Current through Register Vol. 51, No. 19, September 20, 2024
A. Each payor
shall establish and maintain online access for a provider to the following:
(1) A list of each health care service that
requires preauthorization by the payor; and
(2) Key criteria used by the payor for making
a determination on a preauthorization request.
B. Each payor shall establish and maintain an
online process for:
(1) Accepting
electronically a preauthorization request from a provider; and
(2) Assigning to a preauthorization request a
unique electronic identification number that a provider may use to track the
request during the preauthorization process, whether the request is tracked
electronically, through a call center, or by fax.
C. Each payor shall establish and maintain an
online preauthorization system that meets the requirements of Health-General
Article, §19-108.2(e), Annotated Code of Maryland, to:
(1) Approve in real time, electronic
preauthorization requests for pharmaceutical services:
(a) For which no additional information is
needed by the payor to process the preauthorization request; and
(b) That meet the payor's criteria for
approval;
(2) Render a
determination within 1 business day after receiving all pertinent information
on requests not approved in real time, electronic preauthorization requests for
pharmaceutical services that:
(a) Are not
urgent; and
(b) Do not meet the
standards for real-time approval under §C(1) of this regulation;
and
(3) Render a
determination within 2 business days after receiving all pertinent information,
electronic preauthorization requests for health care services, except
pharmaceutical services, that are not urgent.
D. Each payor that requires a step therapy or
fail-first protocol shall:
(1) Establish and
maintain an online process to allow a prescriber to override the step therapy
or fail-first protocol if:
(a) The step
therapy drug has not been approved by the United States Food and Drug
Administration for the medical condition being treated; or
(b) A prescriber provides supporting medical
information to the payor that a prescription drug covered by the payor:
(i) Was ordered by the prescriber for the
insured or enrollee within the past 180 days; and
(ii) Based on the professional judgment of
the prescriber, was effective in treating the insured's or enrollee's disease
or medical condition;
(2) Provide notice to prescribers regarding
the availability of its online process; and
(3) Provide information to insureds or
enrollees on the availability of the step therapy or fail-first protocol within
its network.
E. A payor
that becomes authorized to provide benefits or services within the State of
Maryland after October 1, 2012, shall meet each benchmark within this chapter
within 3 months of the payor's offering of services or benefits within the
State and shall thereafter maintain the processes or actions required by each
benchmark.
