§ 15-10B-06

(a) (1) Except as otherwise provided in this subsection, a private review agent shall:

(i) make all initial determinations on whether to authorize or certify a nonemergency course of treatment or health care service, including pharmaceutical services not submitted electronically, for a patient within 2 working days after receipt of the information necessary to make the determination;

(ii) make all determinations on whether to authorize or certify an extended stay in a health care facility or additional health care services within 1 working day after receipt of the information necessary to make the determination;

(iii) make all determinations to authorize or certify a request for additional visits or days of care submitted as part of an existing course of treatment or treatment plan within 1 working day after receipt of the information necessary to make the determination; and

(iv) promptly notify the health care provider of the determination.

(2) After receipt of the initial request for health care services and confirming through a complete review of information already submitted by the health care provider, if the private review agent determines that the private review agent does not have sufficient information to make a determination, the private review agent shall promptly, but not later than 3 calendar days after receipt of the initial request, inform the health care provider that additional information must be provided by specifying:

(i) the information, including any lab or diagnostic test or other medical information, that must be submitted to complete the request; and

(ii) the criteria and standards to support the need for additional information.

(b) If a private review agent requires prior authorization for an emergency inpatient admission, or an admission for residential crisis services as defined in § 15–840 of this title, for the treatment of a mental, emotional, or substance abuse disorder, the private review agent shall:

(1) make all determinations on whether to authorize or certify an inpatient admission, or an admission for residential crisis services as defined in § 15–840 of this title, within 2 hours after receipt of the information necessary to make the determination;

(2) if additional information is needed, promptly request the specific information needed, including any lab or diagnostic test or other medical information; and

(3) promptly notify the health care provider of the determination.

(c) (1) For a step therapy exception request submitted electronically in accordance with a process established under § 15–142(f) of this title or a prior authorization request submitted electronically for pharmaceutical services, a private review agent shall make a determination:

(i) in real time if:

1. no additional information is needed by the private review agent to process the request; and

2. the request meets the private review agent’s criteria for approval; or

(ii) if a request is not approved in real time under item (i) of this paragraph, within 1 working day after the private review agent receives all of the information necessary to make the determination.

(2) If additional information is needed to make a determination after confirming through a complete review of the information already submitted by the health care provider, the private review agent shall request the information promptly, but not later than 3 calendar days after receipt of the initial request, by specifying:

(i) the information, including any lab or diagnostic test or other medical information, that must be submitted to complete the request; and

(ii) the criteria and standards to support the need for the additional information.

(d) (1) (i) Except as provided in subsections (g) and (h) of this section, a private review agent shall make initial determinations on whether to authorize or certify an emergency course of treatment or health care service for a member within 24 hours after the initial request after receipt of the information necessary to make the determination.

(ii) If the private review agent determines that additional information is needed after confirming through a complete review of the information already submitted by the health care provider, the private review agent shall:

1. promptly request the specific information needed, including any lab or diagnostic test or other medical information; and

2. promptly, but not later than 2 hours after receipt of the information, notify the health care provider of an authorization or certification determination when made by the private review agent.

(2) A private review agent shall initiate the expedited procedure for an emergency case if the patient or the patient’s representative requests or if the health care provider attests that the services are necessary to treat a condition or illness that, without immediate medical attention, would:

(i) seriously jeopardize the life or health of the member or the member’s ability to regain maximum functions;

(ii) cause the member to be in danger to self or others; or

(iii) cause the member to continue using intoxicating substances in an imminently dangerous manner.

(e) If a private review agent fails to make a determination within the time limits required under this section, the request shall be deemed approved.

(f) (1) If an initial determination is made by a private review agent not to authorize or certify a health care service and the health care provider believes the determination warrants an immediate reconsideration, a private review agent shall provide the health care provider the opportunity to speak with the physician that rendered the determination, by telephone on an expedited basis, within a period of time not to exceed 24 hours of the health care provider seeking the reconsideration.

(2) If the physician is unable to immediately speak with the health care provider seeking the reconsideration, the physician shall provide the health care provider with the following contact information for the health care provider to use to contact the physician:

(i) a direct telephone number that is not the general customer call number; or

(ii) a monitored e–mail address that is dedicated to communication related to utilization review.

(g) For emergency inpatient admissions, a private review agent may not render an adverse decision solely because the hospital did not notify the private review agent of the emergency admission within 24 hours or other prescribed period of time after that admission if the patient’s medical condition prevented the hospital from determining:

(1) the patient’s insurance status; and

(2) if applicable, the private review agent’s emergency admission notification requirements.

(h) (1) Subject to paragraph (2) of this subsection, a private review agent may not render an adverse decision as to an admission of a patient during the first 24 hours after admission when:

(i) the admission is based on a determination that the patient is in imminent danger to self or others;

(ii) the determination has been made by the patient’s physician or psychologist in conjunction with a member of the medical staff of the facility who has privileges to make the admission; and

(iii) the hospital immediately notifies the private review agent of:

1. the admission of the patient; and

2. the reasons for the admission.

(2) A private review agent may not render an adverse decision as to an admission of a patient to a hospital for up to 72 hours, as determined to be medically necessary by the patient’s treating physician, when:

(i) the admission is an involuntary admission under §§ 10–615 and 10–617(a) of the Health – General Article; and

(ii) the hospital immediately notifies the private review agent of:

1. the admission of the patient; and

2. the reasons for the admission.

(i) (1) A private review agent that requires a health care provider to submit a treatment plan in order for the private review agent to conduct utilization review of proposed or delivered services for the treatment of a mental illness, emotional disorder, or a substance abuse disorder:

(i) shall accept:

1. the uniform treatment plan form adopted by the Commissioner under § 15–10B–03(d) of this subtitle as a properly submitted treatment plan form; or

2. if a service was provided in another state, a treatment plan form mandated by the state in which the service was provided; and

(ii) may not impose any requirement to:

1. modify the uniform treatment plan form or its content; or

2. submit additional treatment plan forms.

(2) A uniform treatment plan form submitted under the provisions of this subsection:

(i) shall be properly completed by the health care provider; and

(ii) may be submitted by electronic transfer.