Chapter 17. Benchmarks for Preauthorization of Health Care Services

Requires preauthorization for health care services; and

Is required to report to the Maryland Health Care Commission on its attainment and plans for attainment of certain preauthorization benchmarks.

Workers’ compensation claims pursuant to Labor and Employment Article, Title 9, Annotated Code of Maryland; or

Personal injury protection claims pursuant to Insurance Article, Title 19, Annotated Code of Maryland..

“Commission” means the Maryland Health Care Commission.

“Executive Director” means the Executive Director of the Commission or the Executive Director’s designee.

“Health Care Service” has the meaning stated in Insurance Article, §15-10A-01, Annotated Code of Maryland.

“Payor” means one of the following State-regulated entities that require preauthorization for a health care service:

“Preauthorization” means the process of obtaining approval from a payor by meeting certain criteria before a certain health care service can be rendered by the health care provider.

“Prescriber” means a health care practitioner who has the required license and, if necessary, scope of practice or delegation agreement that permits the health care practitioner to prescribe drugs to treat medical conditions or diseases.

Step therapy or fail-first protocol" is a protocol established by an insurer, a nonprofit health service plan, a health maintenance organization, or a pharmacy benefits manager that requires a certain prescription drug or sequence of prescription drugs to be used by an insured individual or an enrollee before another specific prescription drug ordered by a prescriber is covered.

“Supporting medical information” means:

A list of each health care service that requires preauthorization by the payor; and

Key criteria used by the payor for making a determination on a preauthorization request.

Accepting electronically a preauthorization request from a provider; and

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.

Approve in real time, electronic preauthorization requests for pharmaceutical services:

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:

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.

Establish and maintain an online process to allow a prescriber to override the step therapy or fail-first protocol if:

Provide notice to prescribers regarding the availability of its online process; and

Provide information to insureds or enrollees on the availability of the step therapy or fail-first protocol within its network.

For an insurer or nonprofit health service plan, a premium volume that is less than $1,000,000 annually in the State;

For a group model health maintenance organization, as defined in Health-General Article, §19-713.6, Annotated Code of Maryland, preauthorizations of health care services requested by providers not employed by the group model health maintenance organization; or

Other circumstances determined by the Executive Director to be extenuating.

A request for a waiver or renewal of waiver shall be in writing and shall include:

A request for a waiver shall be filed with the Commission in accordance with the following:

The Executive Director may issue a waiver from a preauthorization benchmark to a payor that demonstrates extenuating circumstances within this chapter.

The Executive Director will review and provide a decision to approve or deny all waiver requests within a reasonable time frame.

A waiver or renewal of a waiver shall be valid for 2 years, unless withdrawn by the Executive Director.

The Executive Director may withdraw a waiver or renewal of a waiver if the Executive Director determines that the payor can no longer demonstrate extenuating circumstances.

If the Executive Director withdraws a waiver or renewal of waiver, the Executive Director shall notify the payor, setting forth in writing the reasons for withdrawal.

After a waiver or a renewal of a waiver is withdrawn, a payor shall submit a plan to the Executive Director within 30 days that includes a timeline for attaining each benchmark in Regulation .03 of this chapter in a format approved by the Commission.

If the Executive Director has denied or withdrawn a waiver, a payor may seek Commission review of the denial or withdrawal by filing a written request for review with the Commission within 20 days of receipt of the Executive Director’s notice of denial or withdrawal of a waiver, which shall:

The full Commission may review the written request for review of a denial or withdrawal of a waiver directly or, at the discretion of the Chair of the Commission, appoint a Commissioner to review the request submitted under §E(1) of this regulation, who will make a recommendation to the full Commission.

If a written request was submitted under §E(1)(c) of this regulation, a payor may orally address the Commission before a determination is made by the Commission as to whether or not to issue or withdraw a waiver.

After reviewing and considering a payor’s written request for review of the denial or withdrawal decision and any oral argument, if applicable, the full Commission shall issue a written decision affirming, reversing, or modifying the decision reviewed.