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(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.
Cite this article: FindLaw.com - Maryland Code, Insurance § 15-10B-03 - last updated December 31, 2021 | https://codes.findlaw.com/md/insurance/md-code-insurance-sect-15-10b-03/
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