In this chapter, the following terms have the meanings indicated. Terms Defined. Adverse Decision. “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: 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 May result in noncoverage of the health care service. “Adverse decision” does not include a decision concerning a subscriber's status as a member. “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. “Carrier” means: An insurer that offers health insurance other than long-term care insurance or disability insurance; A nonprofit health service plan; A health maintenance organization; A dental plan organization; or Any other person that provides health benefit plans subject to regulation by the State. “Complaint” means a protest filed with the Commissioner involving an adverse decision or grievance decision concerning a member. “Emergency case” means a case involving an adverse decision for which an expedited review is required under COMAR 31.10.18.05. “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. “Health care provider” means: An individual who is: 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 A treating provider of the member; or A hospital, as defined in Health-General Article, §19-301, Annotated Code of Maryland. “Health care service” means a health or medical care procedure or service rendered by a health care provider including: Testing, diagnosis, or treatment of a human disease or dysfunction; Dispensing of drugs, medical devices, medical appliances, or medical goods for the treatment of a human disease or dysfunction; and 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. “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. “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. “Medical record” has the meaning stated in Health-General Article, §4-301, Annotated Code of Maryland. Member. “Member” means a person entitled to health care benefits under a policy, plan, or certificate issued or delivered in the State by a carrier. “Member” includes: A subscriber; and Unless preempted by federal law, a Medicare recipient. “Member” does not include a Medicaid recipient. “Member’s representative” has the meaning stated in Insurance Article, §15-10A-01, Annotated Code of Maryland. “Private review agent” has the meaning stated in Insurance Article, §15-10B-01, Annotated Code of Maryland.