Code of Maryland Regulations
Title 31 - MARYLAND INSURANCE ADMINISTRATION
Subtitle 10 - HEALTH INSURANCE-GENERAL
Chapter 31.10.20 - Certification of HMO Medical Directors
Section 31.10.20.04 - Denial or Revocation of Certification
Universal Citation: MD Code Reg 31.10.20.04
Current through Register Vol. 51, No. 19, September 20, 2024
A. The Commissioner shall deny a certificate to an applicant if the Commissioner finds that the initial application does not meet the requirements of this chapter.
B. The Commissioner may revoke the certification of a medical director:
(1) Who violates any provision of this chapter;
(2) Who fails to meet the requirements for certification under Regulation .04B of this chapter;
(3) Who obtains certification based on inaccurate information;
(4) Who fraudulently or deceptively obtains, attempts to obtain, or uses a certificate; or
(5) If the Commissioner finds a pattern that the utilization management procedures and policies used by the medical director in making utilization review decisions or used by a private review agent employed by or under contract with the health maintenance organization over whose utilization review decisions the medical director has responsibility are not:
(a) Objective,
(b) Clinically valid,
(c) Compatible with established principles of health care, or
(d) Flexible enough to allow deviations from the norms when justified on a case by case basis.
C. Before denying an initial application for certification or revoking an issued certificate, the Commissioner shall provide the applicant or certificate holder with:
(1) Reasonable time to supply additional information which demonstrates compliance with the requirements of this chapter and the opportunity to request a hearing;
(2) Written notice of the reasons for the denial or revocation; and
(3) 30 days in which to request a hearing in accordance with State Government Article, Title 10, Subtitle 2, Annotated Code of Maryland.
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