Md. Code Regs. 31.10.20.04

Current through Register Vol. 51, No. 24, December 2, 2024

Section 31.10.20.04 - 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.

Md. Code Regs. 31.10.20.04

Regulations .04 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); Regulation .04 recodified from .05 effective 43:9 Md. R. 532, eff. 5/9/2016