§ 15-10B-07. Adverse decisions by private review agent

   (a) In general. --

   (1) Except as provided in paragraphs (2) and (3) of this subsection, all adverse decisions shall be made by a physician, or a panel of other appropriate health care service reviewers with at least one physician on the panel who is board certified or eligible in the same specialty as the treatment under review.

   (2) When the health care service under review is a mental health or substance abuse service, the adverse decision shall be made by a physician, or a panel of other appropriate health care service reviewers with at least one physician, selected by the private review agent who:

      (i) is board certified or eligible in the same specialty as the treatment under review; or

      (ii) is actively practicing or has demonstrated expertise in the substance abuse or mental health service or treatment under review.

   (3) When the health care service under review is a dental service, the adverse decision shall be made by a licensed dentist, or a panel of other appropriate health care service reviewers with at least one licensed dentist on the panel.

(b) Physicians or panel -- Compensation by private review agent prohibited. -- All adverse decisions shall be made by a physician or a panel of other appropriate health care service reviewers who are not compensated by the private review agent in a manner that violates § 19-705.1 of the Health - General Article or that deters the delivery of medically appropriate care.

(c) Retroactive adverse decisions. -- Except as provided in subsection (d) of this section, if a course of treatment has been preauthorized or approved for a patient, a private review agent may not retrospectively render an adverse decision regarding the preauthorized or approved services delivered to that patient.

(d) Retroactive adverse decisions -- Permitted. -- A private review agent may retrospectively render an adverse decision regarding preauthorized or approved services delivered to a patient if:

   (1) the information submitted to the private review agent regarding the services to be delivered to the patient was fraudulent or intentionally misrepresentative;

   (2) critical information requested by the private review agent regarding services to be delivered to the patient was omitted such that the private review agent's determination would have been different had the agent known the critical information; or

   (3) the planned course of treatment for the patient that was approved by the private review agent was not substantially followed by the provider.

(e) Utilization review -- Revision or modification to specific criteria or standards not permitted. -- If a course of treatment has been preauthorized or approved for a patient, a private review agent may not revise or modify the specific criteria or standards used for the utilization review to make an adverse decision regarding the services delivered to that patient.

HISTORY: 2000, ch. 123.