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 31.10.19.02 - Use of Independent Review Organizations and Medical Experts

Universal Citation: MD Code Reg 31.10.19.02

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

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

B. 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:

(1) Timeliness and quality of the reviews;

(2) Qualifications and independence of the expert reviewers and the independent review organization, or the medical expert; and

(3) Confidentiality of medical records and review materials, consistent with federal and State laws.

C. 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.

D. 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:

(1) Obtaining all information relative to the complaint from the carrier, the provider, the member, and the member's representative;

(2) Assigning the expert reviewer for review of an adverse decision; and

(3) Performing conflicts checks relative to the independent review organization and the expert reviewer assigned to review the adverse decision.

E. 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:

(1) Carrier;

(2) Provider;

(3) Member; and

(4) Member's representative.

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.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.