# Insurance (GIN)

## Title 15. Health Insurance

### Subtitle 10C. Medical Directors

#### Section 15-10C-01

(a) In this subtitle the following words have the meanings indicated.

(b) "Board" means the State Board of Physicians established under Title 14 of the Health Occupations Article.

(c) "Certificate" means a certificate issued by the Commissioner under this subtitle to act as a medical director.

(d) "Department" means the Maryland Department of Health.

(e) "Health maintenance organization" has the meaning stated in Sec. 19-701 of the Health - General Article.

(f)

  (1) "Medical director" means a physician employed by or under contract with a health maintenance organization who is responsible for:

    (i) the establishment or maintenance of the policies and procedures at the health maintenance organization for:

      (1) quality assurance; and

      (2) utilization management;

    (ii) compliance with the quality assurance and utilization management policies and procedures of the health maintenance organization; and

    (iii) oversight of utilization review decisions of private review agents employed by or under contract with the health maintenance organization.

  (2) "Medical director" includes an associate medical director or an assistant medical director, as defined by the Commissioner by regulation.

#### Section 15-10C-02

The Commissioner, in consultation with the Department and the Board, shall establish and adopt by regulation standards for:

(1) the certification of medical directors;

(2) the renewal, suspension, and revocation of a certificate; and

(3) the issuance of a temporary certificate.

#### Section 15-10C-03

(a) To be certified as a medical director under this subtitle, an applicant shall:

  (1) submit an application to the Commissioner on the form required by the Commissioner; and

  (2) pay to the Commissioner an application fee of no more than $100 established by the Commissioner by regulation.

(b) The application shall include:

  (1) a description of the applicant's professional qualifications, including medical education information and, if appropriate, board certifications and licensure status;

  (2) the utilization management procedures and policies to be used by the health maintenance organization; and

  (3) certification by the medical director that the utilization management procedures and policies are:

    (i) objective;

    (ii) clinically valid;

    (iii) compatible with established principles of health care; and

    (iv) flexible enough to allow deviations from the norms when justified on a case by case basis.

(c) The delegation by a medical director of any of the medical director's responsibilities under this subtitle to an associate medical director or an assistant medical director does not prevent the medical director, regardless of the delegation, from being held responsible for any violation of this subtitle.

#### Section 15-10C-04

(a) Subject to the hearing procedures in Sec.Sec. 2-210 through 2-214 of this article, the Commissioner may suspend, revoke, or refuse to renew a certificate of a medical director if the Commissioner finds a pattern that the utilization management procedures and policies used by the medical director in making utilization review decisions or used by a private review agent employed by or under contract with the health maintenance organization over whose utilization review decisions the medical director has responsibility are not:

  (1) objective;

  (2) clinically valid;

  (3) compatible with established principles of health care; or

  (4) flexible enough to allow deviations from the norms when justified on a case by case basis.

(b) The Commissioner may consult with an independent review organization or medical expert that meets the requirements of Sec. 15-10A-05 of this title, the Department, the Board, or any other appropriate entity for purposes of taking an action described under subsection (a) of this section.

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Md. Code Ann., Ins. (as displayed at mgaleg.maryland.gov, October 16, 2026)