§ 15-10A-06

(a) (1) On a quarterly basis, each carrier shall submit to the Commissioner, on the form the Commissioner requires, a report that describes the following information aggregated by zip code as required by the Commissioner:

(i) the number of members entitled to health care benefits under a policy, plan, or certificate issued or delivered in the State by the carrier;

(ii) the number of clean claims for reimbursement processed by the carrier;

(iii) the activities of the carrier under this subtitle, including:

1. the outcome of each grievance filed with the carrier;

2. the number and outcomes of cases that were considered emergency cases under § 15–10A–02(b)(2)(i) of this subtitle;

3. the time within which the carrier made a grievance decision on each emergency case;

4. the time within which the carrier made a grievance decision on all other cases that were not considered emergency cases;

5. the number of grievances filed with the carrier that resulted from an adverse decision involving length of stay for inpatient hospitalization as related to the medical procedure involved;

6. the number of adverse decisions issued by the carrier under § 15–10A–02(f) of this subtitle, whether the adverse decision involved a prior authorization or step therapy protocol, the type of service at issue in the adverse decisions, and whether an artificial intelligence, algorithm, or other software tool was used in making the adverse decision;

7. the number of adverse decisions overturned after a reconsideration request under § 15–10B–06 of this title; and

8. the number of requests made and granted under § 15–831(c)(1) and (2) of this title; and

(iv) the number and outcome of all other cases that are not subject to activities of the carrier under this subtitle that resulted from an adverse decision involving the length of stay for inpatient hospitalization as related to the medical procedure involved.

(2) If the number of adverse decisions issued by a carrier for a type of service has grown by 10% or more in the immediately preceding calendar year or 25% or more in the immediately preceding 3 calendar years, the carrier shall submit in the report required under paragraph (1) of this subsection:

(i) a description of any changes in medical management contributing to the rise in adverse decisions for the type of service;

(ii) any other known reasons for the increase; and

(iii) a description of the carrier’s efforts and actions taken to determine the reason for the increase.

(b) The Commissioner shall:

(1) compile an annual summary report based on the information provided:

(i) under subsection (a) of this section; and

(ii) by the Secretary under § 19–705.2(e) of the Health – General Article;

(2) report any violations or actions taken under § 15–10B–11 of this title; and

(3) provide copies of the summary report to the Governor and, subject to § 2–1257 of the State Government Article, to the General Assembly.

(c) The Commissioner may use information provided under subsection (a) of this section as the basis for an examination under Title 2, Subtitle 2 of this article.