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<section article="gin" article_name="Insurance" number="15-1001" title_number="15" title_name="Health Insurance" subtitle_number="10" subtitle_name="Claims and Utilization Review">
  <level label="a">
    <text>This section applies to entities that propose to issue or deliver individual, group, or blanket health insurance policies or contracts in the State or to administer health benefit programs that provide for the coverage of health care services and the utilization review of those services, including:</text>
    <level label="1">
      <text>an authorized insurer that provides health insurance in the State;</text>
    </level>
    <level label="2">
      <text>a nonprofit health service plan;</text>
    </level>
    <level label="3">
      <text>a health maintenance organization;</text>
    </level>
    <level label="4">
      <text>a dental plan organization; or</text>
    </level>
    <level label="5">
      <text>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.</text>
    </level>
  </level>
  <level label="b">
    <level label="1">
      <text>Subject to paragraph (2) of this subsection, each entity subject to this section shall:</text>
      <level label="i">
        <level label="1">
          <text>have a certificate issued under Subtitle 10B of this title; or</text>
        </level>
        <level label="2">
          <text>contract with a private review agent that has a certificate issued under Subtitle 10B of this title; and</text>
        </level>
      </level>
      <level label="ii">
        <text>when conducting utilization review for mental health and substance use benefits, ensure that the criteria and standards used are in compliance with the federal Mental Health Parity and Addiction Equity Act.</text>
      </level>
    </level>
    <level label="2">
      <text>For hospital services, each entity subject to this section may contract with or delegate utilization review to a hospital utilization review program approved under § 19–319(d) of the Health – General Article.</text>
    </level>
  </level>
  <level label="c">
    <text>Notwithstanding any other provision of this article, if the medical necessity of providing a covered benefit is disputed, an entity subject to this section that does not meet the requirements of subsection (b) of this section shall pay any person entitled to reimbursement under the policy or contract in accordance with the determination of medical necessity by:</text>
    <level label="1">
      <text>the treating provider; or</text>
    </level>
    <level label="2">
      <text>when hospital services are provided, the hospital utilization review program approved under § 19-319(d) of the Health - General Article.</text>
    </level>
  </level>
  <level label="d">
    <text>An entity subject to this section may not:</text>
    <level label="1">
      <text>act as a private review agent without holding a certificate issued under Subtitle 10B of this title; or</text>
    </level>
    <level label="2">
      <text>use a private review agent that does not hold a certificate issued under Subtitle 10B of this title.</text>
    </level>
  </level>
  <level label="e">
    <text>An entity that violates any provision of this section is subject to the penalties provided under § 15-10B-12 of this title.</text>
  </level>
</section>
