<?xml version='1.0' encoding='utf-8'?>
<section article="gin" article_name="Insurance" number="15-10B-06" title_number="15" title_name="Health Insurance" subtitle_number="10B" subtitle_name="Private Review Agents">
  <level label="a">
    <level label="1">
      <text>Except as otherwise provided in this subsection, a private review agent shall:</text>
      <level label="i">
        <text>make all initial determinations on whether to authorize or certify a nonemergency course of treatment or health care service, including pharmaceutical services not submitted electronically, for a patient within 2 working days after receipt of the information necessary to make the determination;</text>
      </level>
      <level label="ii">
        <text>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;</text>
      </level>
      <level label="iii">
        <text>make all determinations to authorize or certify a request for additional visits or days of care submitted as part of an existing course of treatment or treatment plan within 1 working day after receipt of the information necessary to make the determination; and</text>
      </level>
      <level label="iv">
        <text>promptly notify the health care provider of the determination.</text>
      </level>
    </level>
    <level label="2">
      <text>After receipt of the initial request for health care services and confirming through a complete review of information already submitted by the health care provider, if the private review agent determines that the private review agent 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 initial request, inform the health care provider that additional information must be provided by specifying:</text>
      <level label="i">
        <text>the information, including any lab or diagnostic test or other medical information, that must be submitted to complete the request; and</text>
      </level>
      <level label="ii">
        <text>the criteria and standards to support the need for additional information.</text>
      </level>
    </level>
  </level>
  <level label="b">
    <text>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:</text>
    <level label="1">
      <text>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;</text>
    </level>
    <level label="2">
      <text>if additional information is needed, promptly request the specific information needed, including any lab or diagnostic test or other medical information; and</text>
    </level>
    <level label="3">
      <text>promptly notify the health care provider of the determination.</text>
    </level>
  </level>
  <level label="c">
    <level label="1">
      <text>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:</text>
      <level label="i">
        <text>in real time if:</text>
        <level label="1">
          <text>no additional information is needed by the private review agent to process the request; and</text>
        </level>
        <level label="2">
          <text>the request meets the private review agent’s criteria for approval; or</text>
        </level>
      </level>
      <level label="ii">
        <text>if a request is not approved in real time under item (i) of this paragraph, within 1 working day after the private review agent receives all of the information necessary to make the determination.</text>
      </level>
    </level>
    <level label="2">
      <text>If additional information is needed to make a determination after confirming through a complete review of the information already submitted by the health care provider, the private review agent shall request the information promptly, but not later than 3 calendar days after receipt of the initial request, by specifying:</text>
      <level label="i">
        <text>the information, including any lab or diagnostic test or other medical information, that must be submitted to complete the request; and</text>
      </level>
      <level label="ii">
        <text>the criteria and standards to support the need for the additional information.</text>
      </level>
    </level>
  </level>
  <level label="d">
    <level label="1">
      <level label="i">
        <text>Except as provided in subsections (g) and (h) of this section, a private review agent shall make initial determinations on whether to authorize or certify an emergency course of treatment or health care service for a member within 24 hours after the initial request after receipt of the information necessary to make the determination.</text>
      </level>
      <level label="ii">
        <text>If the private review agent determines that additional information is needed after confirming through a complete review of the information already submitted by the health care provider, the private review agent shall:</text>
        <level label="1">
          <text>promptly request the specific information needed, including any lab or diagnostic test or other medical information; and</text>
        </level>
        <level label="2">
          <text>promptly, but not later than 2 hours after receipt of the information, notify the health care provider of an authorization or certification determination when made by the private review agent.</text>
        </level>
      </level>
    </level>
    <level label="2">
      <text>A private review agent shall initiate the expedited procedure for an emergency case if the patient or the patient’s representative requests or if the health care provider attests that the services are necessary to treat a condition or illness that, without immediate medical attention, would:</text>
      <level label="i">
        <text>seriously jeopardize the life or health of the member or the member’s ability to regain maximum functions;</text>
      </level>
      <level label="ii">
        <text>cause the member to be in danger to self or others; or</text>
      </level>
      <level label="iii">
        <text>cause the member to continue using intoxicating substances in an imminently dangerous manner.</text>
      </level>
    </level>
  </level>
  <level label="e">
    <text>If a private review agent fails to make a determination within the time limits required under this section, the request shall be deemed approved.</text>
  </level>
  <level label="f">
    <level label="1">
      <text>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 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.</text>
    </level>
    <level label="2">
      <text>If the physician is unable to immediately speak with the health care provider seeking the reconsideration, the physician shall provide the health care provider with the following contact information for the health care provider to use to contact the physician:</text>
      <level label="i">
        <text>a direct telephone number that is not the general customer call number; or</text>
      </level>
      <level label="ii">
        <text>a monitored e–mail address that is dedicated to communication related to utilization review.</text>
      </level>
    </level>
  </level>
  <level label="g">
    <text>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:</text>
    <level label="1">
      <text>the patient’s insurance status; and</text>
    </level>
    <level label="2">
      <text>if applicable, the private review agent’s emergency admission notification requirements.</text>
    </level>
  </level>
  <level label="h">
    <level label="1">
      <text>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:</text>
      <level label="i">
        <text>the admission is based on a determination that the patient is in imminent danger to self or others;</text>
      </level>
      <level label="ii">
        <text>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</text>
      </level>
      <level label="iii">
        <text>the hospital immediately notifies the private review agent of:</text>
        <level label="1">
          <text>the admission of the patient; and</text>
        </level>
        <level label="2">
          <text>the reasons for the admission.</text>
        </level>
      </level>
    </level>
    <level label="2">
      <text>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:</text>
      <level label="i">
        <text>the admission is an involuntary admission under §§ 10–615 and 10–617(a) of the Health – General Article; and</text>
      </level>
      <level label="ii">
        <text>the hospital immediately notifies the private review agent of:</text>
        <level label="1">
          <text>the admission of the patient; and</text>
        </level>
        <level label="2">
          <text>the reasons for the admission.</text>
        </level>
      </level>
    </level>
  </level>
  <level label="i">
    <level label="1">
      <text>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:</text>
      <level label="i">
        <text>shall accept:</text>
        <level label="1">
          <text>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</text>
        </level>
        <level label="2">
          <text>if a service was provided in another state, a treatment plan form mandated by the state in which the service was provided; and</text>
        </level>
      </level>
      <level label="ii">
        <text>may not impose any requirement to:</text>
        <level label="1">
          <text>modify the uniform treatment plan form or its content; or</text>
        </level>
        <level label="2">
          <text>submit additional treatment plan forms.</text>
        </level>
      </level>
    </level>
    <level label="2">
      <text>A uniform treatment plan form submitted under the provisions of this subsection:</text>
      <level label="i">
        <text>shall be properly completed by the health care provider; and</text>
      </level>
      <level label="ii">
        <text>may be submitted by electronic transfer.</text>
      </level>
    </level>
  </level>
</section>
