<?xml version='1.0' encoding='utf-8'?>
<section article="gin" article_name="Insurance" number="15-10B-17" title_number="15" title_name="Health Insurance" subtitle_number="10B" subtitle_name="Private Review Agents">
  <level label="a">
    <level label="1">
      <text>Except as provided in paragraph (2) of this subsection, this section does not apply to:</text>
      <level label="i">
        <text>a private review agent referring an individual to a health care provider or facility that participates in a health maintenance organization;</text>
      </level>
      <level label="ii">
        <text>a preferred provider organization network of participating health care providers or facilities to which the individual would otherwise be referred as part of the individual’s membership or insurance contract; or</text>
      </level>
      <level label="iii">
        <text>an employee assistance program referring an individual to a network of participating health care providers or facilities in accordance with a contract with the individual’s employer or labor union to provide comprehensive mental health and substance abuse services.</text>
      </level>
    </level>
    <level label="2">
      <text>A private review agent or any other individual who is either affiliated with, under contract with, or acting on behalf of a private review agent may not approve or fail to approve a course of treatment based on whether the treatment is delivered by a provider who is a participating or nonparticipating provider in the preferred provider organization or employee assistance program network.</text>
    </level>
  </level>
  <level label="b">
    <text>A private review agent or any individual who is either affiliated with, under contract with, or acting on behalf of a private review agent may not:</text>
    <level label="1">
      <text>refer a patient who has undergone utilization review by the private review agent to:</text>
      <level label="i">
        <text>a health care facility in which the private review agent owns a significant beneficial interest; or</text>
      </level>
      <level label="ii">
        <text>the private review agent’s own health care practice;</text>
      </level>
    </level>
    <level label="2">
      <text>pay or agree to pay any sum to, or accept or agree to accept any sum from, any person for bringing or referring a patient to the private review agent; or</text>
    </level>
    <level label="3">
      <text>provide for different insurance coverage or benefits based on receiving the service from a health care facility or health care provider in which the private review agent owns a significant beneficial interest.</text>
    </level>
  </level>
  <level label="c">
    <text>A private review agent or any individual who is either affiliated with, under contract with, or acting on behalf of a private review agent may refer a patient who has undergone utilization review by the private review agent to another health care provider regulated under the Health Occupations Article if:</text>
    <level label="1">
      <level label="i">
        <text>the patient or provider requests the private review agent to provide the patient with the name of a health care provider appropriate to meet the health care needs of the patient; or</text>
      </level>
      <level label="ii">
        <text>the patient has no attending physician; and</text>
      </level>
    </level>
    <level label="2">
      <text>the private review agent provides the patient with the names of at least two health care providers appropriate to meet the health care needs of the patient.</text>
    </level>
  </level>
</section>
