Code of Maryland Regulations
Title 31 - MARYLAND INSURANCE ADMINISTRATION
Subtitle 10 - HEALTH INSURANCE-GENERAL
Chapter 31.10.19 - Independent Review Organizations and Medical Experts
Section 31.10.19.01 - Definitions

Universal Citation: MD Code Reg 31.10.19.01

Current through Register Vol. 51, No. 19, September 20, 2024

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

(1) Adverse Decision.
(a) "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:
(i) 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

(ii) May result in noncoverage of the health care service.

(b) "Adverse decision" does not include a decision concerning a subscriber's status as a member.

(2) "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.

(3) "Carrier" means:
(a) An insurer that offers health insurance other than long-term care insurance or disability insurance;

(b) A nonprofit health service plan;

(c) A health maintenance organization;

(d) A dental plan organization; or

(e) Any other person that provides health benefit plans subject to regulation by the State.

(4) "Complaint" means a protest filed with the Commissioner involving an adverse decision or grievance decision concerning a member.

(5) "Emergency case" means a case involving an adverse decision for which an expedited review is required under COMAR 31.10.18.05B.

(6) "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, § 15-10 A-05, Annotated Code of Maryland.

(7) "Health care provider" means:
(a) An individual who is:
(i) 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

(ii) A treating provider of the member; or

(b) A hospital, as defined in Health-General Article, §19-301, Annotated Code of Maryland.

(8) "Health care service" means a health or medical care procedure or service rendered by a health care provider including:
(a) Testing, diagnosis, or treatment of a human disease or dysfunction;

(b) Dispensing of drugs, medical devices, medical appliances, or medical goods for the treatment of a human disease or dysfunction; and

(c) 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.

(9) "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, § 15-10 A-05, Annotated Code of Maryland.

(10) "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, § 15-10 A-05, Annotated Code of Maryland.

(11) "Medical record" has the meaning stated in Health-General Article, §4-301, Annotated Code of Maryland.

(12) Member.
(a) "Member" means a person entitled to health care benefits under a policy, plan, or certificate issued or delivered in the State by a carrier.

(b) "Member" includes:
(i) A subscriber; and

(ii) Unless preempted by federal law, a Medicare recipient.

(c) "Member" does not include a Medicaid recipient.

(13) "Member's representative" has the meaning stated in Insurance Article, § 15-10 A-01, Annotated Code of Maryland.

(14) "Private review agent" has the meaning stated in Insurance Article, § 15-10 B-01, Annotated Code of Maryland.

Disclaimer: These regulations may not be the most recent version. Maryland may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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