COMAR 31.10.20 · Chapter 20 Certification of HMO Medical Directors

Administrative History Effective date: Regulations .01 —.07 adopted as an emergency provision effective January 1, 1999 (26:1 Md. R. 18); adopted permanently effective March 22, 1999 (26:6 Md. R. 490) —————— Chapter revised effective May 9, 2016 (43:9 Md. R. 532) Regulation .01B amended effective August 27, 2018 (45:17 Md. R. 804) Regulation .03 amended effective August 27, 2018 (45:17 Md. R. 804) Authority Insurance Article, §§ 2-109 and 15-10 C-02, Annotated Code of Maryland

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.01 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) "Administration" means the Maryland Insurance Administration. (2) "Board" means the State Board of Physician Quality Assurance established under Health Occupations Article, Title 14, Annotated Code of Maryland . (3) "Certificate" means a certificate, issued by the Commissioner under this chapter, to act as a medical director. (4) "Commissioner" means the State Insurance Commissioner. (5) “Contact information” means an individual’s name, job title and department, address, telephone number, facsimile number, and email address. (6) "Department" means the Maryland Department of Health. (7) "Governing authority" means the person or persons designated in the bylaws with the responsibility for operating the health maintenance organization. (8) "Health maintenance organization" has the meaning stated in Health-General Article, §19-701, Annotated Code of Maryland. (9) Medical Director. (a) "Medical director" means a physician employed by or under contract with a health maintenance organization who is responsible for: (i) The establishment or maintenance of the policies and procedures at the health maintenance organization for quality assurance and utilization management; (ii) Compliance with the quality assurance and utilization management policies and procedures of the health maintenance organization; and (iii) Oversight of utilization review decisions of private review agents employed by or under contract with the health maintenance organization. (b) "Medical director" includes an associate medical director or an assistant medical director who has been delegated any of the functions of a medical director. (10) "Quality assurance" means a formal set of activities to review the quality of medical services provided to those persons covered by the health maintenance organization including implementation of corrective actions to address any deficiencies identified in the care and services provided to those persons covered by the health maintenance organization. (11) "Utilization management" means the process of evaluating and determining the appropriateness of the utilization of covered medical services, including prior authorization, concurrent review, retrospective review, discharge planning, and case management.

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.02 Issuance of a Temporary Certificate. A. Not later than the date of hire, a medical director seeking temporary certification shall submit to the Commissioner an application for certification on a form specified by the Commissioner. B. The medical director shall attach the following additional information to the application: (1) A description of the applicant's professional qualifications, including medical education, medical training and experience, clinical experience, history of malpractice claims; and licensures; (2) Evidence of one of the following: (a) An advanced health-related degree; (b) Current board certification from either the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA); or (c) A minimum of 5 years clinical experience; (3) Evidence of licensure status; (4) Disclosure of any disciplinary action or sanction taken by any hospital, professional board, or regulating entity; (5) The name, address, phone number, and facsimile number of the health maintenance organization, and the name of the governing authority of the health maintenance organization that the applicant is employed by or contracted with as a medical director; and (6) The date of hire or expected date of hire. C. A certificate issued under this regulation is effective for 90 days from the date of the applicant's employment as a medical director with the health maintenance organization. D. Extension of Temporary Certificate. (1) Unless the Commissioner extends for good cause under §D(2) of this regulation , a certificate issued under this regulation may not be renewed. (2) At the Commissioner's discretion, the Commissioner may extend for good cause for a 30-day period a temporary certificate issued under this regulation.

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.03 Certification. A. A medical director shall hold a certificate from the Commissioner that authorizes the applicant to act as the medical director of a health maintenance organization. B. To qualify for a certificate to act as a medical director of a health maintenance organization, the applicant: (1) Shall be a physician licensed to practice medicine in Maryland; (2) Shall have one of the following: (a) An advanced health-related degree; (b) Current board certification from either the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA); or (c) A minimum of 5 years clinical experience; (3) May not receive any direct or indirect financial compensation that: (a) Violates Health-General Article, §19-705.1, Annotated Code of Maryland; or (b) Deters the delivery of medically appropriate care to an enrollee; and (4) Shall be of good character and trustworthy. C. An applicant for a certificate to act as a medical director of a health maintenance organization does not qualify if there is a history of disciplinary action or sanction taken by any hospital, professional board, or regulating entity that raises a substantial question as to the applicant's physical, mental, or professional competence. D. An applicant seeking certification as a medical director shall submit to the Commissioner an application for certification on a form specified by the Commissioner. E. A medical director shall submit to the Commissioner the contact information of one person who will be available to respond to inquiries from the Maryland Insurance Administration. If the contact information for the designated person changes, the medical director shall: (1) Notify the Commissioner in writing within 30 days; and (2) Provide new contact information. F. The medical director shall attach the following additional information to the application: (1) A description of the applicant's professional qualifications, including medical education, medical training and experience, history of malpractice claims, and licensures; (2) Evidence of education; (3) Evidence of internship or residency training; (4) Evidence of board certification from either ABMS or AOA, as appropriate; (5) Evidence of licensure status; (6) Disclosure of any disciplinary action or sanction taken by any hospital, professional board, or regulating entity; (7) Verification of status through the federal national practitioner data bank; (8) Disclosure of all methods of compensation to the applicant by the health maintenance organization; (9) Unless already on file with the Commissioner, the utilization management procedures and policies to be used by the health maintenance organization; (10) Certification by the medical director that the utilization management procedures and policies are: (a) Objective; (b) Clinically valid; (c) Compatible with established principles of health care; and (d) Flexible enough to allow deviations from the norms when justified on a case by case basis; (11) A list of all staff who conduct utilization management; and (12) Payment to the Commissioner of the nonrefundable application fee of $100. G. The delegation by a medical director of any of the medical director's responsibilities under this chapter to an associate medical director or an assistant medical director does not prevent the medical director, regardless of the delegation, from being held responsible for any violation of this chapter.

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.04 Denial or Revocation of Certification. A. The Commissioner shall deny a certificate to an applicant if the Commissioner finds that the initial application does not meet the requirements of this chapter. B. The Commissioner may revoke the certification of a medical director: (1) Who violates any provision of this chapter; (2) Who fails to meet the requirements for certification under Regulation .04B of this chapter ; (3) Who obtains certification based on inaccurate information; (4) Who fraudulently or deceptively obtains, attempts to obtain, or uses a certificate; or (5) If the Commissioner finds a pattern that the utilization management procedures and policies used by the medical director in making utilization review decisions or used by a private review agent employed by or under contract with the health maintenance organization over whose utilization review decisions the medical director has responsibility are not: (a) Objective; (b) Clinically valid; (c) Compatible with established principles of health care; or (d) Flexible enough to allow deviations from the norms when justified on a case by case basis. C. Before denying an initial application for certification or revoking an issued certificate, the Commissioner shall provide the applicant or certificate holder with: (1) Reasonable time to supply additional information which demonstrates compliance with the requirements of this chapter and the opportunity to request a hearing; (2) Written notice of the reasons for the denial or revocation; and (3) 30 days in which to request a hearing in accordance with State Government Article, Title 10, Subtitle 2, Annotated Code of Maryland .

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.05 Term of Certification and Recertification. A. A certificate: (1) Is not transferable; and (2) Expires on the second anniversary of its effective date unless certification has been renewed for another 2-year term. B. Before certification expires, a medical director may renew certification if the certified medical director: (1) Otherwise is entitled to be certified; (2) Pays to the Commissioner the nonrefundable renewal fee of $100; and (3) Submits to the Commissioner: (a) A renewal application on a form that the Commissioner requires; and (b) An update of the information required under Regulation .04B of this chapter .

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.06 Notification to the Board of Physician Quality Assurance. A. The Commissioner shall annually provide to the Board a list of certified individuals authorized by the Commissioner to act as a medical director. B. The Commissioner shall notify the Board of the revocation of a certificate issued under this chapter.

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Previous Chapter 19 Independent Review Organizations and Medical Experts

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Next Chapter 21 Private Review Agents

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