Maryland 2023 Regular Session

Maryland Senate Bill SB308 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1
2	2
3	3	EXPLANATION: CAPITALS INDICATE MAT TER ADDED TO EXISTIN G LAW.
4	4	[Brackets] indicate matter deleted from existing law.
5	5	sb0308
6	6
7	7	SENATE BILL 308
8	8	J5, J4, J1 3lr1125
9	9	CF HB 305
10	10	By: Senators Klausmeier and Hershey
11	11	Introduced and read first time: January 27, 2023
12	12	Assigned to: Finance
13	13
14	14	A BILL ENTITLED
15	15
16	16	AN ACT concerning 1
17	17
18	18	Health Insurance – Utilization Review – Revisions 2
19	19
20	20	FOR the purpose of altering and establishing requirements and prohibitions related to 3
21	21	health insurance utilization review, including provisions regarding benchmarks for 4
22	22	standardizing and automating the preauthorization process, the online 5
23	23	preauthorization system for payors, preauthorizations for prescription drugs, and 6
24	24	private review agents; altering timelines related to internal grievance procedures 7
25	25	and adverse decision procedures; increasing the penalties for violating certain 8
26	26	provisions of law regarding private review agents; requiring, rather than 9
27	27	authorizing, the Maryland Insurance Commissioner to establish certain reporting 10
28	28	requirements and requiring the Commissio ner to establish certain review 11
29	29	requirements related to private review agents; and generally relating to health 12
30	30	insurance and utilization review. 13
31	31
32	32	BY repealing and reenacting, with amendments, 14
33	33	Article – Health – General 15
34	34	Section 19–108.2 16
35	35	Annotated Code of Maryland 17
36	36	(2019 Replacement Volume and 2022 Supplement) 18
37	37
38	38	BY repealing and reenacting, without amendments, 19
39	39	Article – Insurance 20
40	40	Section 15–1A–14(a), 15–1001, and 15–10A–01(a) 21
41	41	Annotated Code of Maryland 22
42	42	(2017 Replacement Volume and 2022 Supplement) 23
43	43
44	44	BY repealing and reenacting, with amendments, 24
45	45	Article – Insurance 25
46	46	Section 15–1A–14(b), 15–854, 15–10A–01(k), 15–10A–02, 15–10A–06(a)(1)(vi), 26
47	47	15–10B–02, 15–10B–05 through 15–10B–07, 15–10B–11(8), 15–10B–12, and 27
48	48	15–10B–16 28 2 SENATE BILL 308
49	49
50	50
51	51	Annotated Code of Maryland 1
52	52	(2017 Replacement Volume and 2022 Supplement) 2
53	53
54	54	SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 3
55	55	That the Laws of Maryland read as follows: 4
56	56
57	57	Article – Health – General 5
58	58
59	59	19–108.2. 6
60	60
61	61	(a) (1) In this section the following words have the meanings indicated. 7
62	62
63	63	(2) ‘‘Health care service” has the meaning stated in § 15–10A–01 of the 8
64	64	Insurance Article. 9
65	65
66	66	(3) “Payor” means: 10
67	67
68	68	(i) An insurer or nonprofit health service plan that provides 11
69	69	hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis 12
70	70	under health insurance policies or contracts that are issued or delivered in the State; 13
71	71
72	72	(ii) A health maintenance organization that provides hospital, 14
73	73	medical, or surgical benefits to individuals or groups under contracts that are issued or 15
74	74	delivered in the State; or 16
75	75
76	76	(iii) A pharmacy benefits manager that is registered with the 17
77	77	Maryland Insurance Commissioner. 18
78	78
79	79	(4) “Provider” has the meaning stated in § 19–7A–01 of this title. 19
80	80
81	81	(5) “Step therapy or fail–first protocol” has the meaning stated in § 15–142 20
82	82	of the Insurance Article. 21
83	83
84	84	(b) In addition to the duties stated elsewhere in this subtitle, the Commission 22
85	85	shall work with payors and providers to attain benchmarks for: 23
86	86
87	87	(1) Standardizing and automating the process required by payors for 24
88	88	preauthorizing health care services; and 25
89	89
90	90	(2) Overriding a payor’s step therapy or fail–first protocol. 26
91	91
92	92	(c) The benchmarks described in subsection (b) of this section shall include: 27
93	93
94	94	(1) [On or before October 1, 2012 (“Phase 1”), e stablishment] 28
95	95	ESTABLISHMENT of online access for providers to each payor’s: 29
96	96
97	97	(i) List of health care services that require preauthorization; and 30 SENATE BILL 308 3
98	98
99	99
100	100
101	101	(ii) Key criteria for making a determination on a preauthorization 1
102	102	request, INCLUDING CRITERIA I NCLUDED IN A CERTIFICATE APP LICATION BY A 2
103	103	PRIVATE REVIEW AGENT AS REQUIRED UNDER § 15–10B–05(A) OF THE INSURANCE 3
104	104	ARTICLE; 4
105	105
106	106	(2) [On or before March 1, 2013 (“Phase 2”), establishment ] 5
107	107	ESTABLISHMENT by each payor of an online process for: 6
108	108
109	109	(i) Accepting electronically a preauthorization request from a 7
110	110	provider; and 8
111	111
112	112	(ii) Assigning to a preauthorization request a unique electronic 9
113	113	identification number that a provider may use to track the request during the 10
114	114	preauthorization process, whether or not the request is tracked electronically, through a 11
115	115	call center, or by fax; 12
116	116
117	117	(3) [On or before July 1, 2013 (“Phase 3”), establishment ] 13
118	118	ESTABLISHMENT by each payor of an online preauthorization system to approve: 14
119	119
120	120	(i) In real time, electronic preauthorization requests for 15
121	121	pharmaceutical services: 16
122	122
123	123	1. For which no additional information is needed by the 17
124	124	payor to process the preauthorization request; and 18
125	125
126	126	2. That meet the payor’s criteria for approval, INCLUDING 19
127	127	THE CRITERIA INCLUDE D IN A CERTIFICATE A PPLICATION BY A PRIVAT E REVIEW 20
128	128	AGENT AS REQUIRED UN DER § 15–10B–05 OF THE INSURANCE ARTICLE; 21
129	129
130	130	(ii) Within 1 [business] CALENDAR day after receiving all pertinent 22
131	131	information on requests not approved in real time, electronic preauthorization requests for 23
132	132	pharmaceutical services that: 24
133	133
134	134	1. Are not urgent; and 25
135	135
136	136	2. Do not meet the standards for real–time approval under 26
137	137	item (i) of this item; and 27
138	138
139	139	(iii) Within 2 [business] CALENDAR days after receiving all 28
140	140	pertinent information, electronic preauthorization requests for health care services, except 29
141	141	pharmaceutical services, that are not urgent; 30
142	142
143	143	(4) [On or before July 1, 2015, establishment] ESTABLISHMENT , by each 31
144	144	payor that requires a step therapy or fail–first protocol, of a process for a provider to 32
145	145	override the step therapy or fail–first protocol of the payor; and 33 4 SENATE BILL 308
146	146
147	147
148	148
149	149	(5) [On or before July 1, 2015, utilization] UTILIZATION by providers of: 1
150	150
151	151	(i) The online preauthorization system established by payors; or 2
152	152
153	153	(ii) If a national transaction standard has been established and 3
154	154	adopted by the health care industry, as determined by the Commission, the provider’s 4
155	155	practice management, electronic health record, or e–prescribing system. 5
156	156
157	157	(d) The benchmarks described in subsections (b) and (c) of this section do not 6
158	158	apply to preauthorizations of health care services requested by providers employed by a 7
159	159	group model health maintenance organization as defined in § 19–713.6 of this title. 8
160	160
161	161	(e) The online preauthorization system described in subsection (c)(3) of this 9
162	162	section shall: 10
163	163
164	164	(1) Provide real–time notice to providers about preauthorization requests 11
165	165	approved in real time; [and] 12
166	166
167	167	(2) Provide notice to providers, within the time frames specified in 13
168	168	subsection (c)(3)(ii) and (iii) of this section and in a manner that is able to be tracked by 14
169	169	providers, about preauthorization requests not approved in real time; AND 15
170	170
171	171	(3) COMPLY WITH ANY ADDIT IONAL UTILIZATION RE VIEW CRITERIA 16
172	172	REQUIRED UNDER TITLE 15, SUBTITLE 10 OF THE INSURANCE ARTICLE. 17
173	173
174	174	(f) (1) The Commission shall establish by regulation a process through which 18
175	175	a payor or provider may be waived from attaining the benchmarks described in subsections 19
176	176	(b) and (c) of this section for extenuating circumstances. 20
177	177
178	178	(2) For a provider, the extenuating circumstances may include: 21
179	179
180	180	(i) The lack of broadband Internet access; 22
181	181
182	182	(ii) Low patient volume; or 23
183	183
184	184	(iii) Not making medical referrals or prescribing pharmaceuticals. 24
185	185
186	186	(3) For a payor, the extenuating circumstances may include: 25
187	187
188	188	(i) Low premium volume; or 26
189	189
190	190	(ii) For a group model health maintenance organization, as defined 27
191	191	in § 19–713.6 of this title, preauthorizations of health care services requested by providers 28
192	192	not employed by the group model health maintenance organization. 29
193	193	SENATE BILL 308 5
194	194
195	195
196	196	(g) [(1) On or before October 1, 2012, the Commission shall reconvene the 1
197	197	multistakeholder workgroup whose collaboration resulted in the 2011 report 2
198	198	“Recommendations for Implementing Electronic Prior Authorizations”. 3
199	199
200	200	(2) The workgroup shall: 4
201	201
202	202	(i) Review the progress to date in attaining the benchmarks 5
203	203	described in subsections (b) and (c) of this section; and 6
204	204
205	205	(ii) Make recommendations to the Commission for adjustments to 7
206	206	the benchmark dates. 8
207	207
208	208	(h)] If necessary to attain the benchmarks, the Commission may adopt regulations 9
209	209	to: 10
210	210
211	211	(1) [Adjust the Phase 2 or Phase 3 benchmark dates; 11
212	212
213	213	(2)] Require payors and providers to comply with the benchmarks; and 12
214	214
215	215	[(3)] (2) Establish penalties for noncompliance. 13
216	216
217	217	Article – Insurance 14
218	218
219	219	15–1A–14. 15
220	220
221	221	(a) (1) In this section the following words have the meanings indicated. 16
222	222
223	223	(2) “Emergency medical condition” means a medical condition that 17
224	224	manifests itself by acute symptoms of such severity, including severe pain, that the absence 18
225	225	of immediate medical attention could reasonably be expected by a prudent layperson, who 19
226	226	possesses an average knowledge of health and medicine, to result in a condition described 20
227	227	in § 1867(e)(1) of the Social Security Act. 21
228	228
229	229	(3) “Emergency services” means, with respect to an emergency medical 22
230	230	condition: 23
231	231
232	232	(i) a medical screening examination that is within the capability of 24
233	233	the emergency department of a hospital or freestanding medical facility, including ancillary 25
234	234	services routinely available to the emergency department to evaluate an emergency 26
235	235	medical condition; or 27
236	236
237	237	(ii) any other examination or treatment within the capabilities of the 28
238	238	staff and facilities available at the hospital or freestanding medical facility that is necessary 29
239	239	to stabilize the patient. 30
240	240
241	241	(b) If a carrier provides or covers any benefits for emergency services in an 31
242	242	emergency department of a hospital or freestanding medical facility, the carrier: 32 6 SENATE BILL 308
243	243
244	244
245	245
246	246	(1) may not require an insured individual to obtain prior authorization for 1
247	247	the emergency services, INCLUDING HEALTH CAR E SERVICES PROVIDED 2
248	248	POSTEVALUATION OR PO STSTABILIZATION THAT ARE NECESSARY TO DIS CHARGE 3
249	249	THE PATIENT; and 4
250	250
251	251	(2) shall provide coverage for the emergency services regardless of whether 5
252	252	the health care provider providing the emergency services has a contractual relationship 6
253	253	with the carrier to furnish emergency services. 7
254	254
255	255	15–854. 8
256	256
257	257	(a) (1) This section applies to: 9
258	258
259	259	(i) insurers and nonprofit health service plans that provide coverage 10
260	260	for prescription drugs through a pharmacy benefit under individual, group, or blanket 11
261	261	health insurance policies or contracts that are issued or delivered in the State; and 12
262	262
263	263	(ii) health maintenance organizations that provide coverage for 13
264	264	prescription drugs through a pharmacy benefit under individual or group contracts that 14
265	265	are issued or delivered in the State. 15
266	266
267	267	(2) An insurer, a nonprofit health service plan, or a health maintenance 16
268	268	organization that provides coverage for prescription drugs through a pharmacy benefits 17
269	269	manager or that contracts with a private review agent under Subtitle 10B of this article is 18
270	270	subject to the requirements of this section. 19
271	271
272	272	(3) This section does not apply to a managed care organization as defined 20
273	273	in § 15–101 of the Health – General Article. 21
274	274
275	275	(b) [(1) (i) If an entity subject to this section requires a prior authorization 22
276	276	for a prescription drug, the prior authorization request shall allow a health care provider 23
277	277	to indicate whether a prescription drug is to be used to treat a chronic condition. 24
278	278
279	279	(ii) If a health care provider indicates that the prescription drug is 25
280	280	to treat a chronic condition, an entity subject to this section may not request a 26
281	281	reauthorization for a repeat prescription for the prescription drug for 1 year or for the 27
282	282	standard course of treatment for the chronic condition being treated, whichever is less. 28
283	283
284	284	(2)] For a prior authorization FOR A PRESCRIPTION D RUG that is filed 29
285	285	electronically, the entity shall maintain a database that will prepopulate prior 30
286	286	authorization requests with an insured’s available insurance and demographic 31
287	287	information. 32
288	288
289	289	(c) [If] IN ADDITION TO THE RE QUIREMENTS IN SUBTITLES 10A AND 10B 33
290	290	OF THIS TITLE, IF an entity subject to this section [denies] ISSUES AN ADVERSE 34 SENATE BILL 308 7
291	291
292	292
293	293	DECISION DENYING coverage for a prescription drug, the entity shall provide a detailed 1
294	294	written explanation for the denial of coverage, including whether the denial was based on 2
295	295	a requirement for prior authorization. 3
296	296
297	297	(d) (1) On receipt of information documenting a prior authorization from the 4
298	298	insured or from the insured’s health care provider, an entity subject to this section shall 5
299	299	honor a prior authorization granted to an insured from a previous entity for at least the 6
300	300	[initial 30] LESSER OF 90 days [of an insured’s prescription drug benefit coverage under 7
301	301	the health benefit plan of the new entity] OR THE LENGTH OF THE COURSE OF 8
302	302	TREATMENT . 9
303	303
304	304	(2) During the time period described in paragraph (1) of this subsection, an 10
305	305	entity may perform its own review to grant a prior authorization for the prescription drug. 11
306	306
307	307	(e) (1) An entity subject to this section shall honor a prior authorization issued 12
308	308	by the entity for a prescription drug: 13
309	309
310	310	(i) if the insured changes health benefit plans that are both covered 14
311	311	by the same entity and the prescription drug is a covered benefit under the current health 15
312	312	benefit plan; or 16
313	313
314	314	(ii) except as provided in paragraph (2) of this subsection, when the 17
315	315	dosage for the approved prescription drug changes and the change is consistent with federal 18
316	316	Food and Drug Administration labeled dosages. 19
317	317
318	318	(2) An entity may not be required to honor a prior authorization for a 20
319	319	change in dosage for an opioid under this subsection. 21
320	320
321	321	(F) AN ENTITY SUBJECT TO THIS SECTION MAY NOT REQUIRE A PRIOR 22
322	322	AUTHORIZATION FOR : 23
323	323
324	324	(1) A CHANGE IN DOSAGE O F A PRESCRIPTION DRU G BY A 24
325	325	PRESCRIBER IF THE EN TITY HAS ALREADY PREAUTHOR IZED THE USE OF THE 25
326	326	PRESCRIPTION DRUG FO R THE INSURED AND TH E DOSAGE CHANGE IS C ONSISTENT 26
327	327	WITH FEDERAL FOOD AND DRUG ADMINISTRATION LABELE D DOSAGES; 27
328	328
329	329	(2) A PRESCRIPTION DRUG THAT IS A GENERIC ; OR 28
330	330
331	331	(3) A PRESCRIPTION DRUG IF: 29
332	332
333	333	(I) THE INSURED RECEIVED AN INITIAL PRIOR AUT HORIZATION 30
334	334	FOR THE PRESCRIPTION DRUG; AND 31
335	335	8 SENATE BILL 308
336	336
337	337
338	338	(II) BASED ON THE PROFESS IONAL JUDGMENT OF TH E 1
339	339	PRESCRIBER, THE PRESCRIPTION DRU G IS EFFECTIVELY TRE ATING THE INSURED ’S 2
340	340	MEDICAL CONDITION . 3
341	341
342	342	(G) AN ENTITY SUBJECT TO THIS SECTION MAY NOT REQUIRE MORE THAN 4
343	343	ONE PRIOR AUTHORIZAT ION FOR A PRESCRIPTI ON DRUG WITH DIFFERE NT 5
344	344	FORMULATIONS THAT IS PRESCRIBED THROUGH T WO OR MORE PRESCRIPT IONS AT 6
345	345	THE SAME TIME AS PAR T OF AN INSURED’S TREATMENT PLAN . 7
346	346
347	347	[(f)] (H) If an entity under this section implements a new prior authorization 8
348	348	requirement for a prescription drug, the entity shall provide notice of the new requirement 9
349	349	at least 30 days before the implementation of a new prior authorization requirement: 10
350	350
351	351	(1) in writing to any insured who is prescribed the prescription drug; and 11
352	352
353	353	(2) either in writing or electronically to all contracted health care 12
354	354	providers. 13
355	355
356	356	15–1001. 14
357	357
358	358	(a) This section applies to entities that propose to issue or deliver individual, 15
359	359	group, or blanket health insurance policies or contracts in the State or to administer health 16
360	360	benefit programs that provide for the coverage of health care services and the utilization 17
361	361	review of those services, including: 18
362	362
363	363	(1) an authorized insurer that provides health insurance in the State; 19
364	364
365	365	(2) a nonprofit health service plan; 20
366	366
367	367	(3) a health maintenance organization; 21
368	368
369	369	(4) a dental plan organization; or 22
370	370
371	371	(5) except for a managed care organization as defined in Title 15, Subtitle 23
372	372	1 of the Health – General Article, any other person that provides health benefit plans 24
373	373	subject to regulation by the State. 25
374	374
375	375	(b) (1) Subject to paragraph (2) of this subsection, each entity subject to this 26
376	376	section shall: 27
377	377
378	378	(i) 1. have a certificate issued under Subtitle 10B of this title; or 28
379	379
380	380	2. contract with a private review agent that has a certificate 29
381	381	issued under Subtitle 10B of this title; and 30
382	382	SENATE BILL 308 9
383	383
384	384
385	385	(ii) when conducting utilization review for mental health and 1
386	386	substance use benefits, ensure that the criteria and standards used are in compliance with 2
387	387	the federal Mental Health Parity and Addiction Equity Act. 3
388	388
389	389	(2) For hospital services, each entity subject to this section may contract 4
390	390	with or delegate utilization review to a hospital utilization review program approved under 5
391	391	§ 19–319(d) of the Health – General Article. 6
392	392
393	393	(c) Notwithstanding any other provision of this article, if the medical necessity of 7
394	394	providing a covered benefit is disputed, an entity subject to this section that does not meet 8
395	395	the requirements of subsection (b) of this section shall pay any person entitled to 9
396	396	reimbursement under the policy or contract in accordance with the determination of 10
397	397	medical necessity by: 11
398	398
399	399	(1) the treating provider; or 12
400	400
401	401	(2) when hospital services are provided, the hospital utilization review 13
402	402	program approved under § 19–319(d) of the Health – General Article. 14
403	403
404	404	(d) An entity subject to this section may not: 15
405	405
406	406	(1) act as a private review agent without holding a certificate issued under 16
407	407	Subtitle 10B of this title; or 17
408	408
409	409	(2) use a private review agent that does not hold a certificate issued under 18
410	410	Subtitle 10B of this title. 19
411	411
412	412	(e) An entity that violates any provision of this section is subject to the penalties 20
413	413	provided under § 15–10B–12 of this title. 21
414	414
415	415	15–10A–01. 22
416	416
417	417	(a) In this subtitle the following words have the meanings indicated. 23
418	418
419	419	(k) “Health care service” means a health or medical care procedure or service 24
420	420	rendered by a health care provider that: 25
421	421
422	422	(1) provides testing, diagnosis, or treatment of a human disease or 26
423	423	dysfunction; [or] 27
424	424
425	425	(2) dispenses drugs, medical devices, medical appliances, or medical goods 28
426	426	for the treatment of a human disease or dysfunction; OR 29
427	427
428	428	(3) PROVIDES ANY OTHER C ARE, SERVICE, OR TREATMENT OF 30
429	429	DISEASE OR INJURY , THE CORRECTION OF DE FECTS, OR THE MAINTENANCE O F 31
430	430	PHYSICAL OR MENTAL WELL –BEING OF HUMAN BEING S. 32 10 SENATE BILL 308
431	431
432	432
433	433
434	434	15–10A–02. 1
435	435
436	436	(a) Each carrier shall establish an internal grievance process for its members. 2
437	437
438	438	(b) (1) An internal grievance process shall meet the same requirements 3
439	439	established under Subtitle 10B of this title. 4
440	440
441	441	(2) In addition to the requirements of Subtitle 10B of this title, an internal 5
442	442	grievance process established by a carrier under this section shall: 6
443	443
444	444	(i) include an expedited procedure for use in an emergency case for 7
445	445	purposes of rendering a grievance decision within 24 hours of the date a grievance is filed 8
446	446	with the carrier; 9
447	447
448	448	(ii) provide that a carrier render a final decision in writing on a 10
449	449	grievance within [30 working] 10 CALENDAR days after the date on which the grievance 11
450	450	is filed unless: 12
451	451
452	452	1. the grievance involves an emergency case under item (i) of 13
453	453	this paragraph; 14
454	454
455	455	2. the member, the member’s representative, or a health care 15
456	456	provider filing a grievance on behalf of a member agrees in writing to an extension for a 16
457	457	period of no longer than 30 working days; or 17
458	458
459	459	3. the grievance involves a retrospective denial under item 18
460	460	(iv) of this paragraph; 19
461	461
462	462	(iii) allow a grievance to be filed on behalf of a member by a health 20
463	463	care provider or the member’s representative; 21
464	464
465	465	(iv) provide that a carrier render a final decision in writing on a 22
466	466	grievance within [45 working] 30 CALENDAR days after the date on which the grievance 23
467	467	is filed when the grievance involves a retrospective denial; and 24
468	468
469	469	(v) for a retrospective denial, allow a member, the membe r’s 25
470	470	representative, or a health care provider on behalf of a member to file a grievance for at 26
471	471	least 180 days after the member receives an adverse decision. 27
472	472
473	473	(3) For purposes of using the expedited procedure for an emergency case 28
474	474	that a carrier is required to include under paragraph (2)(i) of this subsection, the 29
475	475	Commissioner shall define by regulation the standards required for a grievance to be 30
476	476	considered an emergency case. 31
477	477	SENATE BILL 308 11
478	478
479	479
480	480	(c) Except as provided in subsection (d) of this section, the carrier’s internal 1
481	481	grievance process shall be exhausted prior to filing a complaint with the Commissioner 2
482	482	under this subtitle. 3
483	483
484	484	(d) (1) (i) A member, the member’s representative, or a health care 4
485	485	provider filing a complaint on behalf of a member may file a complaint with the 5
486	486	Commissioner without first filing a grievance with a carrier and receiving a final decision 6
487	487	on the grievance if: 7
488	488
489	489	1. the carrier waives the requirement that the carrier’s 8
490	490	internal grievance process be exhausted before filing a complaint with the Commissioner; 9
491	491
492	492	2. the carrier has failed to comply with any of the 10
493	493	requirements of the internal grievance process as described in this section; or 11
494	494
495	495	3. the member, the member’s representative, or the health 12
496	496	care provider provides sufficient information and supporting documentation in the 13
497	497	complaint that demonstrates a compelling reason to do so. 14
498	498
499	499	(ii) The Commissioner shall define by regulation the standards that 15
500	500	the Commissioner shall use to decide what demonstrates a compelling reason under 16
501	501	subparagraph (i) of this paragraph. 17
502	502
503	503	(2) Subject to subsections (b)(2)(ii) and (h) of this section, a member, a 18
504	504	member’s representative, or a health care provider may file a complaint with the 19
505	505	Commissioner if the member, the member’s representative, or the health care provider does 20
506	506	not receive a grievance decision from the carrier on or before the [30th working] 10TH 21
507	507	CALENDAR day on which the grievance is filed. 22
508	508
509	509	(3) Whenever the Commissioner receives a complaint under paragraph (1) 23
510	510	or (2) of this subsection, the Commissioner shall notify the carrier that is the subject of the 24
511	511	complaint within 5 working days after the date the complaint is filed with the 25
512	512	Commissioner. 26
513	513
514	514	(e) Each carrier shall: 27
515	515
516	516	(1) file for review with the Commissioner and submit to the Health 28
517	517	Advocacy Unit a copy of its internal grievance process established under this subtitle; and 29
518	518
519	519	(2) file any revision to the internal grievance process with the 30
520	520	Commissioner and the Health Advocacy Unit at least 30 days before its intended use. 31
521	521
522	522	(f) For nonemergency cases, when a carrier renders an adverse decision, the 32
523	523	carrier shall: 33
524	524
525	525	(1) AFTER COMPLYING WITH § 15–10B–07(A) OF THIS TITLE, document 34
526	526	the adverse decision in writing [after the carrier has provided] AND PROVIDE oral 35 12 SENATE BILL 308
527	527
528	528
529	529	communication of the decision to the member, the member’s representative, or the health 1
530	530	care provider acting on behalf of the member; and 2
531	531
532	532	(2) send, within [5 working] 2 CALENDAR days after the adverse decision 3
533	533	has been made, a written notice to the member, the member’s representative, and a health 4
534	534	care provider acting on behalf of the member that: 5
535	535
536	536	(i) states in detail in clear, understandable language the specific 6
537	537	factual bases for the carrier’s decision; 7
538	538
539	539	(ii) references the specific criteria and standards, including 8
540	540	interpretive guidelines, on which the decision was based, and may not solely use 9
541	541	generalized terms such as “experimental procedure not covered”, “cosmetic procedure not 10
542	542	covered”, “service included under another procedure”, or “not medically necessary”; 11
543	543
544	544	(iii) states the name, business address, and business telephone 12
545	545	number of: 13
546	546
547	547	1. the medical director or associate medical director, as 14
548	548	appropriate, who made the decision if the carrier is a health maintenance organization; or 15
549	549
550	550	2. the designated employee or representative of the carrier 16
551	551	who has responsibility for the carrier’s internal grievance process if the carrier is not a 17
552	552	health maintenance organization; 18
553	553
554	554	(iv) gives written details of the carrier’s internal grievance process 19
555	555	and procedures under this subtitle; and 20
556	556
557	557	(v) includes the following information: 21
558	558
559	559	1. that the member, the member’s representative, or a health 22
560	560	care provider on behalf of the member has a right to file a complaint with the Commissioner 23
561	561	within 4 months after receipt of a carrier’s grievance decision; 24
562	562
563	563	2. that a complaint may be filed without first filing a 25
564	564	grievance if the member, the member’s representative, or a health care provider filing a 26
565	565	grievance on behalf of the member can demonstrate a compelling reason to do so as 27
566	566	determined by the Commissioner; 28
567	567
568	568	3. the Commissioner’s address, telephone number, and 29
569	569	facsimile number; 30
570	570
571	571	4. a statement that the Health Advocacy Unit is available to 31
572	572	assist the member or the member’s representative in both mediating and filing a grievance 32
573	573	under the carrier’s internal grievance process; and 33
574	574	SENATE BILL 308 13
575	575
576	576
577	577	5. the address, telephone number, facsimile number, and 1
578	578	electronic mail address of the Health Advocacy Unit. 2
579	579
580	580	(g) If within [5 working] 3 CALENDAR days after a member, the member’s 3
581	581	representative, or a health care provider, who has filed a grievance on behalf of a member, 4
582	582	files a grievance with the carrier, and if the carrier does not have sufficient information to 5
583	583	complete its internal grievance process, the carrier shall: 6
584	584
585	585	(1) notify the member, the member’s representative, or the health care 7
586	586	provider that it cannot proceed with reviewing the grievance unless additional information 8
587	587	is provided AND SPECIFY: 9
588	588
589	589	1. THE ADDITIONAL INFOR MATION THAT MUST BE 10
590	590	PROVIDED TO COMPLETE THE INTERNAL GRIEVANCE PRO CESS; AND 11
591	591
592	592	2. THE CRITERIA AND STA NDARDS TO SUPPORT TH E 12
593	593	NEED FOR THE ADDITIO NAL INFORMATION ; and 13
594	594
595	595	(2) assist the member, the member’s representative, or the health care 14
596	596	provider in gathering the necessary information without further delay. 15
597	597
598	598	(h) A carrier may extend the [30–day] 10–DAY or [45–day] 30–DAY period 16
599	599	required for making a final grievance decision under subsection (b)(2)(ii) of this section with 17
600	600	the written consent of the member, the member’s representative, or the health care 18
601	601	provider who filed the grievance on behalf of the member. 19
602	602
603	603	(i) (1) For nonemergency cases, when a carrier renders a grievance decision, 20
604	604	the carrier shall: 21
605	605
606	606	(i) document the grievance decision in writing after the carrier has 22
607	607	provided oral communication of the decision to the member, the member’s representative, 23
608	608	or the health care provider acting on behalf of the member; and 24
609	609
610	610	(ii) send, within [5 working] 3 CALENDAR days after the grievance 25
611	611	decision has been made, a written notice to the member, the member’s representative, and 26
612	612	a health care provider acting on behalf of the member that: 27
613	613
614	614	1. states in detail in clear, understandable language the 28
615	615	specific factual bases for the carrier’s decision; 29
616	616
617	617	2. references the specific criteria and standards, including 30
618	618	interpretive guidelines, on which the grievance decision was based; 31
619	619
620	620	3. states the name, business address, and business telephone 32
621	621	number of: 33
622	622	14 SENATE BILL 308
623	623
624	624
625	625	A. the medical director or associate medical director, as 1
626	626	appropriate, who made the grievance decision if the carrier is a health maintenance 2
627	627	organization; or 3
628	628
629	629	B. the designated employee or representative of the carrier 4
630	630	who has responsibility for the carrier’s internal grievance process if the carrier is not a 5
631	631	health maintenance organization; and 6
632	632
633	633	4. includes the following information: 7
634	634
635	635	A. that the member or the member’s representative has a 8
636	636	right to file a complaint with the Commissioner within 4 months after receipt of a carrier’s 9
637	637	grievance decision; 10
638	638
639	639	B. the Commissioner’s address, telephone number, and 11
640	640	facsimile number; 12
641	641
642	642	C. a statement that the Health Advocacy Unit is available to 13
643	643	assist the member or the member’s representative in filing a complaint with the 14
644	644	Commissioner; and 15
645	645
646	646	D. the address, telephone number, facsimile number, and 16
647	647	electronic mail address of the Health Advocacy Unit. 17
648	648
649	649	(2) A carrier may not use solely in a notice sent under paragraph (1) of this 18
650	650	subsection generalized terms such as “experimental procedure not covered”, “cosmetic 19
651	651	procedure not covered”, “service included under another procedure”, or “not medically 20
652	652	necessary” to satisfy the requirements of this subsection. 21
653	653
654	654	(j) (1) For an emergency case under subsection (b)(2)(i) of this section, AFTER 22
655	655	THE CARRIER HAS COMP LIED WITH § 15–10B–07(A) OF THIS TITLE AND within 1 23
656	656	CALENDAR day after a decision has been orally communicated to the member, the 24
657	657	member’s representative, or the health care provider, the carrier shall send notice in 25
658	658	writing of any adverse decision or grievance decision to: 26
659	659
660	660	(i) the member and the member’s representative, if any; and 27
661	661
662	662	(ii) if the grievance was filed on behalf of the member under 28
663	663	subsection (b)(2)(iii) of this section, the health care provider. 29
664	664
665	665	(2) A notice required to be sent under paragraph (1) of this subsection shall 30
666	666	include the following: 31
667	667
668	668	(i) for an adverse decision, the information required under 32
669	669	subsection (f) of this section; and 33
670	670	SENATE BILL 308 15
671	671
672	672
673	673	(ii) for a grievance decision, the information required under 1
674	674	subsection (i) of this section. 2
675	675
676	676	(k) (1) Each carrier shall include the information required by subsection 3
677	677	(f)(2)(iii), (iv), and (v) of this section in the policy, plan, certificate, enrollment materials, or 4
678	678	other evidence of coverage that the carrier provides to a member at the time of the member’s 5
679	679	initial coverage or renewal of coverage. 6
680	680
681	681	(2) Each carrier shall include as part of the information required by 7
682	682	paragraph (1) of this subsection a statement indicating that, when filing a complaint with 8
683	683	the Commissioner, the member or the member’s representative will be required to 9
684	684	authorize the release of any medical records of the member that may be required to be 10
685	685	reviewed for the purpose of reaching a decision on the complaint. 11
686	686
687	687	(l) (1) Nothing in this subtitle prohibits a carrier from delegating its internal 12
688	688	grievance process to a private review agent that has a certificate issued under Subtitle 10B 13
689	689	of this title and is acting on behalf of the carrier. 14
690	690
691	691	(2) If a carrier delegates its internal grievance process to a private review 15
692	692	agent, the carrier shall be: 16
693	693
694	694	(i) bound by the grievance decision made by the private review 17
695	695	agent acting on behalf of the carrier; and 18
696	696
697	697	(ii) responsible for a violation of any provision of this subtitle 19
698	698	regardless of the delegation made by the carrier under paragraph (1) of this subsection. 20
699	699
700	700	15–10A–06. 21
701	701
702	702	(a) On a quarterly basis, each carrier shall submit to the Commissioner, on the 22
703	703	form the Commissioner requires, a report that describes: 23
704	704
705	705	(1) the activities of the carrier under this subtitle, including: 24
706	706
707	707	(vi) 1. the number of adverse decisions issued by the carrier 25
708	708	under § 15–10A–02(f) of this subtitle [and]; 26
709	709
710	710	2. the type of service AND THE HEALTH CARE SPECIALTY 27
711	711	at issue in the adverse decisions; AND 28
712	712
713	713	3. THE UTILIZATION MANA GEMENT TECHNIQUE USE D BY 29
714	714	THE CARRIER IN ISSUI NG THE ADVERSE DECIS IONS; and 30
715	715
716	716	15–10B–02. 31
717	717
718	718	The purpose of this subtitle is to: 32 16 SENATE BILL 308
719	719
720	720
721	721
722	722	(1) promote the delivery of quality health care in a cost effective manner 1
723	723	THAT ENSURES TIMELY ACCESS TO HEALTH CAR E SERVICES; 2
724	724
725	725	(2) foster greater coordination, COMMUNICATION , AND TRANSPARENCY 3
726	726	between payors and providers conducting utilization review activities; 4
727	727
728	728	(3) protect patients, business, and providers by ensuring that private 5
729	729	review agents are qualified to perform utilization review activities and to make informed 6
730	730	decisions on the appropriateness of medical care; and 7
731	731
732	732	(4) ensure that private review agents maintain the confidentiality of 8
733	733	medical records in accordance with applicable State and federal laws. 9
734	734
735	735	15–10B–05. 10
736	736
737	737	(a) In conjunction with the application, the private review agent shall submit 11
738	738	information that the Commissioner requires including: 12
739	739
740	740	(1) a utilization review plan that includes: 13
741	741
742	742	(i) the specific criteria and standards to be used in conducting 14
743	743	utilization review of proposed or delivered health care services IN ACCORDANCE WITH 15
744	744	ITEM (11) OF THIS SUBSECTION ; 16
745	745
746	746	(ii) those circumstances, if any, under which utilization review may 17
747	747	be delegated to a hospital utilization review program; and 18
748	748
749	749	(iii) if applicable, any provisions by which patients, physicians, or 19
750	750	hospitals may seek reconsideration; 20
751	751
752	752	(2) the type and qualifications of the personnel either employed or under 21
753	753	contract to perform the utilization review; 22
754	754
755	755	(3) a copy of the private review agent’s internal grievance process if a 23
756	756	carrier delegates its internal grievance process to the private review agent in accordance 24
757	757	with § 15–10A–02(l) of this title; 25
758	758
759	759	(4) the procedures and policies to ensure: 26
760	760
761	761	(I) that a representative of the private review agent is reasonably 27
762	762	accessible to patients and health care providers 7 days a week, 24 hours a day in this State; 28
763	763	AND 29
764	764
765	765	(II) COMPLIANCE WITH § 15–10B–07 OF THIS SUBTITLE ; 30
766	766	SENATE BILL 308 17
767	767
768	768
769	769	(5) if applicable, the procedures and policies to ensure that a representative 1
770	770	of the private review agent is accessible to health care providers to make all determinations 2
771	771	on whether to authorize or certify an emergency inpatient admission, or an admission for 3
772	772	residential crisis services as defined in § 15–840 of this title, for the treatment of a mental, 4
773	773	emotional, or substance abuse disorder within 2 hours after receipt of the information 5
774	774	necessary to make the determination; 6
775	775
776	776	(6) the policies and procedures to ensure that all applicable State and 7
777	777	federal laws to protect the confidentiality of individual medical records are followed; 8
778	778
779	779	(7) a copy of the materials designed to inform applicable patients and 9
780	780	providers of the requirements of the utilization review plan; 10
781	781
782	782	(8) a list of the third party payors for which the private review agent is 11
783	783	performing utilization review in this State; 12
784	784
785	785	(9) the policies and procedures to ensure that the private review agent has 13
786	786	a formal program for the orientation and training of the personnel either employed or under 14
787	787	contract to perform the utilization review; 15
788	788
789	789	(10) a list of the persons AND THEIR QUALIFICAT IONS, INCLUDING ANY 16
790	790	CERTIFICATIONS AND C LINICAL SPECIALTIES , involved in establishing the specific 17
791	791	criteria and standards to be used in conducting utilization review; and 18
792	792
793	793	(11) certification by the private review agent that the criteria and standards 19
794	794	to be used in conducting utilization review [are]: 20
795	795
796	796	[(i) objective; 21
797	797
798	798	(ii) clinically valid; 22
799	799
800	800	(iii) compatible with established principles of health care; and 23
801	801
802	802	(iv) flexible enough to allow deviations from norms when justified on 24
803	803	a case by case basis] 25
804	804
805	805	(I) ARE EVIDENCE –BASED, PEER–REVIEWED, AND DEVELOPED 26
806	806	BY: 27
807	807
808	808	1. AN ORGANIZATION THAT WORKS DIRECTLY WITH 28
809	809	HEALTH CARE PROVIDERS IN THE SAME SPECIALT Y FOR THE DESIGNATED CRITERIA 29
810	810	WHO ARE EMPLOYED OR ENGAGED WITHIN THE O RGANIZATION OR OUTSI DE THE 30
811	811	ORGANIZATION TO DEVE LOP THE CLINICAL CRI TERIA, PROVIDED THAT THE 31
812	812	ORGANIZATION DOES NO T RECEIVE DIRECT PAY MENTS BASED O N THE OUTCOME OR 32
813	813	PRIOR AUTHORIZATION DECISIONS; OR 33
814	814	18 SENATE BILL 308
815	815
816	816
817	817	2. A PROFESSIONAL MEDIC AL SPECIALTY SOCIETY ; AND 1
818	818
819	819	(II) SHALL: 2
820	820
821	821	1. TAKE INTO ACCOUNT TH E NEEDS OF ATYPICAL 3
822	822	PATIENT POPULATIONS AND DIAGNOSES ; 4
823	823
824	824	2. ENSURE QUALITY OF CA RE AND ACCESS TO NEE DED 5
825	825	HEALTH CARE SERVICES ; 6
826	826
827	827	3. BE SUFFICIENTLY FLEX IBLE TO ALLOW DEVIAT IONS 7
828	828	FROM NORMS WHEN JUST IFIED ON A CASE–BY–CASE BASIS; AND 8
829	829
830	830	4. BE EVALUATED AT LEAS T ANNUALLY AND UPDAT ED 9
831	831	AS NECESSARY . 10
832	832
833	833	(b) (1) [On the written request of any person or health care facility, the] THE 11
834	834	private review agent shall [provide 1 copy of] POST the specific criteria and standards to 12
835	835	be used in conducting utilization review of proposed or delivered services and any 13
836	836	subsequent revisions, modifications, or additions to the specific criteria and standards to 14
837	837	be used in conducting utilization review of proposed or delivered services [to the person or 15
838	838	health care facility making the request] IN ACCORDANCE WITH § 19–108.2(C)(1) OF THE 16
839	839	HEALTH – GENERAL ARTICLE. 17
840	840
841	841	(2) THE INFORMATION POSTED IN ACCORDANCE WITH PARAGRAPH 18
842	842	(1) OF THIS SUBSECTION S HALL INCLUDE THE INF ORMATION REQUIRED UN DER 19
843	843	SUBSECTION (A)(10) OF THIS SECTION. 20
844	844
845	845	(c) [The private review agent may charge a reasonable fee for a copy of the specific 21
846	846	criteria and standards or any subsequent revisions, modifications, or additions to the 22
847	847	specific criteria to any person or health care facility requesting a copy under subsection (b) 23
848	848	of this section. 24
849	849
850	850	(d)] A private review agent shall advise the Commissioner, in writing, of a change 25
851	851	in: 26
852	852
853	853	(1) ownership, medical director, or chief executive officer within 30 days of 27
854	854	the date of the change; 28
855	855
856	856	(2) the name, address, or telephone number of the private review agent 29
857	857	within 30 days of the date of the change; or 30
858	858
859	859	(3) the private review agent’s scope of responsibility under a contract. 31
860	860
861	861	15–10B–06. 32 SENATE BILL 308 19
862	862
863	863
864	864
865	865	(a) (1) [A] EXCEPT AS PROVIDED IN § 19–108.2 OF THE HEALTH – 1
866	866	GENERAL ARTICLE, A private review agent shall: 2
867	867
868	868	(i) make all initial determinations on whether to authorize or certify 3
869	869	a nonemergency course of treatment for a patient within 2 [working] CALENDAR days after 4
870	870	receipt of the information necessary to make the determination; 5
871	871
872	872	(ii) make all determinations on whether to authorize or certify an 6
873	873	extended stay in a health care facility or additional health care services within 1 [working] 7
874	874	CALENDAR day after receipt of the information necessary to make the determination; and 8
875	875
876	876	(iii) promptly notify the health care provider of the determination. 9
877	877
878	878	(2) If within [3] 2 calendar days after receipt of the initial request for 10
879	879	health care services the private review agent does not have sufficient information to make 11
880	880	a determination, the private review agent shall [inform] SPECIFY TO the health care 12
881	881	provider [that]: 13
882	882
883	883	(I) THE additional information THAT must be provided TO MAKE 14
884	884	THE DETERMINATION ; AND 15
885	885
886	886	(II) THE CRITERIA AND STA NDARDS TO SUPPORT TH E NEED FOR 16
887	887	THE ADDITIONAL INFOR MATION. 17
888	888
889	889	(3) If a private review agent requires prior authorization for an emergency 18
890	890	inpatient admission, or an admission for residential crisis services as defined in § 15–840 19
891	891	of this title, for the treatment of a mental, emotional, or substance abuse disorder, the 20
892	892	private review agent shall: 21
893	893
894	894	(i) make all determinations on whether to authorize or certify an 22
895	895	inpatient admission, or an admission for residential crisis services as defined in § 15–840 23
896	896	of this title, within 2 hours after receipt of the information necessary to make the 24
897	897	determination; and 25
898	898
899	899	(ii) promptly notify the health care provider of the determination. 26
900	900
901	901	[(b) If an initial determination is made by a private review agent not to authorize 27
902	902	or certify a health care service and the health care provider believes the determination 28
903	903	warrants an immediate reconsideration, a private review agent may provide the health 29
904	904	care provider the opportunity to speak with the physician that rendered the determination, 30
905	905	by telephone on an expedited basis, within a period of time not to exceed 24 hours of the 31
906	906	health care provider seeking the reconsideration.] 32
907	907	20 SENATE BILL 308
908	908
909	909
910	910	(B) BEFORE ISSUING AN ADVERSE DECISION, A PRIVATE REVIEW AGE NT 1
911	911	SHALL GIVE THE PATIE NT’S TREATING PHYSICIAN , DENTIST, OR OTHER HEALTH 2
912	912	CARE PRACTITIONER TH E OPPORTUNITY TO SPE AK ABOUT THE MEDICAL NECESSITY 3
913	913	OF THE TREATMENT REQ UEST WITH THE PHYSIC IAN, DENTIST, OR PANE L 4
914	914	RESPONSIBLE FOR THE ADVERSE DECISION . 5
915	915
916	916	(c) For emergency inpatient admissions, a private review agent may not render 6
917	917	an adverse decision solely because the hospital did not notify the private review agent of 7
918	918	the emergency admission within 24 hours or other prescribed period of time after that 8
919	919	admission if the patient’s medical condition prevented the hospital from determining: 9
920	920
921	921	(1) the patient’s insurance status; and 10
922	922
923	923	(2) if applicable, the private review agent’s emergency admission 11
924	924	notification requirements. 12
925	925
926	926	(d) (1) Subject to paragraph (2) of this subsection, a private review agent may 13
927	927	not render an adverse decision as to an admission of a patient during the first 24 hours 14
928	928	after admission when: 15
929	929
930	930	(i) the admission is based on a determination that the patient is in 16
931	931	imminent danger to self or others; 17
932	932
933	933	(ii) the determination has been made by the patient’s physician or 18
934	934	psychologist in conjunction with a member of the medical staff of the facility who has 19
935	935	privileges to make the admission; and 20
936	936
937	937	(iii) the hospital immediately notifies the private review agent of: 21
938	938
939	939	1. the admission of the patient; and 22
940	940
941	941	2. the reasons for the admission. 23
942	942
943	943	(2) A private review agent may not render an adverse decision as to an 24
944	944	admission of a patient to a hospital for up to 72 hours, as determined to be medically 25
945	945	necessary by the patient’s treating physician, when: 26
946	946
947	947	(i) the admission is an involuntary admission under §§ 10–615 and 27
948	948	10–617(a) of the Health – General Article; and 28
949	949
950	950	(ii) the hospital immediately notifies the private review agent of: 29
951	951
952	952	1. the admission of the patient; and 30
953	953
954	954	2. the reasons for the admission. 31
955	955	SENATE BILL 308 21
956	956
957	957
958	958	(e) (1) A private review agent that requires a health care provider to submit a 1
959	959	treatment plan in order for the private review agent to conduct utilization review of 2
960	960	proposed or delivered services for the treatment of a mental illness, emotional disorder, or 3
961	961	a substance abuse disorder: 4
962	962
963	963	(i) shall accept: 5
964	964
965	965	1. the uniform treatment plan form adopted by the 6
966	966	Commissioner under § 15–10B–03(d) of this subtitle as a properly submitted treatment 7
967	967	plan form; or 8
968	968
969	969	2. if a service was provided in another state, a treatment plan 9
970	970	form mandated by the state in which the service was provided; and 10
971	971
972	972	(ii) may not impose any requirement to: 11
973	973
974	974	1. modify the uniform treatment plan form or its content; or 12
975	975
976	976	2. submit additional treatment plan forms. 13
977	977
978	978	(2) A uniform treatment plan form submitted under the provisions of this 14
979	979	subsection: 15
980	980
981	981	(i) shall be properly completed by the health care provider; and 16
982	982
983	983	(ii) may be submitted by electronic transfer. 17
984	984
985	985	15–10B–07. 18
986	986
987	987	(a) (1) (I) Except as provided in [paragraphs (2) and (3) ] 19
988	988	SUBPARAGRAPHS (II) AND (III) of this [subsection] PARAGRAPH , all adverse decisions 20
989	989	shall be made by a physician, or a panel of other appropriate health care service reviewers 21
990	990	with at least one physician on the panel who is: 22
991	991
992	992	1. board certified or eligible in the same specialty as the 23
993	993	treatment under review; AND 24
994	994
995	995	2. KNOWLEDGEABLE OF AND HAS EXPERIENCE IN TH E 25
996	996	DIAGNOSIS AND TREATM ENT UNDER REVIEW . 26
997	997
998	998	[(2)] (II) When the health care service under review is a mental health or 27
999	999	substance abuse service, the adverse decision shall be made by a physician, or a panel of 28
1000	1000	other appropriate health care service reviewers with at least one physician, selected by the 29
1001	1001	private review agent who IS: 30
1002	1002	22 SENATE BILL 308
1003	1003
1004	1004
1005	1005	[(i)] 1. [is] board certified or eligible in the same specialty as the 1
1006	1006	treatment under review; or 2
1007	1007
1008	1008	[(ii)] 2. [is] actively practicing or has demonstrated expertise in 3
1009	1009	the substance abuse or mental health service or treatment under review. 4
1010	1010
1011	1011	[(3)] (III) When the health care service under review is a dental service, 5
1012	1012	the adverse decision shall be made by a licensed dentist, or a panel of other appropriate 6
1013	1013	health care service reviewers with at least one licensed dentist on the panel. 7
1014	1014
1015	1015	(2) A PHYSICIAN OR DENTIST WHO MAKES AN ADVERSE DECISION OR 8
1016	1016	PARTICIPATES ON THE PANEL THAT MAKES AN ADVERSE DECISION IN ACCORDANCE 9
1017	1017	WITH PARAGRAPH (1) OF THIS SUBSECTION S HALL HOLD A CURRENT , VALID, AND 10
1018	1018	UNRESTRICTED LICENSE TO PRACTICE MEDICINE OR DENTISTRY IN THE STATE. 11
1019	1019
1020	1020	(b) All adverse decisions shall be made by a physician or a panel of other 12
1021	1021	appropriate health care service reviewers who are not compensated by the private review 13
1022	1022	agent in a manner that violates § 19–705.1 of the Health – General Article or that deters 14
1023	1023	the delivery of medically appropriate care. 15
1024	1024
1025	1025	(c) Except as provided in subsection (d) of this section, if a course of treatment 16
1026	1026	has been preauthorized or approved for a patient, a private review agent may not 17
1027	1027	retrospectively render an adverse decision regarding the preauthorized or approved 18
1028	1028	services delivered to that patient. 19
1029	1029
1030	1030	(d) A private review agent may retrospectively render an adverse decision 20
1031	1031	regarding preauthorized or approved services delivered to a patient if: 21
1032	1032
1033	1033	(1) the information submitted to the private review agent regarding the 22
1034	1034	services to be delivered to the patient was fraudulent or intentionally misrepresentative; 23
1035	1035
1036	1036	(2) critical information requested by the private review agent regarding 24
1037	1037	services to be delivered to the patient was omitted such that the private review agent’s 25
1038	1038	determination would have been different had the agent known the critical information; or 26
1039	1039
1040	1040	(3) the planned course of treatment for the patient that was approved by 27
1041	1041	the private review agent was not substantially followed by the provider. 28
1042	1042
1043	1043	(e) If a course of treatment has been preauthorized or approved for a patient, a 29
1044	1044	private review agent may not revise or modify the specific criteria or standards used for the 30
1045	1045	utilization review to make an adverse decision regarding the services delivered to that 31
1046	1046	patient. 32
1047	1047
1048	1048	15–10B–11. 33
1049	1049
1050	1050	A private review agent may not: 34 SENATE BILL 308 23
1051	1051
1052	1052
1053	1053
1054	1054	(8) use criteria and standards to conduct utilization review [unless the 1
1055	1055	criteria and standards used by the private review agent are: 2
1056	1056
1057	1057	(i) objective; 3
1058	1058
1059	1059	(ii) clinically valid; 4
1060	1060
1061	1061	(iii) compatible with established principles of health care; or 5
1062	1062
1063	1063	(iv) flexible enough to allow deviations from norms when justified on 6
1064	1064	a case–by–case basis] THAT DO NOT CONFORM TO INFOR MATION SUBMITTED WIT H 7
1065	1065	THE CERTIFICATE APPL ICATION OF THE PRIVA TE REVIEW AGENT AS R EQUIRED 8
1066	1066	UNDER § 15–10B–05 OF THIS SUBTITLE ; or 9
1067	1067
1068	1068	15–10B–12. 10
1069	1069
1070	1070	(a) (1) A person who violates any provision of § 15–10B–11 of this subtitle is 11
1071	1071	guilty of a misdemeanor and on conviction is subject to a penalty not exceeding [$1,000] 12
1072	1072	$5,000. 13
1073	1073
1074	1074	(2) Each day a violation is continued after the first conviction is a separate 14
1075	1075	offense. 15
1076	1076
1077	1077	(b) In addition to the provisions of subsection (a) of this section, if any person 16
1078	1078	violates any provision of § 15–10B–11 of this subtitle, the Commissioner may: 17
1079	1079
1080	1080	(1) deny, suspend, or revoke the certificate to do business as a private 18
1081	1081	review agent; 19
1082	1082
1083	1083	(2) issue an order to cease and desist from acting as a private review agent 20
1084	1084	without holding a certificate issued under this subtitle; 21
1085	1085
1086	1086	(3) require a private review agent to make restitution to a patient who has 22
1087	1087	suffered actual economic damage because of the violation; and 23
1088	1088
1089	1089	(4) impose an administrative penalty of up to [$5,000] $10,000 for each 24
1090	1090	violation of any provision of this subtitle. 25
1091	1091
1092	1092	15–10B–16. 26
1093	1093
1094	1094	The Commissioner [may] SHALL establish reporting AND REVIEW requirements to: 27
1095	1095
1096	1096	(1) evaluate the effectiveness of private review agents; and 28
1097	1097	24 SENATE BILL 308
1098	1098
1099	1099
1100	1100	(2) determine if the utilization review programs are in compliance with the 1
1101	1101	provisions of this section and applicable regulations. 2
1102	1102
1103	1103	SECTION 2. AND BE IT FURTHER ENACTED, That the Maryland Health Care 3
1104	1104	Commission shall: 4
1105	1105
1106	1106	(1) in consultation with health care practitioners, payors of health care 5
1107	1107	services, and the State–designated health information exchange, develop findings and 6
1108	1108	recommendations for: 7
1109	1109
1110	1110	(i) revising the electronic process required under § 19–108.2 of the 8
1111	1111	Health – General Article, as enacted by Section 1 of this Act, for health care services to 9
1112	1112	achieve greater standardization and uniformity across payors to ease the burden of prior 10
1113	1113	authorization and other utilization management techniques for patients, providers, and 11
1114	1114	payors; 12
1115	1115
1116	1116	(ii) replacing the use of proprietary health plan web–based portals 13
1117	1117	with the adoption of uniform implementation specifications and standardization of 14
1118	1118	certification criteria for health care services, including the use of a single sign–on option 15
1119	1119	for payor and third–party administrator websites; and 16
1120	1120
1121	1121	(iii) a pilot program through the State –designated health 17
1122	1122	information exchange to implement items (i) and (ii) of this item; 18
1123	1123
1124	1124	(2) in consultation with the Maryland Department of Health, examine 19
1125	1125	requiring managed care organizations that participate in the Maryland Medical Assistance 20
1126	1126	Program to use the standardized electronic process recommended in item (1) of this section; 21
1127	1127	and 22
1128	1128
1129	1129	(3) on or before December 1, 2023, submit a report to the General 23
1130	1130	Assembly, in accordance with § 2–1257 of the State Government Article, of its findings and 24
1131	1131	recommendations, including draft legislation necessary to implement the pilot program. 25
1132	1132
1133	1133	SECTION 3. AND BE IT FURTHER ENACTED, That: 26
1134	1134
1135	1135	(a) The Maryland Health Care Commission and the M aryland Insurance 27
1136	1136	Administration, in consultation with health care practitioners and payors of health care 28
1137	1137	services, jointly shall conduct a study on the development of standards for the 29
1138	1138	implementation of payor programs to modify prior authorization requirements for 30
1139	1139	prescription drugs, medical care, and other health care services based on health care 31
1140	1140	practitioner–specific criteria. 32
1141	1141
1142	1142	(b) The study conducted under subsection (a) of this section shall include an 33
1143	1143	examination of: 34
1144	1144
1145	1145	(1) adjustments to payor prior authorization requirements based on a 35
1146	1146	health care practitioner’s: 36 SENATE BILL 308 25
1147	1147
1148	1148
1149	1149
1150	1150	(i) prior approval rates; 1
1151	1151
1152	1152	(ii) ordering and prescribing patterns; and 2
1153	1153
1154	1154	(iii) participation in a payor’s two–sided incentive arrangement or a 3
1155	1155	capitation program; and 4
1156	1156
1157	1157	(2) any other information or metrics necessary to implement the payor 5
1158	1158	programs. 6
1159	1159
1160	1160	(c) On or before December 1, 2023, the Maryland Health Care Commission and 7
1161	1161	Maryland Insurance Administration jointly shall submit a report to the General Assembly, 8
1162	1162	in accordance with § 2–1257 of the State Government Article, with the findings and 9
1163	1163	recommendations from the study, including recommendations for legislative initiatives 10
1164	1164	necessary for the establishment of payor programs modifying prior authorization 11
1165	1165	requirements based on health care practitioner–specific criteria. 12
1166	1166
1167	1167	SECTION 4. AND BE IT FURTHER ENACTED, That, on or before October 1, 2023, 13
1168	1168	the Maryland Insurance Administration, in consultation with the Health Education and 14
1169	1169	Advocacy Unit in the Maryland Office of the Attorney General, shall work with medical 15
1170	1170	associations or societies and consumer advocacy organizations to develop an education 16
1171	1171	campaign to educate the public on their rights under Maryland’s Health Care Appeals and 17
1172	1172	Grievance Law. 18
1173	1173
1174	1174	SECTION 5. AND BE IT FURTHER ENACTED, That Section 1 of this Act shall take 19
1175	1175	effect January 1, 2024. 20
1176	1176
1177	1177	SECTION 6. AND BE IT FURTHER ENACTED, That, except as provided in Section 21
1178	1178	5 of this Act, this Act shall take effect July 1, 2023. 22
1179	1179