Regulation .01 Definitions.
Regulation .01 Definitions.LinkCopy Citation
A.
In this chapter, the following terms have the meanings indicated.
B.
Terms Defined.
(1)
Adverse Decision.
(a)
“Adverse decision” means a utilization review determination by a private review agent, a carrier, or a health care provider acting on behalf of a carrier that:
(i)
A proposed or delivered health care service that is otherwise covered under the member's contract is not or was not medically necessary, appropriate, or efficient; and
(ii)
May result in noncoverage of the health care service.
(b)
“Adverse decision” does not include a decision concerning a subscriber's status as a member.
(2)
“Affiliate” means a person who directly or indirectly, through one or more intermediaries, controls, is controlled by, or is under common control with another person.
(3)
“Carrier” means:
(a)
An insurer that offers health insurance other than long-term care insurance or disability insurance;
(b)
A nonprofit health service plan;
(c)
A health maintenance organization;
(d)
A dental plan organization; or
(e)
Any other person that provides health benefit plans subject to regulation by the State.
(4)
“Complaint” means a protest filed with the Commissioner involving an adverse decision or grievance decision concerning a member.
(5)
“Emergency case” means a case involving an adverse decision for which an expedited review is required under COMAR 31.10.18.05.
(6)
“Expert reviewer” means a physician or other appropriate health care provider who contracts with or is retained by an independent review organization to conduct external review of a carrier's adverse decision pursuant to Insurance Article, §15-10A-05, Annotated Code of Maryland.
(7)
“Health care provider” means:
(a)
An individual who is:
(i)
Licensed under the Health Occupations Article, Annotated Code of Maryland, or holds a nonrestricted license in a state of the United States to provide health care services in the ordinary course of business or practice of a profession, and
(ii)
A treating provider of the member; or
(b)
A hospital, as defined in Health-General Article, §19-301, Annotated Code of Maryland.
(8)
“Health care service” means a health or medical care procedure or service rendered by a health care provider including:
(a)
Testing, diagnosis, or treatment of a human disease or dysfunction;
(b)
Dispensing of drugs, medical devices, medical appliances, or medical goods for the treatment of a human disease or dysfunction; and
(c)
Any other care, service, or treatment of disease or injury, the correction of defects, or the maintenance of the physical and mental well-being of human beings.
(9)
“Independent review organization” means an entity that contracts with the Commissioner to conduct independent review of a carrier's adverse decision pursuant to Insurance Article, §15-10A-05, Annotated Code of Maryland.
(10)
“Medical expert” means a physician or other appropriate health care provider who contracts with the Commissioner to conduct external review of a carrier's adverse decision pursuant to Insurance Article, §15-10A-05, Annotated Code of Maryland.
(11)
“Medical record” has the meaning stated in Health-General Article, §4-301, Annotated Code of Maryland.
(12)
Member.
(a)
“Member” means a person entitled to health care benefits under a policy, plan, or certificate issued or delivered in the State by a carrier.
(b)
“Member” includes:
(i)
A subscriber; and
(ii)
Unless preempted by federal law, a Medicare recipient.
(c)
“Member” does not include a Medicaid recipient.
(13)
“Member’s representative” has the meaning stated in Insurance Article, §15-10A-01, Annotated Code of Maryland.
(14)
“Private review agent” has the meaning stated in Insurance Article, §15-10B-01, Annotated Code of Maryland.