<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".03" citation="COMAR 31.10.20.03" title_num="31" subtitle_num="10" chapter_num="20" heading="Certification.">
  <paragraph num="A.">
    <text>A medical director shall hold a certificate from the Commissioner that authorizes the applicant to act as the medical director of a health maintenance organization.</text>
  </paragraph>
  <paragraph num="B.">
    <text>To qualify for a certificate to act as a medical director of a health maintenance organization, the applicant:</text>
    <paragraph num="(1)">
      <text>Shall be a physician licensed to practice medicine in Maryland;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Shall have one of the following:</text>
      <paragraph num="(a)">
        <text>An advanced health-related degree;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Current board certification from either the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA); or</text>
      </paragraph>
      <paragraph num="(c)">
        <text>A minimum of 5 years clinical experience;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(3)">
      <text>May not receive any direct or indirect financial compensation that:</text>
      <paragraph num="(a)">
        <text>Violates Health-General Article, §19-705.1, Annotated Code of Maryland; or</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Deters the delivery of medically appropriate care to an enrollee; and</text>
      </paragraph>
    </paragraph>
    <paragraph num="(4)">
      <text>Shall be of good character and trustworthy.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>An applicant for a certificate to act as a medical director of a health maintenance organization does not qualify if there is a history of disciplinary action or sanction taken by any hospital, professional board, or regulating entity that raises a substantial question as to the applicant's physical, mental, or professional competence.</text>
  </paragraph>
  <paragraph num="D.">
    <text>An applicant seeking certification as a medical director shall submit to the Commissioner an application for certification on a form specified by the Commissioner.</text>
  </paragraph>
  <paragraph num="E.">
    <text>A medical director shall submit to the Commissioner the contact information of one person who will be available to respond to inquiries from the Maryland Insurance Administration. If the contact information for the designated person changes, the medical director shall:</text>
    <paragraph num="(1)">
      <text>Notify the Commissioner in writing within 30 days; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Provide new contact information.</text>
    </paragraph>
  </paragraph>
  <paragraph num="F.">
    <text>The medical director shall attach the following additional information to the application:</text>
    <paragraph num="(1)">
      <text>A description of the applicant's professional qualifications, including medical education, medical training and experience, history of malpractice claims, and licensures;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Evidence of education;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Evidence of internship or residency training;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Evidence of board certification from either ABMS or AOA, as appropriate;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Evidence of licensure status;</text>
    </paragraph>
    <paragraph num="(6)">
      <text>Disclosure of any disciplinary action or sanction taken by any hospital, professional board, or regulating entity;</text>
    </paragraph>
    <paragraph num="(7)">
      <text>Verification of status through the federal national practitioner data bank;</text>
    </paragraph>
    <paragraph num="(8)">
      <text>Disclosure of all methods of compensation to the applicant by the health maintenance organization;</text>
    </paragraph>
    <paragraph num="(9)">
      <text>Unless already on file with the Commissioner, the utilization management procedures and policies to be used by the health maintenance organization;</text>
    </paragraph>
    <paragraph num="(10)">
      <text>Certification by the medical director that the utilization management procedures and policies are:</text>
      <paragraph num="(a)">
        <text>Objective;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Clinically valid;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Compatible with established principles of health care; and</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Flexible enough to allow deviations from the norms when justified on a case by case basis;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(11)">
      <text>A list of all staff who conduct utilization management; and</text>
    </paragraph>
    <paragraph num="(12)">
      <text>Payment to the Commissioner of the nonrefundable application fee of $100.</text>
    </paragraph>
  </paragraph>
  <paragraph num="G.">
    <text>The delegation by a medical director of any of the medical director's responsibilities under this chapter to an associate medical director or an assistant medical director does not prevent the medical director, regardless of the delegation, from being held responsible for any violation of this chapter.</text>
  </paragraph>
</regulation>