reglab/statecodes huggingface dataset:
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 10 - Claims and Utilization Review › Section 15-1001 - Requirement for Utilization Review

(a)    This section applies to entities that propose to issue or deliver individual, group, or blanket health insurance policies or contracts in the State or to administer health benefit programs that provide for the coverage of health care services and the utilization review of those services, including:
(1)    an authorized insurer that provides health insurance in the State;
(2)    a nonprofit health service plan;
(3)    a health maintenance organization;
(4)    a dental plan organization; or
(5)    except for a managed care organization as defined in Title 15, Subtitle 1 of the Health - General Article, any other person that provides health benefit plans subject to regulation by the State.
(b)    (1)    Subject to paragraph (2) of this subsection, each entity subject to this section shall:
(i)    1.    have a certificate issued under Subtitle 10B of this title; or
2.    contract with a private review agent that has a certificate issued under Subtitle 10B of this title; and
(ii)    when conducting utilization review for mental health and substance use benefits, ensure that the criteria and standards used are in compliance with the federal Mental Health Parity and Addiction Equity Act.
(2)    For hospital services, each entity subject to this section may contract with or delegate utilization review to a hospital utilization review program approved under § 19–319(d) of the Health – General Article.
(c)    Notwithstanding any other provision of this article, if the medical necessity of providing a covered benefit is disputed, an entity subject to this section that does not meet the requirements of subsection (b) of this section shall pay any person entitled to reimbursement under the policy or contract in accordance with the determination of medical necessity by:
(1)    the treating provider; or
(2)    when hospital services are provided, the hospital utilization review program approved under § 19-319(d) of the Health - General Article.
(d)    An entity subject to this section may not:
(1)    act as a private review agent without holding a certificate issued under Subtitle 10B of this title; or
(2)    use a private review agent that does not hold a certificate issued under Subtitle 10B of this title.
(e)    An entity that violates any provision of this section is subject to the penalties provided under § 15-10B-12 of this title.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 10 - Claims and Utilization Review › Section 15-1003 - Adoption of Uniform Claims Forms Required

(a)    (1)    In this section the following words have the meanings indicated.
(2)    (i)    “Health care practitioner” means a person that is licensed or certified under the Health Occupations Article and reimbursed by a third party payor.
(ii)    “Health care practitioner” does not include a physician or other person licensed or certified under this article when the physician or other person is rendering care to a member or subscriber of a health maintenance organization and is compensated by the health maintenance organization for that care on a salaried or capitated basis.
(3)    “Hospital” has the meaning stated in § 19-301 of the Health - General Article.
(b)    The Commissioner shall adopt by regulation as the uniform claims form for reimbursement of hospital services in the State the uniform claims form adopted by the National Uniform Billing Committee and approved by the Centers for Medicare and Medicaid Services for Hospital Payments under Title XVIII of the Social Security Act.
(c)    The Commissioner shall adopt by regulation a uniform claims form for reimbursement of health care practitioners’ services.
(d)    (1)    The Commissioner shall adopt by regulation:
(i)    a definition of a clean claim, including:
1.    the essential data elements that must be completed on the uniform claims form; and
2.    uniform standards for attachments to the uniform claims form;
(ii)    permissible categories of disputed claims for which additional information may be requested under §§ 15-1004(c) and 15-1005(c) of this subtitle; and
(iii)    standards for determining when a claim is considered received for reimbursement.
(2)    In adopting the regulations required under paragraph (1)(i) of this subsection, the Commissioner shall consider:
(i)    standards for attachments required by the federal Centers for Medicare and Medicaid Services for the Medicare Program;
(ii)    standards used by insurance carriers, nonprofit health service plans, and health maintenance organizations in the State; and
(iii)    federal regulations adopted under the Health Insurance Portability and Accountability Act.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 10 - Claims and Utilization Review › Section 15-1006 - Notice of Reason for Denial of Claim

(a)    On written request of the claimant, an insurer that denies a claim made on an individual health insurance policy shall give written notice to the claimant that states fully the reason for the denial.
(b)    The reason given by an insurer for denial of a claim shall not act as an estoppel or limit the insurer from offering an additional reason for the denial.
(c)    The notice given by an insurer under this section is subject to 45 C.F.R. § 164.522(b).
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 10 - Claims and Utilization Review › Section 15-1007 - Summary Explanation of Benefits

(a)    This section applies to insurers and nonprofit health service plans that propose to issue or deliver individual, group, or blanket health insurance policies or contracts or to administer health benefit programs that provide hospital, medical, or surgical benefits on an expense–incurred basis.
(b)    Each entity subject to this section shall provide to an insured individual who has filed a claim described in subsection (c) of this section an annual summary explanation of benefits that covers the preceding 12–month period.
(c)    The summary explanation of benefits required under subsection (b) of this section shall provide a summary of:
(1)    all claims filed by health care providers for services rendered to the insured individual or covered dependent of the insured individual during an inpatient hospitalization or an outpatient surgical procedure;
(2)    the amount paid by the entity for each claim filed; and
(3)    the balance owed by the insured individual for each claim filed.
(d)    The explanation of benefits required under this section is subject to 45 C.F.R. § 164.522(b).
2023 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.
2023 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).
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 10B - Private Review Agents › Section 15-10B-03 - Certificates -- Required; Issuance; Transferability; Regulations; Uniform Treatment Plan Form

(a)    A private review agent may not conduct utilization review in this State unless the Commissioner has granted the private review agent a certificate.
(b)    The Commissioner shall issue a certificate to an applicant that has met all the requirements of this subtitle and all applicable regulations of the Commissioner.
(c)    A certificate issued under this subtitle is not transferable.
(d)    The Commissioner may consider an applicant as having met a particular certification requirement under this subtitle if:
(1)    the applicant has obtained utilization management accreditation from an approved accrediting organization as determined by the Commissioner;
(2)    the approved accrediting organization has requirements that meet or exceed the particular requirement in this subtitle; and
(3)    the applicant demonstrates that the applicant meets or exceeds the particular requirement under this subtitle.
(e)    The Commissioner may adopt regulations to implement the provisions of this section.
(f)    The Commissioner may not issue a certificate to an applicant with utilization management accreditation by an approved accrediting organization unless the applicant meets all the requirements of this subtitle and all applicable regulations of the Commissioner.
(g)    A report of an approved accrediting organization used by the Commissioner as evidence that the applicant has met a particular requirement for a private review agent certificate shall be made available by the Commissioner to the public on request.
(h)    (1)    The Commissioner, after consultation with payors, including the Health Insurance Association of America, the League of Life and Health Insurers of Maryland, and the Maryland Association of Health Plans, and providers of health care, including the MHA: the Association of Maryland Hospitals and Health Systems, CareFirst BlueCross BlueShield, the Medical and Chirurgical Faculty of Maryland, and licensed or certified providers of treatment for a mental illness, emotional disorder, or a drug abuse or alcohol abuse disorder, shall adopt regulations to implement the provisions of this subtitle.
(2)    (i)    Subject to the provisions of subparagraph (iii) of this paragraph, the regulations adopted by the Commissioner shall include a uniform treatment plan form for utilization review of services for the treatment of a mental illness, emotional disorder, or a substance abuse disorder.
(ii)    The uniform treatment plan form adopted by the Commissioner:
1.    shall adequately protect the confidentiality of the patient; and
2.    may only request the patient’s membership number, policy number, or other similar unique patient identifier and first name for patient identification.
(iii)    The Commissioner may waive the requirements of regulations adopted under subparagraph (i) of this paragraph for the use of a uniform treatment plan form for any entity that would be using the form solely for internal purposes.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 10B - Private Review Agents › Section 15-10B-12 - Private Review Agent -- Penalties

(a)    (1)    A person who violates any provision of § 15-10B-11 of this subtitle is guilty of a misdemeanor and on conviction is subject to a penalty not exceeding $1,000.
(2)    Each day a violation is continued after the first conviction is a separate offense.
(b)    In addition to the provisions of subsection (a) of this section, if any person violates any provision of § 15-10B-11 of this subtitle, the Commissioner may:
(1)    deny, suspend, or revoke the certificate to do business as a private review agent;
(2)    issue an order to cease and desist from acting as a private review agent without holding a certificate issued under this subtitle;
(3)    require a private review agent to make restitution to a patient who has suffered actual economic damage because of the violation; and
(4)    impose an administrative penalty of up to $5,000 for each violation of any provision of this subtitle.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 10B - Private Review Agents › Section 15-10B-13 - Right to Hearing and Appeal From Action of Commissioner

Any person aggrieved by an order of the Commissioner under this subtitle has the right to a hearing and the right to appeal from the action of the Commissioner in accordance with §§ 2-210 through 2-215 of this article.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 10B - Private Review Agents › Section 15-10B-17 - Patient Referrals by Private Review Agents

(a)    (1)    Except as provided in paragraph (2) of this subsection, this section does not apply to:
(i)    a private review agent referring an individual to a health care provider or facility that participates in a health maintenance organization;
(ii)    a preferred provider organization network of participating health care providers or facilities to which the individual would otherwise be referred as part of the individual’s membership or insurance contract; or
(iii)    an employee assistance program referring an individual to a network of participating health care providers or facilities in accordance with a contract with the individual’s employer or labor union to provide comprehensive mental health and substance abuse services.
(2)    A private review agent or any other individual who is either affiliated with, under contract with, or acting on behalf of a private review agent may not approve or fail to approve a course of treatment based on whether the treatment is delivered by a provider who is a participating or nonparticipating provider in the preferred provider organization or employee assistance program network.
(b)    A private review agent or any individual who is either affiliated with, under contract with, or acting on behalf of a private review agent may not:
(1)    refer a patient who has undergone utilization review by the private review agent to:
(i)    a health care facility in which the private review agent owns a significant beneficial interest; or
(ii)    the private review agent’s own health care practice;
(2)    pay or agree to pay any sum to, or accept or agree to accept any sum from, any person for bringing or referring a patient to the private review agent; or
(3)    provide for different insurance coverage or benefits based on receiving the service from a health care facility or health care provider in which the private review agent owns a significant beneficial interest.
(c)    A private review agent or any individual who is either affiliated with, under contract with, or acting on behalf of a private review agent may refer a patient who has undergone utilization review by the private review agent to another health care provider regulated under the Health Occupations Article if:
(1)    (i)    the patient or provider requests the private review agent to provide the patient with the name of a health care provider appropriate to meet the health care needs of the patient; or
(ii)    the patient has no attending physician; and
(2)    the private review agent provides the patient with the names of at least two health care providers appropriate to meet the health care needs of the patient.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 10B - Private Review Agents › Section 15-10B-18 - Withdrawal and Submission of Certificate

(a)    A private review agent shall advise the Commissioner, in writing, of its intention to withdraw its certificate within 60 days of intention to cease operations as a private review agent.
(b)    A private review agent shall submit its certificate to the administration within 30 days after the date that the private review agent ceased operations.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 10B - Private Review Agents › Section 15-10B-19 - Examination by Commissioner

(a)    Whenever the Commissioner considers it advisable, the Commissioner shall examine the affairs, transactions, accounts, records, and assets of each private review agent at least once every 5 years.
(b)    The Commissioner shall examine the affairs, transactions, accounts, records, and assets of each private review agent that applies for a certificate of registration under § 15-10B-03 of this subtitle.
(c)    The examination shall be conducted in accordance with § 2-207 of this article.
(d)    The expense of the examination shall be paid in accordance with § 2-208 of this article.
(e)    The reports of the examination and investigation shall be issued in accordance with § 2-209 of this article.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 10B - Private Review Agents › Section 15-10B-20 - Examination by Commissioner -- Pharmacy Benefit Manager

(a)    In addition to the requirements under § 15-10B-19 of this subtitle, the Commissioner shall conduct an examination of any pharmacy benefit manager registered as a private review agent to determine whether the pharmacy benefit manager is acting in compliance with this subtitle.
(b)    The examination shall be conducted:
(1)    in accordance with § 2-207 of this article; and
(2)    at least once every 3 years.
(c)    The expense of the examination shall be paid in accordance with § 2-208 of this article.
(d)    The reports of the examination shall be issued in accordance with § 2-209 of this article.
(e)    Within 30 days after the completion of a final report of an examination under this section, the Commissioner shall submit a copy of the report to the Senate Finance Committee and the House Health and Government Operations Committee in accordance with § 2–1257 of the State Government Article.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 10C - Medical Directors › Section 15-10C-01 - Definitions

(a)    In this subtitle the following words have the meanings indicated.
(b)    “Board” means the State Board of Physicians established under Title 14 of the Health Occupations Article.
(c)    “Certificate” means a certificate issued by the Commissioner under this subtitle to act as a medical director.
(d)    “Department” means the Maryland Department of Health.
(e)    “Health maintenance organization” has the meaning stated in § 19–701 of the Health – General Article.
(f)    (1)    “Medical director” means a physician employed by or under contract with a health maintenance organization who is responsible for:
(i)    the establishment or maintenance of the policies and procedures at the health maintenance organization for:
1.    quality assurance; and
2.    utilization management;
(ii)    compliance with the quality assurance and utilization management policies and procedures of the health maintenance organization; and
(iii)    oversight of utilization review decisions of private review agents employed by or under contract with the health maintenance organization.
(2)    “Medical director” includes an associate medical director or an assistant medical director, as defined by the Commissioner by regulation.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 10C - Medical Directors › Section 15-10C-02 - Establishment of Regulations by Commissioner

The Commissioner, in consultation with the Department and the Board, shall establish and adopt by regulation standards for:
(1)    the certification of medical directors;
(2)    the renewal, suspension, and revocation of a certificate; and
(3)    the issuance of a temporary certificate.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 10C - Medical Directors › Section 15-10C-03 - Requirements for Application of Medical Director

(a)    To be certified as a medical director under this subtitle, an applicant shall:
(1)    submit an application to the Commissioner on the form required by the Commissioner; and
(2)    pay to the Commissioner an application fee of no more than $100 established by the Commissioner by regulation.
(b)    The application shall include:
(1)    a description of the applicant’s professional qualifications, including medical education information and, if appropriate, board certifications and licensure status;
(2)    the utilization management procedures and policies to be used by the health maintenance organization; and
(3)    certification by the medical director that the utilization management procedures and policies are:
(i)    objective;
(ii)    clinically valid;
(iii)    compatible with established principles of health care; and
(iv)    flexible enough to allow deviations from the norms when justified on a case by case basis.
(c)    The delegation by a medical director of any of the medical director’s responsibilities under this subtitle to an associate medical director or an assistant medical director does not prevent the medical director, regardless of the delegation, from being held responsible for any violation of this subtitle.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 10C - Medical Directors › Section 15-10C-04 - Suspension or Revocation by Commissioner of Certificate of Medical Director

(a)    Subject to the hearing procedures in §§ 2-210 through 2-214 of this article, the Commissioner may suspend, revoke, or refuse to renew a certificate of a medical director if the Commissioner finds a pattern that the utilization management procedures and policies used by the medical director in making utilization review decisions or used by a private review agent employed by or under contract with the health maintenance organization over whose utilization review decisions the medical director has responsibility are not:
(1)    objective;
(2)    clinically valid;
(3)    compatible with established principles of health care; or
(4)    flexible enough to allow deviations from the norms when justified on a case by case basis.
(b)    The Commissioner may consult with an independent review organization or medical expert that meets the requirements of § 15-10A-05 of this title, the Department, the Board, or any other appropriate entity for purposes of taking an action described under subsection (a) of this section.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 10D - Complaint Process for Coverage Decisions › Section 15-10D-03 - Obligations of Carrier

(a)    It is a violation of this subtitle for a carrier to fail to fulfill the carrier’s obligations to provide or reimburse for health care services specified in the carrier’s policies or contracts with members.
(b)    If, in rendering a coverage decision or appeal decision, a carrier fails to fulfill the carrier’s policies or contracts with members, the Commissioner may:
(1)    issue an administrative order that requires the carrier to:
(i)    cease inappropriate conduct or practices by the carrier or any of the personnel employed or associated with the carrier;
(ii)    fulfill the carrier’s contractual obligations;
(iii)    provide a health care service or payment that has been denied improperly; or
(iv)    take appropriate steps to restore the carrier’s ability to provide a health care service or payment that is provided under a contract; or
(2)    impose any penalty or fine or take any action as authorized:
(i)    for an insurer, nonprofit health service plan, or dental plan organization, under this article; or
(ii)    for a health maintenance organization, under the Health - General Article or under this article.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 11 - Miscellaneous Health Insurance Policies and Contracts and Health Benefit Plans › Section 15-1102 - Franchise Health Insurance Policies

(a)    In this section, “employee” includes:
(1)    an officer, manager, or retired employee of an employer;
(2)    a sole proprietor if the employer is a sole proprietorship; and
(3)    a partner if the employer is a partnership.
(b)    Health insurance on a franchise plan is the form of health insurance:
(1)    that is issued to:
(i)    three or more employees of a corporation, partnership, sole proprietorship, or governmental corporation, agency, or department; or
(ii)    ten or more members, employees, or employees of members of a labor union, or trade, professional, or other association, that is organized in good faith for purposes other than obtaining insurance, has a constitution or bylaws, and has had an active existence for at least 2 years;
(2)    under which the individuals insured, with or without their dependents, are issued the same form of an individual policy that varies only as to amounts and kinds of coverage applied for; and
(3)    under which the premiums on the individual policies may be paid to the insurer periodically by:
(i)    the employer, with or without payroll deductions;
(ii)    the labor union or association for its members; or
(iii)    a designated person acting on behalf of the employer, labor union, or association.
2023 Maryland Statutes › Insurance › Title 15 - Health Insurance › Subtitle 11 - Miscellaneous Health Insurance Policies and Contracts and Health Benefit Plans › Section 15-1103 - Transportation Ticket Health Insurance Policies

(a)    In this section, “transportation ticket policy” means a ticket policy of health insurance that:
(1)    has as its dominant feature the protection of the insured from a transportation hazard; and
(2)    is sold at transportation stations, ticket offices, or travel bureaus by:
(i)    vending machines;
(ii)    employees of railroads, steam lines, airlines, or other organizations engaged in transporting individuals on common carriers;
(iii)    individuals or employees of persons engaged in selling transportation on common carriers; or
(iv)    other qualified agents.
(b)    A transportation ticket policy may not be issued or delivered in the State unless it conforms to the requirements and provisions of §§ 15-102, 15-201, 15-202, 15-203, 15-205, and 15-207 through 15-226 of this title, subject to § 15-202(c) of this title that relates to inapplicable or inconsistent provisions.