Md. Code Regs. 10.25.17.02

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.25.17.02 - Definitions

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

(1) "Commission" means the Maryland Health Care Commission.

(2) "Executive Director" means the Executive Director of the Commission or the Executive Director's designee.

(3) "Health Care Service" has the meaning stated in Insurance Article, §15-10 A-01, Annotated Code of Maryland.

(4) "Payor" means one of the following State-regulated entities that require preauthorization for a health care service:

(a) An insurer or nonprofit health service plan that provides hospital, medical, or surgical benefits to individuals or groups on an expense-incurred basis under health insurance policies or contracts that are issued or delivered in the State;

(b) A health maintenance organization that provides hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State; or

(c) A pharmacy benefits manager that is registered with the Maryland Insurance Commissioner, except for a pharmacy benefits manager that only provides services for:

(i) Workers' compensation claims pursuant to Labor and Employment Article, Title 9, Annotated Code of Maryland; or

(ii) Personal injury protection claims pursuant to Insurance Article, Title 19, Annotated Code of Maryland.

(5) "Preauthorization" means the process of obtaining approval from a payor by meeting certain criteria before a certain health care service can be rendered by the health care provider.

(6) "Prescriber" means a health care practitioner who has the required license and, if necessary, scope of practice or delegation agreement that permits the health care practitioner to prescribe drugs to treat medical conditions or diseases.

(7) "Step therapy or fail-first protocol" is a protocol established by an insurer, a nonprofit health service plan, a health maintenance organization, or a pharmacy benefits manager that requires a certain prescription drug or sequence of prescription drugs to be used by an insured individual or an enrollee before another specific prescription drug ordered by a prescriber is covered

(8) "Supporting medical information" means:

(a) A paid claim from a payor that requires a step therapy or fail-first protocol for an insured or an enrollee;

(b) A pharmacy record that documents that a prescription has been filled and delivered to an insured or enrollee, or to a representative of an insured or enrollee; or

(c) Other information mutually agreed to that constitutes sufficient supporting medical information by an insured's or enrollee's prescriber and a payor that requires a step therapy or fail-first protocol

Md. Code Regs. 10.25.17.02

Regulation .02 amended effective 42:20 Md. R. 1265, eff.10/12/2015; amended effective 49:27 Md. R. 1110, eff. 1/9/2023