Regulation .03 Benchmarks.
Regulation .03 Benchmarks.LinkCopy Citation
A.
Each payor shall establish and maintain online access for a provider to the following:
(1)
A list of each health care service that requires preauthorization by the payor; and
(2)
Key criteria used by the payor for making a determination on a preauthorization request.
B.
Each payor shall establish and maintain an online process for:
(1)
Accepting electronically a preauthorization request from a provider; and
(2)
Assigning to a preauthorization request a unique electronic identification number that a provider may use to track the request during the preauthorization process, whether the request is tracked electronically, through a call center, or by fax.
C.
Each payor shall establish and maintain an online preauthorization system that meets the requirements of Health-General Article, §19-108.2(e), Annotated Code of Maryland, to:
(1)
Approve in real time, electronic preauthorization requests for pharmaceutical services:
(a)
For which no additional information is needed by the payor to process the preauthorization request; and
(b)
That meet the payor’s criteria for approval;
(2)
Render a determination within 1 business day after receiving all pertinent information on requests not approved in real time, electronic preauthorization requests for pharmaceutical services that:
(a)
Are not urgent; and
(b)
Do not meet the standards for real-time approval under §C(1) of this regulation; and
(3)
Render a determination within 2 business days after receiving all pertinent information, electronic preauthorization requests for health care services, except pharmaceutical services, that are not urgent.
D.
Each payor that requires a step therapy or fail-first protocol shall:
(1)
Establish and maintain an online process to allow a prescriber to override the step therapy or fail-first protocol if:
(a)
The step therapy drug has not been approved by the United States Food and Drug Administration for the medical condition being treated; or
(b)
A prescriber provides supporting medical information to the payor that a prescription drug covered by the payor:
(i)
Was ordered by the prescriber for the insured or enrollee within the past 180 days; and
(ii)
Based on the professional judgment of the prescriber, was effective in treating the insured's or enrollee's disease or medical condition;
(2)
Provide notice to prescribers regarding the availability of its online process; and
(3)
Provide information to insureds or enrollees on the availability of the step therapy or fail-first protocol within its network.
E.
A payor that becomes authorized to provide benefits or services within the State of Maryland after October 1, 2012, shall meet each benchmark within this chapter within 3 months of the payor's offering of services or benefits within the State and shall thereafter maintain the processes or actions required by each benchmark.