<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".02" citation="COMAR 31.10.19.02" title_num="31" subtitle_num="10" chapter_num="19" heading="Use of Independent Review Organizations and Medical Experts.">
  <paragraph num="A.">
    <text>In cases considered appropriate by the Commissioner, the Commissioner shall seek advice concerning adverse decisions from an independent review organization or medical expert, as provided in Insurance Article, §15-10A-05, Annotated Code of Maryland.</text>
  </paragraph>
  <paragraph num="B.">
    <text>For any independent review organization or medical expert that contracts with the Commissioner, the independent review organization or medical expert shall have a quality assurance mechanism in place that assures the:</text>
    <paragraph num="(1)">
      <text>Timeliness and quality of the reviews;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Qualifications and independence of the expert reviewers and the independent review organization, or the medical expert; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Confidentiality of medical records and review materials, consistent with federal and State laws.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>An independent review organization seeking to contract with the Commissioner shall submit to the Commissioner a copy of the accreditation certificate issued by a nationally recognized private accrediting organization.</text>
  </paragraph>
  <paragraph num="D.">
    <text>An independent review organization designated by the Commissioner to review an adverse decision shall have the authority and powers as delegated by the Commissioner for the following functions related to conducting an independent review:</text>
    <paragraph num="(1)">
      <text>Obtaining all information relative to the complaint from the carrier, the provider, the member, and the member’s representative;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Assigning the expert reviewer for review of an adverse decision; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Performing conflicts checks relative to the independent review organization and the expert reviewer assigned to review the adverse decision.</text>
    </paragraph>
  </paragraph>
  <paragraph num="E.">
    <text>A medical expert designated by the Commissioner to review an adverse decision shall have the authority and powers, as delegated by the Commissioner, for obtaining all information relative to the complaint from the:</text>
    <paragraph num="(1)">
      <text>Carrier;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Provider;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Member; and</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Member’s representative.</text>
    </paragraph>
  </paragraph>
</regulation>