(a) In this subtitle the following words have the meanings indicated.
(b) (1) “Adverse decision” means a utilization review determination made by a private review agent that a proposed or delivered health care service:
(i) is or was not medically necessary, appropriate, or efficient; and
(ii) may result in noncoverage of the health care service.
(2) “Adverse decision” includes a utilization review determination based on a prior authorization or step therapy requirement.
(3) “Adverse decision” does not include a decision concerning a subscriber’s status as a member.
(c) “Certificate” means a certificate of registration granted by the Commissioner to a private review agent.
(d) (1) “Employee assistance program” means a health care service plan that, in accordance with a contract with an employer or labor union:
(i) consults with employees or members of an employee’s family or both to:
1. identify the employee’s or the employee’s family member’s mental health, alcohol, or substance abuse problems; and
2. refer the employee or the employee’s family member to health care providers or other community resources for counseling, therapy, or treatment; and
(ii) performs utilization review for the purpose of making claims or payment decisions on behalf of the employer’s or labor union’s health insurance or health benefit plan.
(2) “Employee assistance program” does not include a health care service plan operated by a hospital solely for employees, or members of an employee’s family, of that hospital.
(e) (1) “Grievance” means a protest filed by a patient or a health care provider on behalf of a patient with a private review agent through the private review agent’s internal grievance process regarding an adverse decision concerning a patient.
(2) “Grievance” does not include a verbal request for reconsideration of a utilization review determination.
(f) “Grievance decision” means a final determination by a private review agent that arises from a grievance filed with the private review agent under its internal grievance process regarding an adverse decision concerning a patient.
(g) “Health care facility” means:
(1) a hospital as defined in § 19–301 of the Health – General Article;
(2) a related institution as defined in § 19–301 of the Health – General Article;
(3) an ambulatory surgical facility or center which is any entity or part thereof that operates primarily for the purpose of providing surgical services to patients not requiring hospitalization and seeks reimbursement from third party payors as an ambulatory surgical facility or center;
(4) a facility that is organized primarily to help in the rehabilitation of disabled individuals;
(5) a home health agency as defined in § 19–401 of the Health – General Article;
(6) a hospice as defined in § 19–901 of the Health – General Article;
(7) a facility that provides radiological or other diagnostic imagery services;
(8) a medical laboratory as defined in § 17–201 of the Health – General Article; or
(9) an alcohol abuse and drug abuse treatment program as defined in § 8–403 of the Health – General Article.
(h) “Health care provider” means:
(1) an individual who:
(i) is licensed or otherwise authorized to provide health care services in the ordinary course of business or practice of a profession; and
(ii) is a treating provider of a patient; or
(2) a hospital, as defined in § 19–301 of the Health – General Article.
(i) “Health care service” means a health or medical care procedure or service rendered by a health care provider licensed or authorized to provide health care services that:
(1) provides testing, diagnosis, or treatment of a human disease or dysfunction;
(2) dispenses drugs, medical devices, medical appliances, or medical goods for the treatment of a human disease or dysfunction; or
(3) provides 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.
(j) “Health care service reviewer” means an individual who is licensed or otherwise authorized to provide health care services in the ordinary course of business or practice of a profession.
(k) “Private review agent” means:
(1) a nonhospital–affiliated person or entity performing utilization review that is either affiliated with, under contract with, or acting on behalf of:
(i) a Maryland business entity; or
(ii) a third party that pays for, provides, or administers health care services to citizens of this State; or
(2) any person or entity including a hospital–affiliated person performing utilization review for the purpose of making claims or payment decisions for health care services on behalf of the employer’s or labor union’s health insurance plan under an employee assistance program for employees other than the employees employed by:
(i) the hospital; or
(ii) a business wholly owned by the hospital.
(l) “Significant beneficial interest” means the ownership of any financial interest that is greater than the lesser of:
(1) 5 percent of the whole; or
(2) $5,000.
(m) “Utilization review” means a system for reviewing the appropriate and efficient allocation of health care resources and services given or proposed to be given to a patient or group of patients.
(n) “Utilization review plan” means a description of the standards governing utilization review activities performed by a private review agent.