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This entry was published on 2022-04-22
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Required and prohibited practices
Public Health (PBH) CHAPTER 45, ARTICLE 49, TITLE 1
§ 4905. Required and prohibited practices. 1. Each utilization review
agent shall have written procedures for assuring that patient-specific
information obtained during the process of utilization review will be:

(a) kept confidential in accordance with applicable state and federal
laws; and

(b) shared only with the enrollee, the enrollee's designee, the
enrollee's health care provider and those who are authorized by law to
receive such information.

2. Summary data shall not be considered confidential if it does not
provide information to allow identification of individual patients.

3. Any health care professional who makes determinations regarding the
medical necessity of health care services during the course of
utilization review shall be appropriately licensed, registered or

4. A utilization review agent shall not, with respect to utilization
review activities, permit or provide compensation or anything of value
to its employees, agents, or contractors based on:

(a) either a percentage of the amount by which a claim is reduced for
payment or the number of claims or the cost of services for which the
person has denied authorization or payment; or

(b) any other method that encourages the rendering of an adverse

5. If a health care service has been specifically pre-authorized or
approved for an enrollee by a utilization review agent, a utilization
review agent shall not, pursuant to retrospective review, revise or
modify the specific standards, criteria or procedures used for the
utilization review for procedures, treatment and services delivered to
the enrollee during the same course of treatment.

6. Utilization review shall not be conducted more frequently than is
reasonably required to assess whether the health care services under
review are medically necessary.

7. When making prospective, concurrent and retrospective
determinations, utilization review agents shall collect only such
information as is necessary to make such determination and shall not
routinely require health care providers to numerically code diagnoses or
procedures to be considered for certification or routinely request
copies of medical records of all patients reviewed. During prospective
or concurrent review, copies of medical records shall only be required
when necessary to verify that the health care services subject to such
review are medically necessary. In such cases, only the necessary or
relevant sections of the medical record shall be required. A utilization
review agent may request copies of partial or complete medical records

8. In no event shall information be obtained from the health care
providers for the use of the utilization review agent by persons other
than health care professionals, medical record technologists or
administrative personnel who have received appropriate training.

9. The utilization review agent shall not undertake utilization review
at the site of the provision of health care services unless the
utilization review agent:

(a) Identifies himself or herself by name and the name of his or her
organization, including displaying photographic identification which
includes the name of the utilization review agent and clearly identifies
the individual as representative of the utilization review agent;

(b) Whenever possible, schedules review at least one business day in
advance with the appropriate health care provider;

(c) If requested by a health care provider, assures that the on-site
review staff register with the appropriate contact person, if available,
prior to requesting any clinical information or assistance from the
health care provider;

(d) Obtains consent from the enrollee or the enrollee's designee
before interviewing the patient's family, or observing any health care
service being provided to the enrollee; and

(e) This subdivision shall not apply to health care professionals
engaged in providing care, case management or making on-site discharge

10. A utilization review agent shall not base an adverse determination
on a refusal to consent to observing any health care service.

11. A utilization review agent shall not base an adverse determination
on lack of reasonable access to a health care provider's medical or
treatment records unless the utilization review agent has provided
reasonable notice to the enrollee, the enrollee's designee or the
enrollee's health care provider, in which case the enrollee must be
notified, and has complied with all provisions of subdivision nine of
this section.

12. Neither the utilization review agent nor the entity for which the
agent provides utilization review shall take any action with respect to
a patient or a health care provider that is intended to penalize such
enrollee, the enrollee's designee, or the enrollee's health care
provider for, or to discourage such enrollee, the enrollee's designee,
or the enrollee's health care provider from undertaking an appeal,
dispute resolution or judicial review of an adverse determination.

13. In no event shall an enrollee, an enrollee's designee, an
enrollee's health care provider, any other health care provider, or any
other person or entity, be required to inform or contact the utilization
review agent prior to the provision of emergency care, including
emergency treatment or emergency admission.

14. No contract or agreement between a utilization review agent and a
health care provider shall contain any clause purporting to transfer to
the health care provider by indemnification or otherwise any liability
relating to activities, actions or omissions of the utilization review
agent as opposed to the health care provider.

15. A health care professional providing health care services to an
enrollee shall be prohibited from serving as the clinical peer reviewer
for such enrollee in connection with the health care services being
provided to the enrollee.