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<chapter num="16" heading="Carrier Provider Panels — Application Process" title_num="31" subtitle_num="10">
  <regulation prefix="Regulation" num=".01" heading="Applicability.">
    <text>This chapter applies to all insurers, nonprofit health service plans, health maintenance organizations, dental plans, and to any other person or organization which utilizes a provider panel and which provides health benefit plans subject to regulation in this State.</text>
  </regulation>
  <regulation prefix="Regulation" num=".02" heading="Definitions.">
    <paragraph num="A.">
      <text>In this chapter, the following terms have the meanings indicated.</text>
    </paragraph>
    <paragraph num="B.">
      <text>Terms Defined.</text>
      <paragraph num="(1)">
        <text>Carrier.</text>
        <paragraph num="(a)">
          <text>“Carrier” means:</text>
          <paragraph num="(i)">
            <text>An insurer;</text>
          </paragraph>
          <paragraph num="(ii)">
            <text>A nonprofit health service plan;</text>
          </paragraph>
          <paragraph num="(iii)">
            <text>A health maintenance organization;</text>
          </paragraph>
          <paragraph num="(iv)">
            <text>A dental plan organization; and</text>
          </paragraph>
          <paragraph num="(v)">
            <text>Any other person or organization that provides health benefit plans subject to State regulation.</text>
          </paragraph>
        </paragraph>
        <paragraph num="(b)">
          <text>“Carrier” includes an entity that arranges a provider panel for a carrier.</text>
        </paragraph>
      </paragraph>
      <paragraph num="(2)">
        <text>“Provider” means a health care practitioner or a group of health care practitioners licensed or otherwise authorized by law to provide health care services.</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Provider Panel.</text>
        <paragraph num="(a)">
          <text>“Provider panel” means those providers with which a carrier contracts to provide health care services to the carrier's enrollees under the carrier's health benefit plan.</text>
        </paragraph>
        <paragraph num="(b)">
          <text>“Provider panel” does not include an arrangement between a carrier and providers in which a provider may participate solely on the basis of the provider's contracting with the carrier to provide services at a discounted fee-for-service rate.</text>
        </paragraph>
      </paragraph>
    </paragraph>
  </regulation>
  <regulation prefix="Regulation" num=".03" heading="Requirements for Application Process.">
    <paragraph num="A.">
      <text>A carrier that utilizes a provider panel shall establish written procedures for reviewing applications for participation in the provider panel.</text>
    </paragraph>
    <paragraph num="B.">
      <text>A carrier that utilizes a provider panel shall, upon request, make its applications publicly available.</text>
    </paragraph>
    <paragraph num="C.">
      <text>The form of application:</text>
      <paragraph num="(1)">
        <text>Shall include instructions for completion of the application;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Shall provide a specifically designated space for dating the receipt of the application by the carrier; and</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Shall comply with federal and State laws concerning the Americans with Disability Act.</text>
      </paragraph>
    </paragraph>
    <paragraph num="D.">
      <text>A carrier shall maintain an application log which, at a minimum, provides the following information:</text>
      <paragraph num="(1)">
        <text>Name of the provider requesting or submitting the application;</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Date the provider requested an application, if applicable;</text>
      </paragraph>
      <paragraph num="(3)">
        <text>Date the application is sent or delivered to the provider, if applicable;</text>
      </paragraph>
      <paragraph num="(4)">
        <text>Date the application is received from the provider;</text>
      </paragraph>
      <paragraph num="(5)">
        <text>Date the application is returned to the provider with a request for additional information to complete the application, if applicable;</text>
      </paragraph>
      <paragraph num="(6)">
        <text>Date of receipt by the carrier of an application previously returned for additional information, if applicable;</text>
      </paragraph>
      <paragraph num="(7)">
        <text>Date that the provider is notified of:</text>
        <paragraph num="(a)">
          <text>Rejection, or</text>
        </paragraph>
        <paragraph num="(b)">
          <text>Carrier's intent to continue the credentialing process; and</text>
        </paragraph>
      </paragraph>
      <paragraph num="(8)">
        <text>Date after completion of credentialing that the provider is notified of acceptance or rejection in the provider panel.</text>
      </paragraph>
    </paragraph>
    <paragraph num="E.">
      <text>The log shall be available for inspection by the Commissioner.</text>
    </paragraph>
    <paragraph num="F.">
      <text>Notice.</text>
      <paragraph num="(1)">
        <text>A carrier shall:</text>
        <paragraph num="(a)">
          <text>If the carrier maintains a web site:</text>
          <paragraph num="(i)">
            <text>Post on the web site a notice of how to apply to the carrier's provider panel; and</text>
          </paragraph>
          <paragraph num="(ii)">
            <text>Provide, on request, a paper copy of the notice of how to apply to the carrier's provider panel; or</text>
          </paragraph>
        </paragraph>
        <paragraph num="(b)">
          <text>If the carrier does not maintain a web site, provide on request a paper copy of the notice of how to apply to the carrier's provider panel.</text>
        </paragraph>
      </paragraph>
      <paragraph num="(2)">
        <text>The notice required pursuant to §F(1) of this regulation shall include relevant addresses and telephone numbers for contact purposes.</text>
      </paragraph>
    </paragraph>
  </regulation>
  <regulation prefix="Regulation" num=".04" heading="Application Fees.">
    <paragraph num="A.">
      <text>A carrier may charge a reasonable fee for any application that a provider submits to the carrier.</text>
    </paragraph>
    <paragraph num="B.">
      <text>The fee shall be nonrefundable and uniform for all applicants within a practice specialty.</text>
    </paragraph>
    <paragraph num="C.">
      <text>The fee may not exceed $75 for each provider application.</text>
    </paragraph>
    <paragraph num="D.">
      <text>A carrier may not charge additional fees for processing an application which was returned because of insufficient information.</text>
    </paragraph>
  </regulation>
  <regulation prefix="Regulation" num=".05" heading="Document Retention.">
    <paragraph num="A.">
      <text>A carrier shall maintain its provider application log for a minimum of 3 years or until its next market conduct examination, whichever occurs last.</text>
    </paragraph>
    <paragraph num="B.">
      <text>A carrier shall:</text>
      <paragraph num="(1)">
        <text>Date stamp each application received from a provider upon initial receipt; and</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Maintain a legible copy of each application, and any correspondence regarding that application, for a minimum of 3 years or until its next market conduct examination, whichever occurs last.</text>
      </paragraph>
    </paragraph>
  </regulation>
  <annotations>
    <annotation type="Authority">Insurance Article, §§2-109 and 15-112, Annotated Code of Maryland</annotation>
    <annotation type="History" subtype="Administrative History">Effective date: June 17, 1996 (23:12 Md. R. 870)</annotation>
    <annotation type="History" subtype="Administrative History">Chapter recodified from COMAR 09.31.13 to COMAR 31.10.16 effective September 7, 1998 (25:18 Md. R. 1439)</annotation>
    <annotation type="History" subtype="Administrative History">Regulation .03C amended effective April 21, 2008 (35:8 Md. R. 812)</annotation>
    <annotation type="History" subtype="Administrative History">Regulation .03D amended effective May 9, 2016 (43:9 Md. R. 532)</annotation>
    <annotation type="History" subtype="Administrative History">Regulation .03F amended effective December 23, 2002 (29:25 Md. R. 1984)</annotation>
    <annotation type="History" subtype="Administrative History">Regulation .05B amended effective December 6, 2018 (45:24 Md. R. 1164)</annotation>
  </annotations>
</chapter>