Review Agents|Section 15-10B-02 - Purpose of Subtitle

    The purpose of this subtitle is to:         (1)    promote the delivery of quality health care in a cost effective manner;        (2)    foster greater coordination between payors and providers conducting utilization review activities;        (3)    protect patients, business, and providers by ensuring that private review agents are qualified to perform utilization review activities and to make informed decisions on the appropriateness of medical care; and        (4)    ensure that private review agents maintain the confidentiality of medical records in accordance with applicable State and federal laws.
MD. Insurance Code Ann. §  15-10B-04 (2021)
2021 Maryland Statutes|Insurance|Title 15 - Health Insurance|Subtitle 10B - Private Review Agents|Section 15-10B-04 - Certificates -- Application; Fees

    (a)    An applicant for a certificate shall:        (1)    submit an application to the Commissioner; and        (2)    pay to the Commissioner the application fee established by the Commissioner through regulation.    (b)    The application shall:        (1)    be on a form and accompanied by any supporting documentation that the Commissioner requires; and        (2)    be signed and verified by the applicant.    (c)    The fees required under subsection (a)(2) of this section or § 15-10B-10(b)(2) of this subtitle shall be sufficient to pay for the administrative costs of the certificate program and any other costs associated with carrying out the provisions of this subtitle.
MD. Insurance Code Ann. §  15-10B-07 (2021)
2021 Maryland Statutes|Insurance|Title 15 - Health Insurance|Subtitle 10B - Private Review Agents|Section 15-10B-07 - Adverse Decisions by Private Review Agent

    (a)    (1)    Except as provided in paragraphs (2) and (3) of this subsection, all adverse decisions shall be made by a physician, or 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 health care service under review is a mental health or substance abuse service, the adverse decision shall be made by a physician, or a panel of other appropriate health care service reviewers with at least one physician, selected by the private review agent who:            (i)    is board certified or eligible in the same specialty as the treatment under review; or            (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.
MD. Insurance Code Ann. §  15-10B-08 (2021)
2021 Maryland Statutes|Insurance|Title 15 - Health Insurance|Subtitle 10B - Private Review Agents|Section 15-10B-08 - Requirements of Internal Grievance Process

    (a)    If a carrier delegates its internal grievance process to a private review agent, the private review agent shall establish an internal grievance process for its patients and health care providers acting on behalf of a patient.    (b)    A private review agent’s internal grievance process shall meet the same requirements established under §§ 15-10A-02 through 15-10A-05 of this title.    (c)    A private review agent may not charge a fee to a patient or health care provider for filing a grievance.
MD. Insurance Code Ann. §  15-10B-09.1 (2021)
2021 Maryland Statutes|Insurance|Title 15 - Health Insurance|Subtitle 10B - Private Review Agents|Section 15-10B-09.1 - Requirements of Grievance Decision

    A grievance decision shall be made based on the professional judgment of:         (1)    (i)    a physician who is board certified or eligible in the same specialty as the treatment under review; or            (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.
MD. Insurance Code Ann. §  15-10B-10 (2021)
2021 Maryland Statutes|Insurance|Title 15 - Health Insurance|Subtitle 10B - Private Review Agents|Section 15-10B-10 - Certificates -- Expiration; Renewal

    (a)    A certificate expires on the second anniversary of its effective date unless the certificate is renewed for a 2-year term as provided in this section.    (b)    Before the certificate expires, a certificate may be renewed for an additional 2-year term if the applicant:        (1)    otherwise is entitled to the certificate;        (2)    pays to the Commissioner the renewal fee set by the Commissioner through regulation; and        (3)    submits to the Commissioner:            (i)    a renewal application on the form that the Commissioner requires; and            (ii)    satisfactory evidence of compliance with any requirement under this subtitle for certificate renewal.    (c)    If the requirements of this section are met, the Commissioner shall renew a certificate.
MD. Insurance Code Ann. §  15-10B-11 (2021)
2021 Maryland Statutes|Insurance|Title 15 - Health Insurance|Subtitle 10B - Private Review Agents|Section 15-10B-11 - Private Review Agent -- Prohibitions

    A private review agent may not:         (1)    violate any provision of this subtitle or any rule or regulation adopted under this subtitle;        (2)    fail to meet the requirements for certification under this subtitle;        (3)    obtain or attempt to obtain certification based on inaccurate information;        (4)    fraudulently or deceptively obtain or use a certificate;        (5)    fail to make available the services of sufficient numbers of registered nurses, medical records technicians, or similarly qualified persons supported and supervised by appropriate physicians to carry out its utilization review activities;        (6)    fail to meet any applicable regulations the Commissioner adopts under this subtitle relating to the qualifications of private review agents or the performance of utilization review;        (7)    fail to protect the confidentiality of medical records in accordance with applicable State and federal laws;        (8)    use criteria and standards to conduct utilization review unless the criteria and standards used by the private review agent are:            (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; or        (9)    act as a private review agent without holding a certificate issued under this subtitle.