COMAR 31.10.16 · Chapter 16 Carrier Provider Panels — Application Process

Administrative History Effective date: June 17, 1996 (23:12 Md. R. 870) —————— Chapter recodified from COMAR 09.31.13 to COMAR 31.10.16 effective September 7, 1998 (25:18 Md. R. 1439) Regulation .03C amended effective April 21, 2008 (35:8 Md. R. 812) Regulation .03D amended effective May 9, 2016 (43:9 Md. R. 532) Regulation .03F amended effective December 23, 2002 (29:25 Md. R. 1984) Regulation .05B amended effective December 6, 2018 (45:24 Md. R. 1164) Authority Insurance Article, §§ 2-109 and 15-112 , Annotated Code of Maryland

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.01 Applicability. This chapter applies to all insurers, nonprofit health service plans, health maintenance organizations, dental plans, and to any other person or organization which utilizes a provider panel and which provides health benefit plans subject to regulation in this State.

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.02 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) Carrier. (a) "Carrier" means: (i) An insurer; (ii) A nonprofit health service plan; (iii) A health maintenance organization; (iv) A dental plan organization; and (v) Any other person or organization that provides health benefit plans subject to State regulation. (b) "Carrier" includes an entity that arranges a provider panel for a carrier. (2) "Provider" means a health care practitioner or a group of health care practitioners licensed or otherwise authorized by law to provide health care services. (3) Provider Panel. (a) "Provider panel" means those providers with which a carrier contracts to provide health care services to the carrier's enrollees under the carrier's health benefit plan. (b) "Provider panel" does not include an arrangement between a carrier and providers in which a provider may participate solely on the basis of the provider's contracting with the carrier to provide services at a discounted fee-for-service rate.

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.03 Requirements for Application Process. A. A carrier that utilizes a provider panel shall establish written procedures for reviewing applications for participation in the provider panel. B. A carrier that utilizes a provider panel shall, upon request, make its applications publicly available. C. The form of application: (1) Shall include instructions for completion of the application; (2) Shall provide a specifically designated space for dating the receipt of the application by the carrier; and (3) Shall comply with federal and State laws concerning the Americans with Disability Act. D. A carrier shall maintain an application log which, at a minimum, provides the following information: (1) Name of the provider requesting or submitting the application; (2) Date the provider requested an application, if applicable; (3) Date the application is sent or delivered to the provider, if applicable; (4) Date the application is received from the provider; (5) Date the application is returned to the provider with a request for additional information to complete the application, if applicable; (6) Date of receipt by the carrier of an application previously returned for additional information, if applicable; (7) Date that the provider is notified of: (a) Rejection, or (b) Carrier's intent to continue the credentialing process; and (8) Date after completion of credentialing that the provider is notified of acceptance or rejection in the provider panel. E. The log shall be available for inspection by the Commissioner. F. Notice. (1) A carrier shall: (a) If the carrier maintains a web site: (i) Post on the web site a notice of how to apply to the carrier's provider panel; and (ii) Provide, on request, a paper copy of the notice of how to apply to the carrier's provider panel; or (b) If the carrier does not maintain a web site, provide on request a paper copy of the notice of how to apply to the carrier's provider panel. (2) The notice required pursuant to §F(1) of this regulation shall include relevant addresses and telephone numbers for contact purposes.

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.04 Application Fees. A. A carrier may charge a reasonable fee for any application that a provider submits to the carrier. B. The fee shall be nonrefundable and uniform for all applicants within a practice specialty. C. The fee may not exceed $75 for each provider application. D. A carrier may not charge additional fees for processing an application which was returned because of insufficient information.

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.05 Document Retention. A. A carrier shall maintain its provider application log for a minimum of 3 years or until its next market conduct examination, whichever occurs last. B. A carrier shall: (1) Date stamp each application received from a provider upon initial receipt; and (2) Maintain a legible copy of each application, and any correspondence regarding that application, for a minimum of 3 years or until its next market conduct examination, whichever occurs last.

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Previous Chapter 15 Substantial, Available, and Affordable Coverage Plan [Repealed]

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Next Chapter 17 Health Care Consumer Information and Education Act

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