MD Insurance Bulletin 99-07
Review of Application for Private Review Agent Certification
BULLETIN
To:
Private Review Agents
Re:
Review of Application for Private Review Agent Certification
Date:
April 8, 1999
Bulletin:
Life and Health 99-7
Effective January 1, 1999, regulation of private review agents was transferred from the Department of
Health and Mental Hygiene to the Insurance Administration.
Sixty days before the expiration of your certification to act as a private review agent, a copy of the
application will be mailed to you, accompanied by copies of Title 15, Subtitles 10A-10B of the
Insurance Article and applicable regulations.
Applicants for renewal must respond to each question on the application provided by the
Administration. Failure to respond to each question will delay the processing of your application. No
other application may be substituted for the application provided by the Administration.
It is imperative that you read the law before completing the application. The utilization review plan
must conform to the newly enacted requirements. To date, applications for renewal have been
submitted by private review agents whose certification expired in January, February and March. Many
of the applications have been deficient because questions on the application form have been left blank
or answered incorrectly. Moreover, the utilization review plan does not reflect the newly enacted
requirements.
Any private review agent to whom the internal grievance process has been delegated by a carrier must
file an internal grievance procedure that satisfies the provisions of Title 10A of the Insurance Article
and COMAR 31.10.18. In the instance where the carrier is also the private review agent, the
“delegation” of the internal grievance process may be to the carrier acting in its capacity as the private
review agent. (I NEED SUGGESTIONS ON HOW TO EXPLAIN THAT)
Personnel of the Administration with medical/legal experience and training will review the application
and utilization review plan that must be submitted with the application. The review will determine
compliance of the utilization review plan with the requirements. Certification will not be granted to any
private review agent who fails to submit information necessary to determine compliance with the
requirements.
The law prohibits any person from conducting utilization review without certification.
If you have any questions about this bulletin, please contact the Maryland Insurance Administration at
(410) 468-2259.
_________________________________
Donna B. Imhoff, Associate Commissioner