Md. Code Regs. 31.10.21.01

Current through Register Vol. 51, No. 22, November 1, 2024

Section 31.10.21.01 - Definitions

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

(1) "Accrediting organization" means an entity that accredits or certifies the utilization management activities of a private review agent.

(2) "Administration" means the Maryland Insurance Administration.

(3) Adverse Decision.

(a) "Adverse decision" means a utilization review determination made by a private review agent that a proposed or delivered health care service that is otherwise covered under the patient's contract:

(i) Is or was not medically necessary, appropriate, or efficient; and

(ii) May result in noncoverage of the health care service.

(b) "Adverse decision" does not include a decision concerning a subscriber's status as a member.

(4) "Approved accrediting organization" means an accrediting organization that has been approved by the Commissioner as having accreditation standards that meet or exceed standards in this chapter.

(5) "Carrier" has the meaning stated in Insurance Article, § 15-10 A-01, Annotated Code of Maryland.

(6) "Certificate" means a certificate of registration granted by the Commissioner to a private review agent.

(7) "Commissioner" means the State Insurance Commissioner.

(8) "Contact information" means an individual's name, job title and department, address, telephone number, facsimile number, and email address.

(9) "Emergency case" means a case involving an adverse decision for which an expedited review is required under COMAR 31.10.18.05B.

(10) Employee Assistance Program.

(a) "Employee assistance program" means a health care service plan that, in accordance with a contract with an employer or labor union:

(i) Consults with employees or members of an employee's family or both to identify the employee's or the employee's family member's mental health, alcohol, or substance abuse problems, and refers the employee or the employee's family member to health care providers or other community resources for counseling, therapy, or treatment; and

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

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

(11) Grievance.

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

(b) "Grievance" does not include a verbal request for reconsideration of a utilization review determination.

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

(13) "Health care facility" means:

(a) A hospital as defined in Health-General Article, §19-301, Annotated Code of Maryland;

(b) A related institution as defined in Health-General Article, §19-301, Annotated Code of Maryland;

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

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

(e) A home health agency as defined in Health-General Article, §19-401, Annotated Code of Maryland;

(f) A hospice as defined in Health-General Article, §19-901, Annotated Code of Maryland;

(g) A facility that provides radiological or other diagnostic imagery services;

(h) A medical laboratory as defined in Health-General Article, §17-201, Annotated Code of Maryland; or

(i) An alcohol abuse and drug abuse treatment program as defined in Health-General Article, §8-403, Annotated Code of Maryland.

(14) "Health care provider" means:

(a) An individual who is:

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

(ii) A treating provider of the patient; or

(b) A hospital, as defined in Health-General Article, §19-301, Annotated Code of Maryland.

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

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

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

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

(16) "Private review agent" means:

(a) A non-hospital-affiliated person or entity performing utilization review that is either affiliated with, under contract with, or acting on behalf of a Maryland business entity, or a third party that pays for, provides, or administers health care services to citizens of this State; or

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

(i) Employed by the hospital; or

(ii) Employed by a business wholly owned by the hospital.

(17) "Reconsideration" means a verbal request or verbal inquiry by a patient, the patient's representative, or a provider regarding an adverse decision.

(18) "Significant beneficial interest" means the ownership of any financial interest that is greater than the lesser of:

(a) 5 percent of the whole; or

(b) $5,000.

(19) "Specific criteria and standards" means professionally developed objective measures used during utilization review to make determinations to authorize or certify the appropriate use and efficient allocation of health care resources.

(20) "Uniform treatment plan form" means a form specified by the Commissioner to be used for utilization review of services for the treatment of a mental illness, emotional disorder, or a substance abuse disorder.

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

(22) "Utilization review plan" means a description of the standards governing utilization review activities performed by a private review agent.

Md. Code Regs. 31.10.21.01

Regulation .01 amended effective 45:17 Md. R. 804, eff. 8/27/2018