WES MOORE, Governor Ch. 848
– 1 –
Chapter 848
(Senate Bill 791)
AN ACT concerning
Health Insurance – Utilization Review – Revisions
FOR the purpose of altering and establishing requirements and prohibitions related to
health insurance utilization review; altering requirements related to internal
grievance procedures and adverse decision procedures; altering certain reporting
requirements on health insurance carriers relating to adverse decisions; establishing
requirements on health insurance carriers and health care providers relating to the
provision of patient benefit information; and generally relating to health insurance
and utilization review.
BY adding to
Article – Health – General
Section 19–108.5
Annotated Code of Maryland
(2023 Replacement Volume)
BY repealing and reenacting, without amendments,
Article – Insurance
Section 15–851 and 15–10B–01(a)
Annotated Code of Maryland
(2017 Replacement Volume and 2023 Supplement)
BY repealing and reenacting, with amendments,
Article – Insurance
Section 15–854 and 15–10B–06
Annotated Code of Maryland
(2017 Replacement Volume and 2023 Supplement)
(As enacted by Chapters 364 and 365 of the Acts of the General Assembly of 2023)
BY adding to
Article – Insurance
Section 15–854.1
Annotated Code of Maryland
(2017 Replacement Volume and 2023 Supplement)
BY repealing and reenacting, with amendments,
Article – Insurance
Section 15–10A–01, 15–10A–02, 15–10A–04(c), 15–10A–06, 15–10A–08,
15–10B–01(b), 15–10B–02, 15–10B–05, 15–10B–07, and 15–10B–09.1
Annotated Code of Maryland
(2017 Replacement Volume and 2023 Supplement) Ch. 848 2024 LAWS OF MARYLAND
– 2 –
SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND,
That the Laws of Maryland read as follows:
Article – Health – General
19–108.5.
(A) (1) IN THIS SECTION THE F OLLOWING WORDS HAVE THE MEANINGS
INDICATED.
(2) “CARRIER” HAS THE MEANING STAT ED IN § 15–1301 OF THE
INSURANCE ARTICLE.
(3) “HEALTH CARE PROVIDER ” HAS THE MEANING STAT ED IN §
19–108.3 OF THIS SUBTITLE.
(B) (1) ON OR BEFORE JULY 1, 2026, A CARRIER SHALL ESTA BLISH AND
MAINTAIN AN ONLINE P ROCESS THAT:
(I) LINKS DIRECTLY TO ALL E–PRESCRIBING SYSTEMS AND
ELECTRONIC HEALTH RE CORD SYSTEMS THAT US E THE NATIONAL COUNCIL FOR
PRESCRIPTION DRUG PROGRAMS SCRIPT STANDARD AND THE NATIONAL
COUNCIL FOR PRESCRIPTION DRUG PROGRAMS REAL TIME BENEFIT STANDARD;
(II) CAN ACCEPT ELECTRONIC PRIOR AUTHORIZATION
REQUESTS FROM A HEAL TH CARE PROVIDER ;
(III) CAN APPROVE ELECTRONI C PRIOR AUTHORIZATIO N
REQUESTS:
1. FOR WHICH NO ADDITIONAL INFORMATION IS
NEEDED BY THE CARRIE R TO PROCESS THE PRI OR AUTHORIZATION REQ UEST;
2. FOR WHICH NO CLINICAL REVIEW IS REQUIRED ; AND
3. THAT MEET THE CARRIER ’S CRITERIA FOR
APPROVAL; AND
(IV) LINKS DIRECTLY TO REA L–TIME PATIENT OUT–OF–POCKET
COSTS, INCLUDING COPAYMENT , DEDUCTIBLE, AND COINSURANCE COST S, AND
MORE AFFORDABLE MEDI CATION ALTERNATIVES MADE AVAILABLE BY TH E
CARRIER.
WES MOORE, Governor Ch. 848
– 3 –
(2) A CARRIER MAY NOT :
(I) IMPOSE A FEE OR CHARG E ON A PERSON FOR AC CESSING
THE ONLINE PROCESS REQUIRED UNDER PARAG RAPH (1) OF THIS SUBSECTION ; OR
(II) ACCESS, WITHOUT HEALTH CARE PROVIDER CONSENT ,
HEALTH CARE PROVIDER DATA VIA THE ONLINE PROCESS OTHER THAN F OR THE
INSURED OR ENROLLEE .
(C) ON OR BEFORE JULY 1, 2025, A CARRIER SHALL :
(1) ON REQUEST OF A HEALTH CARE PROVIDER , PROVIDE CONTACT
INFORMATION FOR EACH THIRD–PARTY VENDOR OR OTHE R ENTITY THAT THE
CARRIER WILL USE TO MEET THE REQUIREMENT S OF SUBSECTION (B) OF THIS
SECTION; AND
(2) POST THE CONTACT INFO RMATION REQUIRED TO BE PROVIDE D
UNDER ITEM (1) OF THIS SUBSECTION O N ITS WEBSITE.
(D) (1) ON OR BEFORE JULY 1, 2026, EACH HEALTH CARE PRO VIDER
SHALL ENSURE THAT EA CH E–PRESCRIBING SYSTEM O R ELECTRONIC HEALTH
RECORD SYSTEM OWNED OR CONTRACTED FOR BY THE HEALTH CARE PROV IDER TO
MAINTAIN A HEALTH RECORD OF AN INSURED OR ENROLL EE HAS THE ABILITY T O
ACCESS, AT THE POINT OF PRES CRIBING:
(I) THE ELECTRONIC PRIOR AUTHORIZATION PROCES S
ESTABLISHED BY A CAR RIER UNDER SUBSECTIO N (B) OF THIS SECTION; AND
(II) THE REAL –TIME PATIENT OUT–OF–POCKET COST
INFORMATION AND AVAI LABLE MEDICATION ALT ERNATIVES REQUIRED U NDER
SUBSECTION (B) OF THIS SECTION.
(2) THE COMMISSION SHALL ESTA BLISH BY REGULATION A PROCESS
THROUGH WHICH A HEAL TH CARE PROVIDER MAY REQUEST AND RECEIVE A WAIVER
OF COMPLIANCE FROM THE REQUI REMENTS OF THIS SUBS ECTION.
(E) (1) ON OR BEFORE JULY 1, 2026, EACH CARRIER , OR A PHARMACY
BENEFITS MANAGER ON BEHALF OF THE CARRIE R, SHALL:
(I) PROVIDE REAL –TIME PATIENT –SPECIFIC BENEFIT
INFORMATION TO INSUR EDS AND ENROLLEES AN D CONTRACTED HEALTH CA RE
PROVIDERS, INCLUDING ANY OUT –OF–POCKET COSTS AND MOR E AFFORDABLE
MEDICATION ALTERNATI VES OR PRIOR AUTHORI ZATION REQUIREMENTS ; AND
Ch. 848 2024 LAWS OF MARYLAND
– 4 –
(II) ENSURE THAT THE INFOR MATION PROVIDED UNDE R ITEM
(I) OF THIS PARAGRAPH IS ACCURATE.
(2) EACH CARRIER, OR A PHARMACY BENEFI TS MANAGER ON BEHALF
OF THE CARRIER , SHALL MAKE AVAILABLE THE INFORMATION REQU IRED TO BE
PROVIDED UNDER PARAG RAPH (1) OF THIS SUBSECTION T O THE HEALTH CARE
PROVIDER AT THE POIN T OF PRESCRIBING IN AN ACCESSIBLE AND
UNDERSTANDAB LE FORMAT, SUCH AS THROUGH THE HEALTH CARE PROVIDER ’S
E–PRESCRIBING SYSTEM O R ELECTRONIC HEALTH RECORD SYSTEM THAT T HE
CARRIER, PHARMACY BENEFITS MA NAGER, OR DESIGNATED SUBCON TRACTOR HAS
ADOPTED THAT USES TH E NATIONAL COUNCIL FOR PRESCRIPTION DRUG
PROGRAM S SCRIPT STANDARD AND THE NATIONAL COUNCIL FOR PRESCRIPTION
DRUG PROGRAMS REAL TIME BENEFIT STANDARD FROM WHICH T HE HEALTH
CARE PROVIDER MAKES THE REQUEST .
Article – Insurance
15–851.
(a) (1) This section applies to:
(i) insurers and nonprofit health service plans that provide coverage
for substance use disorder benefits or prescription drugs under individual, group, or
blanket health insurance policies or contracts that are issued or delivered in the State; and
(ii) health maintenance organizations that provide coverage for
substance use disorder benefits or prescription drugs under individual or group contracts
that are issued or delivered in the State.
(2) An insurer, a nonprofit health service plan, or a health maintenance
organization that provides coverage for substance use disorder benefits under the medical
benefit or for prescription drugs through a pharmacy benefits manager is subject to the
requirements of this section.
(b) An entity subject to this section may not apply a prior authorization
requirement for a prescription drug:
(1) when used for treatment of an opioid use disorder; and
(2) that contains methadone, buprenorphine, or naltrexone.
15–854.
(a) (1) This section applies to:
WES MOORE, Governor Ch. 848
– 5 –
(i) insurers and nonprofit health service plans that provide coverage
for prescription drugs through a pharmacy benefit under individual, group, or blanket
health insurance policies or contracts that are issued or delivered in the State; and
(ii) health maintenance organizations that provide coverage for
prescription drugs through a pharmacy benefit under individual or group contracts that
are issued or delivered in the State.
(2) An insurer, a nonprofit health service plan, or a health maintenance
organization that provides coverage for prescription drugs through a pharmacy benefits
manager or that contracts with a private review agent under Subtitle 10B of this article is
subject to the requirements of this section.
(3) This section does not apply to a managed care organization as defined
in § 15–101 of the Health – General Article.
(b) (1) (i) If an entity subject to this section requires a prior authorization
for a prescription drug, the prior authorization request shall allow a health care provider
to indicate whether a prescription drug is to be used to treat a chronic condition.
(ii) If a health care provider indicates that the prescription drug is
to treat a chronic condition, an entity subject to this section may not request a
reauthorization for a repeat prescription for the prescription drug for 1 year or for the
standard course of treatment for the chronic condition being treated, whichever is less.
(2) For a prior authorization that is filed electronically, the entity shall
maintain a database that will prepopulate prior authorization requests with an insured’s
available insurance and demographic information.
(c) [If an entity subject to this section denies coverage for a prescription drug, the
entity shall provide a detailed written explanation for the denial of coverage, including
whether the denial was based on a requirement for prior authorization.
(d)] (1) On receipt of information documenting a prior authorization from the
insured or from the insured’s health care provider, an entity subject to this section shall
honor a prior authorization granted to an insured from a previous entity for at least the
[initial 30] LESSER OF 90 days [of an insured’s prescription drug benefit coverage under
the health benefit plan of the new entity] OR THE LENGTH OF THE COURSE OF
TREATMENT .
(2) During the time period described in paragraph (1) of this subsection, an
entity may perform its own review to grant a prior authorization for the prescription drug.
[(e)] (D) (1) An entity subject to this section shall honor a prior authorization
issued by the entity for a prescription drug AND MAY NOT REQUIRE A HEALTH CARE Ch. 848 2024 LAWS OF MARYLAND
– 6 –
PROVIDER TO SUBMIT A REQUEST FOR ANOTHER PRIOR AUTHORIZATION FOR THE
PRESCRIPTION DRUG :
(i) if the insured changes health benefit plans that are both covered
by the same entity and the prescription drug is a covered benefit under the current health
benefit plan; or
(ii) except as provided in paragraph (2) of this subsection, when the
dosage for the approved prescription drug changes and the change is consistent with federal
Food and Drug Administration labeled dosages.
(2) [An] EXCEPT AS PROVIDED IN § 15–851 OF THIS SUBTITLE , AN
entity may [not be required to honor] REQUIRE a prior authorization for a change in dosage
for an opioid under this subsection.
[(f)] (E) (1) If an entity under this section implements a new prior
authorization requirement for a prescription drug, the entity shall provide notice of the new
requirement at least [30] 60 days before the implementation of a new prior authorization
requirement:
[(1)] (I) in writing to any insured who is prescribed the prescription drug;
and
[(2)] (II) either in writing or electronically to all contracted health care
providers.
(2) THE NOTICE REQUIRED U NDER PARAGRAPH (1) OF THIS
SUBSECTION SHALL IND ICATE THAT THE INSUR ED MAY REMAIN ON THE
PRESCRIPTION DRUG AT THE TIME OF REAUTHOR IZATION IN ACCORDANC E WITH
SUBSECTION (G) OF THIS SECTION.
[(g)] (F) (1) Except as provided in paragraph (2) of this subsection, an entity
subject to this section may not require more than one prior authorization if two or more
tablets of different dosage strengths of the same prescription drug are:
(i) prescribed at the same time as part of an insured’s treatment
plan; and
(ii) manufactured by the same manufacturer.
(2) This subsection does not prohibit an entity from requiring more than
one prior authorization if the prescription is for two or more tablets of different dosage
strengths of an opioid that is not an opioid partial agonist.
WES MOORE, Governor Ch. 848
– 7 –
(G) (1) THIS SUBSECTION DOES NOT APPLY WITH RESPE CT TO A
REAUTHORIZATION OF A PRESCRIPTION DRUG RE QUESTED BY A PROVIDE R
EMPLOYED BY A GROUP MODEL HEALTH MAINTEN ANCE ORGANIZATION , AS DEFINED
IN § 19–713.6 OF THE HEALTH – GENERAL ARTICLE.
(2) AN ENTITY SUBJEC T TO THIS SECTION MA Y NOT ISSUE AN
ADVERSE DECISION ON A REAUTHORIZATION FO R THE SAME PRESCRIPT ION DRUG
OR REQUEST ADDITIONA L DOCUMENTATION FROM THE PRESCRIBER FOR T HE
REAUTHORIZATION REQU EST IF:
(I) THE PRESCRIPTION DRU G IS A BIOLOGICAL PRODUCT USED
FOR IMMUNOTHERAPY OR :
1. AN IMMUNE GLOBULIN (HUMAN) AS DEFINED IN 21
C.F.R. § 640.100; OR
2. USED FOR THE TREATMENT OF A MENTAL DISORDER
LISTED IN THE MOST R ECENT EDITION OF THE DIAGNOSTIC AND STATISTICAL
MANUAL OF MENTAL DISORDERS PUBLISHED B Y THE AMERICAN PSYCHIATRIC
ASSOCIATION;
(I) (II) THE ENTITY PREVIOUSL Y APPROVED A PRIOR
AUTHORIZATION FOR TH E PRESCRIPTION DRUG FOR THE INSURED ;
(II) (III) THE INSURED HAS BEEN TREATED WITH THE
PRESCRIPTION DRUG WI THOUT INTERRUPTION S INCE THE INITIAL APPROVAL OF
THE PRIOR AUTHORIZAT ION; AND
(III) (IV) THE PRESCRIBER ATTES TS THAT, BASED ON THE
PRESCRIBER’S PROFESSIONAL JUDGM ENT, THE PRESCRIPTION DRU G CONTINUES
TO BE NECESSARY TO E FFECTIVELY TREAT THE INSURED’S CONDITION.
(3) (2) IF THE PRESCRIPTION DRUG THAT IS BEING REQUESTED H AS
BEEN REMOVED FROM TH E FORMULARY OR HAS B EEN MOVED TO A HIGHE R
DEDUCTIBLE, COPAYMENT , OR COINSURANCE TIER , THE ENTITY SHALL PRO VIDE
THE INSURED AND INSU RED’S HEALTH CARE PROVID ER THE INFORMATION
REQUIRED UNDER § 15–831 OF THIS SUBTITLE .
15–854.1.
(A) (1) IN THIS SECTION THE F OLLOWING WORDS HAVE THE MEANINGS
INDICATED.
Ch. 848 2024 LAWS OF MARYLAND
– 8 –
(2) “ACTIVE COURSE OF TREA TMENT” MEANS A COURSE OF
TREATMENT FOR WHICH AN INSURED IS ACTIVE LY SEEING A HEALTH C ARE
PROVIDER AND FOLLOWI NG THE COURSE OF TREATMENT .
(3) “COURSE OF TREATMENT ” MEANS TREATMENT THAT :
(I) IS PRESCRIBED TO TRE AT OR ORDERED FOR TH E
TREATMENT OF AN INSU RED WITH A SPECIFIC CONDITION;
(II) IS OUTLINED AND AGRE ED TO BY THE INSURED AND THE
HEALTH CARE PROVIDER BEFORE THE TREATMENT BEG INS; AND
(III) MAY BE PART OF A TRE ATMENT PLAN .
(B) (1) THIS SECTION APPLIES TO:
(I) INSURERS AND NONPROF IT HEALTH SERVICE PL ANS THAT
PROVIDE HOSPITAL , MEDICAL, OR SURGICAL BENEFITS TO INDIVIDUALS OR GR OUPS
ON AN EXPENSE–INCURRED BASIS UNDER HEALTH INSURANCE POL ICIES OR
CONTRACTS THAT ARE I SSUED OR DELIVERED I N THE STATE; AND
(II) HEALTH MAINTENANCE O RGANIZATIONS THAT PR OVIDE
HOSPITAL, MEDICAL, OR SURGICAL BENEFITS TO INDIVIDUALS OR GR OUPS UNDER
CONTRACTS THAT ARE ISSUED OR DELIVE RED IN THE STATE.
(2) AN INSURER, A NONPROFIT HEALTH S ERVICE PLAN, OR A HEALTH
MAINTENANCE ORGANIZA TION THAT CONTRACTS WITH A PRIVATE REVIE W AGENT
UNDER SUBTITLE 10B OF THIS TITLE IS SUB JECT TO THE REQUIREM ENTS OF THIS
SECTION.
(3) AN INSURER, A NONPROFIT HEALTH S ERVICE PLAN, OR A HEALTH
MAINTENANCE ORGANIZA TION THAT CONTRACTS WITH A THIRD PARTY T O
DISPENSE MEDICAL DEV ICES, MEDICAL APPLIANCES , OR MEDICAL GOODS FOR THE
TREATMENT OF A HUMAN DISEASE OR DYSFUNCTI ON IS SUBJECT TO THE
REQUIREMENTS OF THIS S ECTION.
(C) (1) NOTWITHSTANDING § 15–854 OF THIS SUBTITLE AS IT APPLIES TO
COVERAGE FOR PRESCRI PTION DRUGS , AN ENTITY SUBJECT TO THIS SECTION
SHALL APPROVE A REQU EST FOR THE PRIOR AU THORIZATION OF A COU RSE OF
TREATMENT , INCLUDING FOR CHRONIC CONDITIONS , REHABILITATIVE SERVI CES,
SUBSTANCE USE DISORD ERS, AND MENTAL HEALTH CO NDITIONS, THAT IS:
WES MOORE, Governor Ch. 848
– 9 –
(I) FOR A PERIOD OF TIME THAT IS AS LONG AS N ECESSARY TO
AVOID DISRUPTIONS IN CARE; AND
(II) DETERMINED IN ACCORD ANCE WITH APPLICABLE
COVERAGE CRITERIA, THE INSURED’S MEDICAL HISTORY , AND THE HEALTH CARE
PROVIDER’S RECOMMENDATION .
(2) FOR NEW ENROLLEES , AN ENTITY SUBJECT TO THIS SECTION MAY
NOT DISRUPT OR REQUI RE REAUTHORIZATION F OR AN ACTIVE COURSE OF
TREATMENT FOR COVERED SERVICES FOR AT LEAST 90 DAYS AFTER THE DATE OF
ENROLLMENT .
15–10A–01.
(a) In this subtitle the following words have the meanings indicated.
(b) (1) “Adverse decision” means:
(i) a utilization review determination by a private review agent, a
carrier, or a health care provider acting on behalf of a carrier that:
1. a proposed or delivered health care service covered under
the member’s contract is or was not medically necessary, appropriate, or efficient; and
2. may result in noncoverage of the health care service; or
(ii) a denial by a carrier of a request by a member for an alternative
standard or a waiver of a standard to satisfy the requirements of a wellness program under
§ 15–509 of this title.
(2) “ADVERSE DECISION ” INCLUDES A UTILIZATI ON REVIEW
DETERMINATION BASED ON A PRIOR AUTHORIZA TION OR STEP THERAPY
REQUIREMENT .
[(2)] (3) “Adverse decision” does not include a decision concerning a
subscriber’s status as a member.
(c) “Carrier” means a person that offers a health benefit plan and is:
(1) an authorized insurer that provides health insurance in the State;
(2) a nonprofit health service plan;
(3) a health maintenance organization;
Ch. 848 2024 LAWS OF MARYLAND
– 10 –
(4) a dental plan organization;
(5) a self–funded student health plan operated by an indep endent
institution of higher education, as defined in § 10–101 of the Education Article, that
provides health care to its students and their dependents; or
(6) 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.
(d) “Complaint” means a protest filed with the Commissioner involving an
adverse decision or grievance decision concerning the member.
(e) “Designee of the Commissioner” means any person to whom the Commissioner
has delegated the authority to review and decide complaints filed under this subtitle,
including an administrative law judge to whom the authority to conduct a hearing has been
delegated for recommended or final decision.
(f) “Grievance” means a protest filed by a member, a member’s representative, or
a health care provider on behalf of a member with a carrier through the carrier’s internal
grievance process regarding an adverse decision concerning the member.
(g) “Grievance decision” means a final determination by a carrier that arises from
a grievance filed with the carrier under its internal grievance process regarding an adverse
decision concerning a member.
(h) “Health Advocacy Unit” means the Health Education and Advocacy Unit in
the Division of Consumer Protection of the Office of the Attorney General established under
Title 13, Subtitle 4A of the Commercial Law Article.
(i) “Health benefit plan” has the meaning stated in § 2–112.2(a) of this article.
(j) “Health care provider” means:
(1) an individual who is licensed under the Health Occupations Article to
provide health care services in the ordinary course of business or practice of a profession
and is a treating provider of the member; or
(2) a hospital, as defined in § 19–301 of the Health – General Article.
(k) “Health care service” means a health or medical care procedure or service
rendered by a health care provider that:
(1) provides testing, diagnosis, or treatment of a human disease or
dysfunction; [or]
WES MOORE, Governor Ch. 848
– 11 –
(2) dispenses drugs, medical devices, medical appliances, or medical goods
for the treatment of a human disease or dysfunction; OR
(3) PROVIDES ANY OTHER C ARE, SERVICE, OR TREATMENT OF
DISEASE OR INJURY , THE CORRECTION OF DE FECTS, OR THE MAINTENANCE O F
PHYSICAL OR MENTAL W ELL–BEING OF INDIVIDUALS .
(l) (1) “Member” means a person entitled to health care benefits under a
policy, plan, or certificate issued or delivered in the State by a carrier.
(2) “Member” includes:
(i) a subscriber; and
(ii) unless preempted by federal law, a Medicare recipient.
(3) “Member” does not include a Medicaid recipient.
(m) “Member’s representative” means an individual who has been authorized by
the member to file a grievance or a complaint on the member’s behalf.
(n) “Private review agent” has the meaning stated in § 15–10B–01 of this title.
15–10A–02.
(a) Each carrier shall establish an internal grievance process for its members.
(b) (1) An internal grievance process shall meet the same requirements
established under Subtitle 10B of this title.
(2) In addition to the requirements of Subtitle 10B of this title, an internal
grievance process established by a carrier under this section shall:
(i) include an expedited procedure for use in an emergency case for
purposes of rendering a grievance decision within 24 hours of the date a grievance is filed
with the carrier;
(ii) provide that a carrier render a final decision in writing on a
grievance within 30 working days after the date on which the grievance is filed unless:
1. the grievance involves an emergency case under item (i) of
this paragraph;
2. the member, the member’s representative, or a health care
provider filing a grievance on behalf of a member agrees in writing to an extension for a
period of no longer than 30 working days; or Ch. 848 2024 LAWS OF MARYLAND
– 12 –
3. the grievance involves a retrospective denial under item
(iv) of this paragraph;
(iii) allow a grievance to be filed on behalf of a member by a health
care provider or the member’s representative;
(iv) provide that a carrier render a final decision in writing on a
grievance within 45 working days after the date on which the grievance is filed when the
grievance involves a retrospective denial; and
(v) for a retrospective denial, allow a member, the member’s
representative, or a health care provider on behalf of a member to file a grievance for at
least 180 days after the member receives an adverse decision.
(3) For purposes of using the expedited procedure for an emergency case
that a carrier is required to include under paragraph (2)(i) of this subsection, the
[Commissioner shall define by regulation the standards required for a grievance to be
considered an emergency case] CARRIER SHALL INITIATE THE EXPEDITED PROCEDURE
FOR AN EMERGENCY CAS E IF THE MEMBER OR THE ME MBER’S REPRESENTATIVE
REQUESTS THE EXPEDIT ED REVIEW OR THE HEALTH CARE PROV IDER OR THE
MEMBER OR THE MEMBER ’S REPRESENTATIVE ATTESTS THAT:
(I) THE ADVERSE DECISION WAS RENDERED FOR HEALT H CARE
SERVICES THAT ARE PR OPOSED BUT HAVE NOT BEEN PROVIDED ; AND
(II) THE SERVICES ARE NEC ESSARY TO TREAT A CO NDITION OR
ILLNESS THAT, WITHOUT IMMEDIATE ME DICAL ATTENTION , WOULD:
1. SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH O F THE
MEMBER OR THE MEMBER ’S ABILITY TO REGAIN MAXIMUM FUNCTIONS ;
2. CAUSE THE MEMBER TO BE IN DANGER TO SELF OR
OTHERS; OR
3. CAUSE THE MEMBER TO CONTINUE USING
INTOXICATING SUBSTAN CES IN AN IMMINENTLY DANGEROUS MANNER .
(c) Except as provided in subsection (d) of this section, the carrier’s internal
grievance process shall be exhausted prior to filing a complaint with the Commissioner
under this subtitle.
(d) (1) (i) A member, the member’s representative, or a health care
provider filing a complaint on behalf of a member may file a complaint with the WES MOORE, Governor Ch. 848
– 13 –
Commissioner without first filing a grievance with a carrier and receiving a final decision
on the grievance if:
1. the carrier waives the requirement that the carrier’s
internal grievance process be exhausted before filing a complaint with the Commissioner;
2. the carrier has failed to comply with any of the
requirements of the internal grievance process as described in this section; or
3. the member, the member’s representative, or the health
care provider provides sufficient information and supporting documentation in the
complaint that demonstrates a compelling reason to do so.
(ii) The Commissioner shall define by regulation the standards that
the Commissioner shall use to decide what demonstrates a compelling reason under
subparagraph (i) of this paragraph.
(2) Subject to subsections (b)(2)(ii) and (h) of this section, a member, a
member’s representative, or a health care provider may file a complaint with the
Commissioner if the member, the member’s representative, or the health care provider does
not receive a grievance decision from the carrier on or before the 30th working day on which
the grievance is filed.
(3) Whenever the Commissioner receives a complaint under paragraph (1)
or (2) of this subsection, the Commissioner shall notify the carrier that is the subject of the
complaint within 5 working days after the date the complaint is filed with the
Commissioner.
(e) Each carrier shall:
(1) file for review with the Commissioner and submit to the Health
Advocacy Unit a copy of its internal grievance process established under this subtitle; and
(2) file any revision to the internal grievance process with the
Commissioner and the Health Advocacy Unit at least 30 days before its intended use.
(f) (1) For nonemergency cases, when a carrier renders an adverse decision,
the carrier shall:
[(1)] (I) inform the member, the member’s representative, or the health
care provider acting on behalf of the member of the adverse decision:
[(i)] 1. orally by telephone; or
Ch. 848 2024 LAWS OF MARYLAND
– 14 –
[(ii)] 2. with the affirmative consent of the member, the member’s
representative, or the health care provider acting on behalf of the member, by text,
facsimile, e–mail, an online portal, or other expedited means; and
[(2)] (II) send, within 5 working days after the adverse decision has been
made, a written notice to the member, the member’s representative, and a health care
provider acting on behalf of the member that:
[(i)] 1. states in detail in clear, understandable language the
specific factual bases for the carrier’s decision AND THE REASONING US ED TO
DETERMINE THAT THE H EALTH CARE SERVICE I S NOT MEDICALLY NECE SSARY AND
DID NOT MEET THE CAR RIER’S CRITERIA AND STAND ARDS USED IN CONDUCT ING
THE UTILIZATION REVI EW;
[(ii)] 2. [references] PROVIDES the specific REFERENCE ,
LANGUAGE, OR REQUIREMENTS FROM THE criteria and standards, including ANY
interpretive guidelines, on which the decision was based, and may not solely use:
A. generalized terms such as “experimental procedure not
covered”, “cosmetic procedure not covered”, “service included under another procedure”, or
“not medically necessary”; OR
B. LANGUAGE DIRECTING T HE MEMBER TO REVIEW THE
ADDITIONAL COVERAGE CRITERIA IN THE MEMBER ’S POLICY OR PLAN DOC UMENTS;
[(iii)] 3. states the name, business address, and business telephone
number of:
[1.] A. IF THE CARRIER IS A HEALTH MAINTENANCE
ORGANIZATION , the medical director or associate medical director, as appropriate, who
made the decision [if the carrier is a health maintenance organization]; or
[2.] B. IF THE CARRIER IS NO T A HEALTH
MAINTENANCE ORGANIZA TION, the designated employee or representative of the carrier
who has responsibility for the carrier’s internal grievance process [if the carrier is not a
health maintenance organization] AND THE PHYSICIAN WH O IS REQUIRED TO MAK E
ALL ADVERSE DECISION S AS REQUIRED IN § 15–10B–07(A) OF THIS TITLE;
[(iv)] 4. gives written details of the carrier’s internal grievance
process and procedures under this subtitle; and
[(v)] 5. includes the following information:
WES MOORE, Governor Ch. 848
– 15 –
[1.] A. that the member, the member’s representative, or a
health care provider on behalf of the member has a right to file a complaint with the
Commissioner within 4 months after receipt of a carrier’s grievance decision;
[2.] B. that a complaint may be filed without first filing a
grievance if the member, the member’s representative, or a health care provider filing a
grievance on behalf of the member can demonstrate a compelling reason to do so as
determined by the Commissioner;
[3.] C. the Commissioner’s address, telephone number,
and facsimile number;
[4.] D. a statement that the Health Advocacy Unit is
available to assist the member or the member’s representative in both mediating and filing
a grievance under the carrier’s internal grievance process; and
[5.] E. the address, telephone number, facsimile number,
and electronic mail address of the Health Advocacy Unit.
(2) THE BUSINESS TELEPHON E NUMBER INCLUDED IN THE NOTICE AS
REQUIRED UNDER PARAG RAPH (1)(II)3 OF THIS SUBSECTION M UST BE A DEDICATED
NUMBER FOR ADVERSE D ECISIONS AND MAY NOT BE THE GENERAL CUSTO MER CALL
NUMBER FOR THE CARRI ER.
(g) If within 5 working days after a member, the member’s representative, or a
health care provider, who has filed a grievance on behalf of a member, files a grievance
with the carrier, and if the carrier does not have sufficient information to complete its
internal grievance process, the carrier shall:
(1) AFTER CONFIRMING THR OUGH A COMPLETE REVI EW OF ANY
INFORMATION ALREADY SUBMITTED BY THE HEA LTH CARE PROVIDER :
(I) notify the member, the member’s representative, or the health
care provider that it cannot proceed with reviewing the grievance unless additional
information is provided;
(II) REQUEST THE SPECIFIC INFORMATION , INCLUDING ANY
LAB OR DIAGNOSTIC TE ST OR OTHER MEDICAL INFORMATION THAT MUS T BE
SUBMITTED TO COMPLET E THE INTERNAL GRIEV ANCE PROCESS ; AND
(III) PROVIDE T HE SPECIFIC REFERENC E, LANGUAGE, OR
REQUIREMENTS FROM TH E CRITERIA AND STAND ARDS USED BY THE CAR RIER TO
SUPPORT THE NEED FOR THE ADDITIONAL INFOR MATION; and
Ch. 848 2024 LAWS OF MARYLAND
– 16 –
(2) assist the member, the member’s representative, or the health care
provider in gathering the necessary information without further delay.
(h) A carrier may extend the 30–day or 45–day period required for making a final
grievance decision under subsection (b)(2)(ii) of this section with the written consent of the
member, the member’s representative, or the health care provider who filed the grievance
on behalf of the member.
(i) (1) For nonemergency cases, when a carrier renders a grievance decision,
the carrier shall:
(i) document the grievance decision in writing after the carrier has
provided oral communication of the decision to the member, the member’s representative,
or the health care provider acting on behalf of the member; and
(ii) send, within 5 working days after the grievance decision has been
made, a written notice to the member, the member’s representative, and a health care
provider acting on behalf of the member that:
1. states in detail in clear, understandable language the
specific factual bases for the carrier’s decision AND THE REASONING US ED TO
DETERMINE THAT THE HEALTH C ARE SERVICE IS NOT M EDICALLY NECESSARY A ND
DID NOT MEET THE CAR RIER’S CRITERIA AND STAND ARDS USED IN CONDUCT ING
UTILIZATION REVIEW ;
2. [references] PROVIDES the specific REFERENCE ,
LANGUAGE, OR REQUIREMENTS FROM THE criteria and standards, including ANY
interpretive guidelines USED BY THE CARRIER , on which the grievance decision was
based;
3. states the name, business address, and business telephone
number of:
A. IF THE CARRIER IS A HEALTH MAINTENANCE
ORGANIZATION , the medical director or associate medical director, as appropriate, who
made the grievance decision; or
B. IF THE CARRIER IS NO T A HEALTH MAINTENAN CE
ORGANIZATION , the designated employee or representative of the carrier who has
responsibility for the carrier’s internal grievance process [if the carrier is not a health
maintenance organization] AND THE DESIGNATED E MPLOYEE OR REPRESENT ATIVE’S
TITLE AND CLINICAL S PECIALTY; and
4. includes the following information:
WES MOORE, Governor Ch. 848
– 17 –
A. that the member or the member’s representative has a
right to file a complaint with the Commissioner within 4 months after receipt of a carrier’s
grievance decision;
B. the Commissioner’s address, telephone number, and
facsimile number;
C. a statement that the Health Advocacy Unit is available to
assist the member or the member’s representative in filing a complaint with the
Commissioner; and
D. the address, telephone number, facsimile number, and
electronic mail address of the Health Advocacy Unit.
(2) THE BUSINESS TELEPHON E NUMBER INCLUDED IN THE NOTICE AS
REQUIRED UNDER PARAG RAPH (1)(II)3 OF THIS SUBSECTION M UST BE A DEDICATED
NUMBER FOR GRIEVANCE DECISIONS AND MAY NO T BE THE GENERAL CUSTOMER
CALL NUMBER FOR THE CARRIER.
[(2)] (3) [A] TO SATISFY THE REQUIR EMENTS OF THIS SUBSE CTION,
A carrier may not use solely in [a] THE WRITTEN notice sent under paragraph (1) of this
subsection:
(I) generalized terms such as “experimental procedure not covered”,
“cosmetic procedure not covered”, “service included under another procedure”, or “not
medically necessary” [to satisfy the requirements of this subsection]; OR
(II) LANGUAGE DIRECTING T HE MEMBER TO REVIEW THE
ADDITIONAL COVERAGE CRITERIA IN THE MEMB ER’S POLICY OR PLAN DOC UMENTS.
(j) (1) For an emergency case under subsection (b)(2)(i) of this section, within
1 day after a decision has been orally communicated to the member, the member’s
representative, or the health care provider, the carrier shall send notice in writing of any
adverse decision or grievance decision to:
(i) the member and the member’s representative, if any; and
(ii) if the grievance was filed on behalf of the member under
subsection (b)(2)(iii) of this section, the health care provider.
(2) A notice required to be sent under paragraph (1) of this subsection shall
include the following:
(i) for an adverse decision, the information required under
subsection (f) of this section; and
Ch. 848 2024 LAWS OF MARYLAND
– 18 –
(ii) for a grievance decision, the information required under
subsection (i) of this section.
(k) (1) Each carrier shall include the information required by subsection
[(f)(2)(iii), (iv), and (v)] (F)(1)(II)3, 4, AND 5 of this section in the policy, plan, certificate,
enrollment materials, or other evidence of coverage that the carrier provides to a member
at the time of the member’s initial coverage or renewal of coverage.
(2) Each carrier shall include as part of the information required by
paragraph (1) of this subsection a statement indicating that, when filing a complaint with
the Commissioner, the member or the member’s representative will be required to
authorize the release of any medical records of the member that may be required to be
reviewed for the purpose of reaching a decision on the complaint.
(l) (1) Nothing in this subtitle prohibits a carrier from delegating its internal
grievance process to a private review agent that has a certificate issued under Subtitle 10B
of this title and is acting on behalf of the carrier.
(2) If a carrier delegates its internal grievance process to a private review
agent, the carrier shall be:
(i) bound by the grievance decision made by the private review
agent acting on behalf of the carrier; and
(ii) responsible for a violation of any provision of this subtitle
regardless of the delegation made by the carrier under paragraph (1) of this subsection.
15–10A–04.
(c) (1) 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.
(2) If, in rendering an adverse decision or grievance decision, a carrier fails
to fulfill the carrier’s obligations to provide or reimburse for health care services specified
in the carrier’s policies or contracts with members, the Commissioner may:
(i) issue an administrative order that requires the carrier to:
1. cease inappropriate conduct or practices by the carrier or
any of the personnel employed or associated with the carrier;
2. fulfill the carrier’s contractual obligations;
3. provide a health care service or payment that has been
denied improperly; or WES MOORE, Governor Ch. 848
– 19 –
4. take appropriate steps to restore the carrier’s ability to
provide a health care service or payment that is provided under a contract; or
(ii) impose any penalty or fine or take any action as authorized:
1. for an insurer, nonprofit health service plan, or dental
plan organization, under this article; or
2. for a health maintenance organization, under the Health
– General Article or under this article.
(3) In addition to paragraph (1) of this subsection, it is a violation of this
subtitle, if the Commissioner, in consultation with an independent review organization,
medical expert, the Department, or other appropriate entity, determines that the criteria
and standards used by a health maintenance organization to conduct utilization review are
not[:
(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] IN ACCORDANCE WITH § 15–10B–06 § 15–10B–05 OF THIS TITLE.
15–10A–06.
(a) On [a quarterly] AN ANNUAL 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;
Ch. 848 2024 LAWS OF MARYLAND
– 20 –
(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, THE TYPE OF UTILIZAT ION REVIEW PROCESS U SED, IF
APPLICABLE, WHETHER THE ADVERSE D ECISION INVOLVED A P RIOR
AUTHORIZATION OR STE P THERAPY PROTOCOL , and the type of service at issue in the
adverse decisions; [and]
(VII) THE TIME WITHIN WHIC H THE CARRIER MADE T HE ADVERSE
DECISIONS UNDER EACH TYPE OF SERVICE AT I SSUE IN THE ADVERSE DECIS IONS;
(VIII) (VII) THE NUMBER OF ADVERS E DECISIONS OVERTURN ED
AFTER A RECONSIDERAT ION REQUEST UNDER § 15–10B–06 OF THIS TITLE; AND
(IX) (VIII) THE NUMBER OF REQUES TS MADE AND GRANTED
UNDER § 15–831(C)(1) AND (2) OF THIS TITLE; 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) REPORT ANY VIOLATION S OR ACTIONS TAKEN U NDER §
15–10B–11 OF THIS TITLE; AND
[(2)] (3) provide copies of the summary report to the Governor and,
subject to § 2–1257 of the State Government Article, to the General Assembly.
15–10A–08.
(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.
WES MOORE, Governor Ch. 848
– 21 –
(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 TO THE LAW that it considers necessary TO ENSURE
COMPLIANCE WITH THE PURPOSES OF THE LAW .
15–10B–01.
(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 UTILIZATI ON REVIEW
DETERMINATION BASED ON A PRIOR AUTHORIZA TION OR STEP THERAPY
REQUIREMENT .
[(2)] (3) “Adverse decision” does not include a decision concerning a
subscriber’s status as a member.
15–10B–02.
The purpose of this subtitle is to:
(1) promote the delivery of quality health care in a cost effective manner
THAT ENSURES TIMELY ACCESS TO HEALTH CAR E SERVICES;
(2) foster greater coordination, COMMUNICATION , AND TRANSPARENCY
between payors, PATIENTS, 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 Ch. 848 2024 LAWS OF MARYLAND
– 22 –
(4) ensure that private review agents maintain the confidentiality of
medical records in accordance with applicable State and federal laws.
15–10B–05.
(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, or
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; WES MOORE, Governor Ch. 848
– 23 –
(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 PERSO N’S
BOARD CERTIFICATION OR PRACTICE SPECIALT Y, LICENSURE CATEGORY , AND
TITLE WITHIN THE PER SON’S ORGANIZATION ; and
(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 PRACT ICING IN THE RELEVAN T CLINICAL SPECIALTI ES AND ARE:
(i) objective;
(ii) clinically valid;
[(iii) compatible with established principles of health care; and
(iv) flexible enough to allow deviations from norms when justified on
a case by case basis;]
(III) REFLECTED IN PUBLISHED PEER–REVIEWED SCIENTIFIC
STUDIES AND MEDICAL LITERATURE;
(IV) DEVELOPED BY :
1. A NONPROFIT HEALTH C ARE PROVIDER
PROFESSIONAL MEDICAL OR CLINICAL SPECIALT Y SOCIETY, INCLUDING THROUGH
THE USE OF PATIENT P LACEMENT CRITERIA AN D CLINICAL PRACTICE GUIDELINES;
OR
2. FOR CRITERIA NOT WIT HIN THE SCOPE OF A
NONPROFIT HEALTH CARE PROVIDER PROFESSIONAL MEDICAL OR CLINICAL
SPECIALTY SOCIETY , AN ORGANIZATION THAT WORKS DIRECTLY WITH HEALTH
CARE PROVIDERS IN TH E SAME SPECIALTY FOR THE DESIGNATED CRITE RIA WHO
ARE EMPLOYED OR ENGA GED WITHIN THE ORGAN IZATION OR OUTSIDE T HE
ORGANIZATION TO DEVELO P THE CLINICAL CRITE RIA, IF THE ORGANIZATION :
A. DOES NOT RECEIVE DIR ECT PAYMENTS BASED O N THE
OUTCOME OF THE UTILI ZATION REVIEW ; AND
Ch. 848 2024 LAWS OF MARYLAND
– 24 –
B. DEMONSTRATES THAT IT S CLINICAL CRITERIA ARE
CONSISTENT WITH CRIT ERIA AND STANDARDS G ENERALLY RECOGNIZED BY HE ALTH
CARE PROVIDERS PRACT ICING IN THE RELEVAN T CLINICAL SPECIALTI ES;
(V) RECOMMENDED BY FEDER AL AGENCIES;
(VI) APPROVED BY THE FEDE RAL FOOD AND DRUG
ADMINISTRATION AS PAR T OF DRUG LABELING ;
(VII) TAKING INTO ACCOUNT THE NEEDS OF ATYPICAL PA TIENT
POPULATIONS AND DIAG NOSES, INCLUDING THE UNIQUE NEEDS OF CHILDREN AN D
ADOLESCENTS ;
(VIII) SUFFICIENTLY FLEXIBL E TO ALLOW DEVIATION S FROM
NORMS WHEN JUSTIFIED ON A CASE–BY–CASE BASIS, INCLUDING THE NEED T O 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 NECE SSARY TO REFLECT ANY CHANGES; AND
(XI) IN COMPLIANCE WITH A NY OTHER CRITERIA AN D
STANDARDS REQUIRED F OR COVERAGE UNDER THIS TITLE, INCLUDING
COMPLIANCE WITH § 15–802(D) OF THIS TITLE FOR TH E TREATMENT OF SUBST ANCE
USE DISORDERS .
(b) [On the written request of any person or health care facility, the] THE private
review agent shall [provide 1 copy of]:
(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
[to the person or health care facility making the request]; AND
(2) ON THE REQUEST OF A PERSON, INCLUDING A HEALTH C ARE
FACILITY, PROVIDE A COPY OF TH E INFORMATION SPECIF IED UNDER ITEM (1) OF
THIS SUBSECTION TO T HE 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)] (B)(2) of this section. WES MOORE, Governor Ch. 848
– 25 –
(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.
15–10B–06.
(a) (1) Except as OTHERWISE provided in [paragraph (4) of] this subsection,
a private review agent shall:
(i) make all initial determinations on whether to authorize or certify
a nonemergency course of treatment OR HEALTH CARE SERVI CE, INCLUDING
PHARMACEUTICAL SERVICES NOT SUBMITTED ELECTR ONICALLY, 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; [and]
(III) MAKE ALL DETERMINATI ONS TO AUTHORIZE OR CERTIFY A
REQUEST FOR ADDITION AL VISITS OR DAYS OF CARE SUBMITT ED AS PART OF AN
EXISTING COURSE OF T REATMENT OR TREATMEN T PLAN WITHIN 1 WORKING DAY
AFTER RECEIPT OF THE INFORMATION NECESSAR Y TO MAKE THE DETERM INATION;
AND
[(iii)] (IV) promptly notify the health care provider of the
determination.
(2) [If within 3 calendar days after] AFTER receipt of the initial request
for health care services AND CONFIRMING THROU GH A COMPLETE REVIEW OF
INFORMATION ALREADY SUBMITTED BY THE HEA LTH CARE PROVIDER , IF the private
review agent DETERMINES THAT THE PRIVATE REVIEW AGEN T 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 INITI AL REQUEST, inform
the health care provider that additional information must be provided BY SPECIFYING:
Ch. 848 2024 LAWS OF MARYLAND
– 26 –
(I) THE INFORMATION , INCLUDING ANY LAB OR DIAGNOSTIC
TEST OR OTHER MEDICA L INFORMATION , THAT MUST BE SUBMITT ED TO COMPLETE
THE REQUEST ; AND
(II) THE CRITERIA AND STA NDARDS TO SUPPORT TH E NEED FOR
ADDITIONAL INFORMATI ON.
[(3)] (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:
[(i)] (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; [and]
(2) IF ADDITIONAL INFORM ATION IS NEEDED , PROMPTLY REQUEST
THE SPECIFIC INFORMA TION NEEDED, INCLUDING ANY LAB OR DIAGNOSTIC TEST OR
OTHER MEDICAL INFORM ATION; AND
[(ii)] (3) promptly notify the health care provider of the
determination.
[(4)] (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 [business] WORKING day after the private review agent receives all of
the information necessary to make the determination.
(2) IF ADDITIONAL INFORMA TION IS NEEDED TO MA KE A
DETERMINATION AFTER CONFIRMING THROUGH A COMPLETE REVIEW OF T HE
INFORMATION ALREADY SUBMITTED BY THE HEA LTH CARE PROVIDER , THE PRIVATE WES MOORE, Governor Ch. 848
– 27 –
REVIEW AGENT SHALL R EQUEST THE INFORMATI ON PROMPTLY , BUT NOT LATER
THAN 3 CALENDAR DAYS AFTER R ECEIPT OF THE INITIA L REQUEST, BY SPECIFYING:
(I) THE INFORMATION , INCLUDING ANY LAB OR DIAGNOSTIC
TEST OR OTHER MEDICA L INFORMATION , THAT MUST BE SUBMITT ED TO COMPLETE
THE REQUEST ; AND
(II) THE CRITERIA AND STA NDARDS TO SUPPORT THE NEED FOR
THE ADDITIONAL INFOR MATION.
(D) (1) (I) A EXCEPT AS PROVIDED IN SUBSECTIONS (G) AND (H) OF
THIS SECTION, A PRIVATE REVIEW AGENT SHALL MAKE INITIAL D ETERMINATIONS
ON WHETHER TO AUTHOR IZE OR CERTIFY AN EM ERGENCY COURSE OF TR EATMENT
OR HEALTH CARE SERVICE FOR A M EMBER WITHIN 24 HOURS AFTER THE INIT IAL
REQUEST AFTER RECEIP T OF THE INFORMATION NECESSARY TO MAKE TH E
DETERMINATION .
(II) IF THE PRIVATE REVIEW AGENT DETERMINES THA T
ADDITIONAL INFORMATI ON IS NEEDED AFTER C ONFIRMING THROUGH A COMPLETE
REVIEW OF THE INFORM ATION ALREADY SUBMIT TED BY THE HEALTH CA RE
PROVIDER, THE PRIVATE REVIEW A GENT SHALL:
1. PROMPTLY REQUEST THE SPECIFIC INFORMATION
NEEDED, INCLUDING ANY LAB OR DIAGNOSTIC TEST OR O THER MEDICAL
INFORMATION ; AND
2. PROMPTLY, BUT NOT LATER THAN 2 HOURS AFTER
RECEIPT OF THE INFOR MATION, NOTIFY THE HEALTH CA RE PROVIDER OF AN
AUTHORIZATION OR CER TIFICATION DETERMINA TION WHEN MADE BY TH E PRIVATE
REVIEW AGENT .
(2) A PRIVATE REVIEW AGENT SHALL INITIATE THE E XPEDITED
PROCEDURE FOR AN EMERGENCY CASE IF THE PATIENT OR THE P ATIENT’S
REPRESENTATIVE REQUE STS OR IF THE HEALTH CARE PROV IDER ATTESTS THAT
THE SERVICES ARE NEC ESSARY TO TREAT A CO NDITION OR ILLNESS T HAT, WITHOUT
IMMEDIATE MEDICAL AT TENTION, WOULD:
(I) SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH O F THE
MEMBER OR THE MEMBER ’S ABILITY TO REGAIN MAXIMUM FUNCTIONS ;
(II) CAUSE THE MEMBER TO BE IN DANGER TO SELF OR OTHERS;
OR
Ch. 848 2024 LAWS OF MARYLAND
– 28 –
(III) CAUSE THE MEMBER TO CONTINUE USING INTOX ICATING
SUBSTANCES IN AN IMM INENTLY DANGEROUS MA NNER.
(E) IF A PRIVATE REVIEW A GENT FAILS TO MAKE A DETERMINATION WITHIN
THE TIME LIMITS REQU IRED UNDER THIS SECT ION, THE REQUEST SHALL BE
DEEMED APPROVED .
[(b)] (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 [may]
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 U NABLE TO IMMEDIATELY SPEAK WITH THE
HEALTH CARE PROVIDER SEEKING THE RECONSID ERATION, THE PHYSICIAN SHALL
PROVIDE THE HEALTH C ARE PROVIDER WITH TH E FOLLOWING CONTACT
INFORMATION FOR THE HEALTH CARE PROVIDER TO USE TO CONTACT TH E
PHYSICIAN:
(I) A DIRECT TELEPHONE N UMBER THAT IS NOT TH E GENERAL
CUSTOMER CALL NUMBER ; OR
(II) A MONITORED E –MAIL ADDRESS THAT IS DEDICATED TO
COMMUNICATION RELATE D TO UTILIZATION REV IEW.
[(c)] (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.
[(d)] (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;
WES MOORE, Governor Ch. 848
– 29 –
(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.
[(e)] (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:
Ch. 848 2024 LAWS OF MARYLAND
– 30 –
(i) shall be properly completed by the health care provider; and
(ii) may be submitted by electronic transfer.
15–10B–07.
(a) (1) Except as provided in paragraphs (2) and (3) of this subsection, all
adverse decisions shall be made by a LICENSED physician, or a panel of other appropriate
health care service reviewers with at least one physician on the panel, who is:
(I) board certified or eligible in the same specialty as the treatment
under review; AND
(II) KNOWLEDGEABLE ABOUT THE REQUESTED HEALTH CARE
SERVICE OR TREATMENT THROUGH ACTUAL CLINI CAL EXPERIENCE .
(2) When the health care service under review is a mental health or
substance abuse service, the adverse decision shall be made by a LICENSED physician, or
a panel of other appropriate health care service reviewers with at least one LICENSED
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 WHO IS
KNOWLEDGEABLE ABOUT THE REQUESTED HEALTH CARE SERVICE OR TREA TMENT
THROUGH ACTUAL CLINI CAL EXPERIENCE .
(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: WES MOORE, Governor Ch. 848
– 31 –
(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.
15–10B–09.1.
A grievance decision shall be made based on the professional judgment of:
(1) (i) a LICENSED physician who is board certified or eligible in the
same specialty as the treatment under review AND KNOWLEDGEABLE AB OUT THE
REQUESTED HEALTH CAR E SERVICE OR TREATME NT THROUGH ACTUAL CL INICAL
EXPERIENCE ; or
(ii) a panel of other appropriate health care service reviewers with
at least one LICENSED physician on the panel who is board certified or eligible in the same
specialty as the treatment under review AND KNOWLEDGEABLE AB OUT THE
REQUESTED HEALTH CAR E SERVICE OR TREATME NT THROUGH ACTUAL CL INICAL
EXPERIENCE ;
(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 AND KNOWLEDGEABLE
ABOUT THE REQUESTED HEALTH CARE SERVICE OR TREATMENT THROUGH ACTUAL
CLINICAL EXPERIENCE ; 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
Ch. 848 2024 LAWS OF MARYLAND
– 32 –
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 LICENSED 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.
SECTION 2. AND BE IT FURTHER ENACTED, That:
(a) The Maryland Health Care Commission and the Maryland Insurance
Administration, in consultation with health care practitioners and payors of health care
services, jointly shall conduct a study on the development of standards for the
implementation of payor programs to modify prior authorization requirements for
prescription drugs, medical care, and other health care services based on health care
practitioner–specific criteria.
(b) The study conducted under subsection (a) of this section shall include, through
an examination of literature review and legislatively or voluntarily established programs
that have been implemented or are being considered in other states, an analysis of:
(1) adjustments to payor prior authorization requirements based on a
health care practitioner’s:
(i) prior approval rates;
(ii) ordering and prescribing patterns; and
(iii) participation in a payor’s two–sided incentive arrangement or a
capitation program; and
(2) any other information or metrics necessary to implement the payor
programs.
(c) On or before December 1, 2024, the Maryland Health Care Commission and
the Maryland Insurance Administration jointly shall submit a report to the General
Assembly, in accordance with § 2–1257 of the State Government Article, with the findings
and recommendations from the study, including recommendations for legislative initiatives
necessary for the establishment of payor programs modifying prior authorization
requirements based on health care practitioner–specific criteria.
SECTION 3. AND BE IT FURTHER ENACTED, That: WES MOORE, Governor Ch. 848
– 33 –
(a) The Maryland Health Care Commission and the Maryland Insurance
Administration jointly shall establish a workgroup to, in consultation with the Maryland
Insurance Administration, shall:
(1) assess monitor the progress toward implementing the requirements in
§ 19–108.5 of the Health – General Article, as enacted by Section 1 of this Act, including
monitoring any federal or State developments relating to the requirements; and
(2) review issues or recommendations from other states that are
implementing a real–time benefit requirement, including establishing a link at the point of
prescribing for any available coupons.
(b) On or before December 1, 2025, the Maryland Health Care Commission and
the Maryland Insurance Administration jointly shall submit a report to shall inform the
General Assembly, in accordance with § 2–1257 of the State Government Article, with of
any findings and recommendations from the workgroup relating to the implementation of
§ 19–108.5 of the Health – General Article, as enacted by Section 1 of this Act.
SECTION 4. AND BE IT FURTHER ENACTED, That Section 1 of this Act shall take
effect January 1, 2025.
SECTION 5. AND BE IT FURTHER ENACTED, That, except as provided in Section
4 of this Act, this Act shall take effect July 1, 2024.
Approved by the Governor, May 16, 2024.