State Law

Maryland Statutes-Article 15-Insurance-Subtitle 10B. Private Review Agents

01/16/2025 Maryland Sections 15-10B-01, 15–10B–05, 15–10B–06 and 15-10B-11

Definitions; Certificates — Additional Information; Determinations by Private Review Agent; Determinations by Private Review Agent; Private Review Agent — Prohibitions

State Medical Necessity Decisions-Deadlines, U.R. Criteria

See bold text below:

Section 15-10B-01. Definitions

(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” includes a utilization review determination based on a prior authorization or step therapy requirement.

(3) “Adverse decision” does not include a decision concerning a subscriber’s status as a member.

(c) “Certificate” means a certificate of registration granted by the Commissioner to a private review agent.

(d) (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

(ii) performs utilization review for the purpose of making claims or payment decisions on behalf of the employer’s or labor union’s health insurance or health benefit plan.

(2) “Employee assistance program” does not include a health care service plan operated by a hospital solely for employees, or members of an employee’s family, of that hospital.

(e) (1) “Grievance” means a protest filed by a patient or a health care provider on behalf of a patient with a private review agent through the private review agent’s internal grievance process regarding an adverse decision concerning a patient.

(2) “Grievance” does not include a verbal request for reconsideration of a utilization review determination.

(f) “Grievance decision” means a final determination by a private review agent that arises from a grievance filed with the private review agent under its internal grievance process regarding an adverse decision concerning a patient.

(g) “Health care facility” means:

(1) a hospital as defined in § 19–301 of the Health – General Article;

(2) a related institution as defined in § 19–301 of the Health – General Article;

(3) an ambulatory surgical facility or center which is any entity or part thereof that operates primarily for the purpose of providing surgical services to patients not requiring hospitalization and seeks reimbursement from third party payors as an ambulatory surgical facility or center;

(4) a facility that is organized primarily to help in the rehabilitation of disabled individuals;

(5) a home health agency as defined in § 19–401 of the Health – General Article;

(6) a hospice as defined in § 19–901 of the Health – General Article;

(7) a facility that provides radiological or other diagnostic imagery services;

(8) a medical laboratory as defined in § 17–201 of the Health – General Article; or

(9) an alcohol abuse and drug abuse treatment program as defined in § 8–403 of the Health – General Article.

(h) “Health care provider” means:

(1) an individual who:

(i) is licensed or otherwise authorized to provide health care services in the ordinary course of business or practice of a profession; and

(ii) is a treating provider of a patient; or

(2) a hospital, as defined in § 19–301 of the Health – General Article.

(i) “Health care service” means a health or medical care procedure or service rendered by a health care provider licensed or authorized to provide health care services that:

(1) provides testing, diagnosis, or treatment of a human disease or dysfunction;

(2) dispenses drugs, medical devices, medical appliances, or medical goods for the treatment of a human disease or dysfunction; or

(3) provides any other care, service, or treatment of disease or injury, the correction of defects, or the maintenance of the physical and mental well–being of human beings.

(j) “Health care service reviewer” means an individual who is licensed or otherwise authorized to provide health care services in the ordinary course of business or practice of a profession.

(k) “Private review agent” means:

(1) a nonhospital–affiliated person or entity performing utilization review that is either affiliated with, under contract with, or acting on behalf of:

(i) a Maryland business entity; or

(ii) a third party that pays for, provides, or administers health care services to citizens of this State; or

(2) any person or entity including a hospital–affiliated person performing utilization review for the purpose of making claims or payment decisions for health care services on behalf of the employer’s or labor union’s health insurance plan under an employee assistance program for employees other than the employees employed by:

(i) the hospital; or

(ii) a business wholly owned by the hospital.

(l) “Significant beneficial interest” means the ownership of any financial interest that is greater than the lesser of:

(1) 5 percent of the whole; or

(2) $5,000.

(m) “Utilization review” means a system for reviewing the appropriate and efficient allocation of health care resources and services given or proposed to be given to a patient or group of patients.

(n) “Utilization review plan” means a description of the standards governing utilization review activities performed by a private review agent.

See https://mgaleg.maryland.gov/mgawebsite/laws/StatuteText?article=gin&section=15-10B-01&enactments=False&archived=False

Section 15–10B–05. Certificates — Additional Information

(a) In conjunction with the application, the private review agent shall submit information that the Commissioner requires including:

(1) a utilization review plan that includes:

(i) the specific criteria and standards to be used in conducting utilization review of proposed or delivered health care services;

(ii) those circumstances, if any, under which utilization review may be delegated to a hospital utilization review program; and

(iii) if applicable, any provisions by which patients or physicians, hospitals, or other health care providers may seek reconsideration;

(2) the type and qualifications of the personnel either employed or under contract to perform the utilization review;

(3) a copy of the private review agent’s internal grievance process if a carrier delegates its internal grievance process to the private review agent in accordance with § 15–10A–02(l) of this title;

(4) the procedures and policies to ensure that a representative of the private review agent is reasonably accessible to patients and health care providers 7 days a week, 24 hours a day in this State;

(5) if applicable, the procedures and policies to ensure that a representative of the private review agent is accessible to health care providers to make all determinations on whether to authorize or certify an emergency inpatient admission, or an admission for residential crisis services as defined in § 15–840 of this title, for the treatment of a mental, emotional, or substance abuse disorder within 2 hours after receipt of the information necessary to make the determination;

(6) the policies and procedures to ensure that all applicable State and federal laws to protect the confidentiality of individual medical records are followed;

(7) a copy of the materials designed to inform applicable patients and providers of the requirements of the utilization review plan;

(8) a list of the third party payors for which the private review agent is performing utilization review in this State;

(9) the policies and procedures to ensure that the private review agent has a formal program for the orientation and training of the personnel either employed or under contract to perform the utilization review;

(10) a list of the persons involved in establishing the specific criteria and standards to be used in conducting utilization review, including each person’s board certification or practice specialty, licensure category, and title within the person’s organization; and

U.R. Criteria

(11) certification by the private review agent that the criteria and standards to be used in conducting utilization review are generally recognized by health care providers practicing in the relevant clinical specialties and are:

(i) objective;

(ii) clinically valid;

(iii) reflected in published peer–reviewed scientific studies and medical literature;

(iv) developed by:

1. a nonprofit health care provider professional medical or clinical specialty society, including through the use of patient placement criteria and clinical practice guidelines; or

2. for criteria not within the scope of a nonprofit health care provider professional medical or clinical specialty society, an organization that works directly with health care providers in the same specialty for the designated criteria who are employed or engaged within the organization or outside the organization to develop the clinical criteria, if the organization:

A. does not receive direct payments based on the outcome of the utilization review; and

B. demonstrates that its clinical criteria are consistent with criteria and standards generally recognized by health care providers practicing in the relevant clinical specialties;

(v) recommended by federal agencies;

(vi) approved by the federal Food and Drug Administration as part of drug labeling;

(vii) taking into account the needs of atypical patient populations and diagnoses, including the unique needs of children and adolescents;

(viii) sufficiently flexible to allow deviations from norms when justified on a case–by–case basis, including the need to use an off–label prescription drug;

(ix) ensuring quality of care of health care services;

(x) reviewed, evaluated, and updated at least annually and as necessary to reflect any changes; and

(xi) in compliance with any other criteria and standards required for coverage under this title, including compliance with § 15–802(d) of this title for the treatment of substance use disorders.

(b) The private review agent shall:

(1) post on its website or the carrier’s website the specific criteria and standards to be used in conducting utilization review of proposed or delivered services and any subsequent revisions, modifications, or additions to the specific criteria and standards to be used in conducting utilization review of proposed or delivered services; and

(2) on the request of a person, including a health care facility, provide a copy of the information specified under item (1) of this subsection to the person making the request.

(c) The private review agent may charge a reasonable fee for a hard copy of the specific criteria and standards or any subsequent revisions, modifications, or additions to the specific criteria to any person or health care facility requesting a copy under subsection (b)(2) of this section.

(d) A private review agent shall advise the Commissioner, in writing, of a change in:

(1) ownership, medical director, or chief executive officer within 30 days of the date of the change;

(2) the name, address, or telephone number of the private review agent within 30 days of the date of the change; or

(3) the private review agent’s scope of responsibility under a contract.

See https://mgaleg.maryland.gov/mgawebsite/laws/StatuteText?article=gin&section=15-10B-05&enactments=False&archived=False

Section 15-10B-06.  Determinations by Private Review Agent

(a) (1) Except as otherwise provided in this subsection, a private review agent shall:

State Medical Necessity Decisions-Deadlines

(i) make all initial determinations on whether to authorize or certify a nonemergency course of treatment or health care service, including pharmaceutical services not submitted electronically, for a patient within 2 working days after receipt of the information necessary to make the determination;

(ii) make all determinations on whether to authorize or certify an extended stay in a health care facility or additional health care services within 1 working day after receipt of the information necessary to make the determination;

(iii) make all determinations to authorize or certify a request for additional visits or days of care submitted as part of an existing course of treatment or treatment plan within 1 working day after receipt of the information necessary to make the determination; and

(iv) promptly notify the health care provider of the determination.

(2) After receipt of the initial request for health care services and confirming through a complete review of information already submitted by the health care provider, if the private review agent determines that the private review agent does not have sufficient information to make a determination, the private review agent shall promptly, but not later than 3 calendar days after receipt of the initial request, inform the health care provider that additional information must be provided by specifying:

(i) the information, including any lab or diagnostic test or other medical information, that must be submitted to complete the request; and

(ii) the criteria and standards to support the need for additional information.

State Medical Necessity Decisions-Deadlines

(b) If a private review agent requires prior authorization for an emergency inpatient admission, or an admission for residential crisis services as defined in § 15–840 of this title, for the treatment of a mental, emotional, or substance abuse disorder, the private review agent shall:

(1) make all determinations on whether to authorize or certify an inpatient admission, or an admission for residential crisis services as defined in § 15–840 of this title, within 2 hours after receipt of the information necessary to make the determination;

(2) if additional information is needed, promptly request the specific information needed, including any lab or diagnostic test or other medical information; and

(3) promptly notify the health care provider of the determination.

(c) (1) For a step therapy exception request submitted electronically in accordance with a process established under § 15–142(f) of this title or a prior authorization request submitted electronically for pharmaceutical services, a private review agent shall make a determination:

(i) in real time if:

1. no additional information is needed by the private review agent to process the request; and

2. the request meets the private review agent’s criteria for approval; or

(ii) if a request is not approved in real time under item (i) of this paragraph, within 1 working day after the private review agent receives all of the information necessary to make the determination.

(2) If additional information is needed to make a determination after confirming through a complete review of the information already submitted by the health care provider, the private review agent shall request the information promptly, but not later than 3 calendar days after receipt of the initial request, by specifying:

(i) the information, including any lab or diagnostic test or other medical information, that must be submitted to complete the request; and

(ii) the criteria and standards to support the need for the additional information.

State Medical Necessity Decisions-Deadlines

(d) (1) (i) Except as provided in subsections (g) and (h) of this section, a private review agent shall make initial determinations on whether to authorize or certify an emergency course of treatment or health care service for a member within 24 hours after the initial request after receipt of the information necessary to make the determination.

(ii) If the private review agent determines that additional information is needed after confirming through a complete review of the information already submitted by the health care provider, the private review agent shall:

1. promptly request the specific information needed, including any lab or diagnostic test or other medical information; and

2. promptly, but not later than 2 hours after receipt of the information, notify the health care provider of an authorization or certification determination when made by the private review agent.

(2) A private review agent shall initiate the expedited procedure for an emergency case if the patient or the patient’s representative requests or if the health care provider attests that the services are necessary to treat a condition or illness that, without immediate medical attention, would:

(i) seriously jeopardize the life or health of the member or the member’s ability to regain maximum functions;

(ii) cause the member to be in danger to self or others; or

(iii) cause the member to continue using intoxicating substances in an imminently dangerous manner.

(e) If a private review agent fails to make a determination within the time limits required under this section, the request shall be deemed approved.

(f) (1) If an initial determination is made by a private review agent not to authorize or certify a health care service and the health care provider believes the determination warrants an immediate reconsideration, a private review agent shall provide the health care provider the opportunity to speak with the physician that rendered the determination, by telephone on an expedited basis, within a period of time not to exceed 24 hours of the health care provider seeking the reconsideration.

(2) If the physician is unable to immediately speak with the health care provider seeking the reconsideration, the physician shall provide the health care provider with the following contact information for the health care provider to use to contact the physician:

(i) a direct telephone number that is not the general customer call number; or

(ii) a monitored e–mail address that is dedicated to communication related to utilization review.

(g) For emergency inpatient admissions, a private review agent may not render an adverse decision solely because the hospital did not notify the private review agent of the emergency admission within 24 hours or other prescribed period of time after that admission if the patient’s medical condition prevented the hospital from determining:

(1) the patient’s insurance status; and

(2) if applicable, the private review agent’s emergency admission notification requirements.

(h) (1) Subject to paragraph (2) of this subsection, a private review agent may not render an adverse decision as to an admission of a patient during the first 24 hours after admission when:

(i) the admission is based on a determination that the patient is in imminent danger to self or others;

(ii) the determination has been made by the patient’s physician or psychologist in conjunction with a member of the medical staff of the facility who has privileges to make the admission; and

(iii) the hospital immediately notifies the private review agent of:

1. the admission of the patient; and

2. the reasons for the admission.

(2) A private review agent may not render an adverse decision as to an admission of a patient to a hospital for up to 72 hours, as determined to be medically necessary by the patient’s treating physician, when:

(i) the admission is an involuntary admission under §§ 10–615 and 10–617(a) of the Health – General Article; and

(ii) the hospital immediately notifies the private review agent of:

1. the admission of the patient; and

2. the reasons for the admission.

(i) (1) A private review agent that requires a health care provider to submit a treatment plan in order for the private review agent to conduct utilization review of proposed or delivered services for the treatment of a mental illness, emotional disorder, or a substance abuse disorder:

(i) shall accept:

1. the uniform treatment plan form adopted by the Commissioner under § 15–10B–03(d) of this subtitle as a properly submitted treatment plan form; or

2. if a service was provided in another state, a treatment plan form mandated by the state in which the service was provided; and

(ii) may not impose any requirement to:

1. modify the uniform treatment plan form or its content; or

2. submit additional treatment plan forms.

(2) A uniform treatment plan form submitted under the provisions of this subsection:

(i) shall be properly completed by the health care provider; and

(ii) may be submitted by electronic transfer.

See https://mgaleg.maryland.gov/mgawebsite/laws/StatuteText?article=gin&section=15-10B-06&enactments=False&archived=False

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;

U.R. Criteria

(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.

See https://mgaleg.maryland.gov/mgawebsite/laws/StatuteText?article=gin&section=15-10B-11&enactments=False&archived=False