# COMAR Title 10 — Maryland Department of Health

## Subtitle 25 — Maryland Health Care Commission

### Chapter 17 — Benchmarks for Preauthorization of Health Care Services

#### Regulation .03 Benchmarks.

*COMAR 10.25.17.03*

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.