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<regulation prefix="Regulation" num=".01" citation="COMAR 31.10.20.01" title_num="31" subtitle_num="10" chapter_num="20" 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>“Administration” means the Maryland Insurance Administration.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>“Board” means the State Board of Physician Quality Assurance established under Health Occupations Article, Title 14, Annotated Code of Maryland.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>“Certificate” means a certificate, issued by the Commissioner under this chapter, to act as a medical director.</text>
    </paragraph>
    <paragraph num="(4)">
      <text>“Commissioner” means the State Insurance Commissioner.</text>
    </paragraph>
    <paragraph num="(5)">
      <text>“Contact information” means an individual’s name, job title and department, address, telephone number, facsimile number, and email address.</text>
    </paragraph>
    <paragraph num="(6)">
      <text>“Department” means the Maryland Department of Health.</text>
    </paragraph>
    <paragraph num="(7)">
      <text>“Governing authority” means the person or persons designated in the bylaws with the responsibility for operating the health maintenance organization.</text>
    </paragraph>
    <paragraph num="(8)">
      <text>“Health maintenance organization” has the meaning stated in Health-General Article, §19-701, Annotated Code of Maryland.</text>
    </paragraph>
    <paragraph num="(9)">
      <text>Medical Director.</text>
      <paragraph num="(a)">
        <text>“Medical director” means a physician employed by or under contract with a health maintenance organization who is responsible for:</text>
        <paragraph num="(i)">
          <text>The establishment or maintenance of the policies and procedures at the health maintenance organization for quality assurance and utilization management;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Compliance with the quality assurance and utilization management policies and procedures of the health maintenance organization; and</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>Oversight of utilization review decisions of private review agents employed by or under contract with the health maintenance organization.</text>
        </paragraph>
      </paragraph>
      <paragraph num="(b)">
        <text>“Medical director” includes an associate medical director or an assistant medical director who has been delegated any of the functions of a medical director.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(10)">
      <text>“Quality assurance” means a formal set of activities to review the quality of medical services provided to those persons covered by the health maintenance organization including implementation of corrective actions to address any deficiencies identified in the care and services provided to those persons covered by the health maintenance organization.</text>
    </paragraph>
    <paragraph num="(11)">
      <text>“Utilization management” means the process of evaluating and determining the appropriateness of the utilization of covered medical services, including prior authorization, concurrent review, retrospective review, discharge planning, and case management.</text>
    </paragraph>
  </paragraph>
</regulation>