Md. Code Regs. 10.25.17.03

Current through Register Vol. 51, No. 12, June 14, 2024

Section 10.25.17.03 - Benchmarks

A. Each payor shall establish and maintain online access for a provider to the following:

(1) A list of each health care service that requires preauthorization by the payor; and

(2) Key criteria used by the payor for making a determination on a preauthorization request.

B. Each payor shall establish and maintain an online process for:

(1) Accepting electronically a preauthorization request from a provider; and

(2) Assigning to a preauthorization request a unique electronic identification number that a provider may use to track the request during the preauthorization process, whether the request is tracked electronically, through a call center, or by fax.

C. Each payor shall establish and maintain an online preauthorization system that meets the requirements of Health-General Article, §19-108.2(e), Annotated Code of Maryland, to:

(1) Approve in real time, electronic preauthorization requests for pharmaceutical services:

(a) For which no additional information is needed by the payor to process the preauthorization request; and

(b) That meet the payor's criteria for approval;

(2) Render a determination within 1 business day after receiving all pertinent information on requests not approved in real time, electronic preauthorization requests for pharmaceutical services that:

(a) Are not urgent; and

(b) Do not meet the standards for real-time approval under §C(1) of this regulation; and

(3) Render a determination within 2 business days after receiving all pertinent information, electronic preauthorization requests for health care services, except pharmaceutical services, that are not urgent.

D. Each payor that requires a step therapy or fail-first protocol shall:

(1) Establish and maintain an online process to allow a prescriber to override the step therapy or fail-first protocol if:

(a) The step therapy drug has not been approved by the United States Food and Drug Administration for the medical condition being treated; or

(b) A prescriber provides supporting medical information to the payor that a prescription drug covered by the payor:

(i) Was ordered by the prescriber for the insured or enrollee within the past 180 days; and

(ii) Based on the professional judgment of the prescriber, was effective in treating the insured's or enrollee's disease or medical condition;

(2) Provide notice to prescribers regarding the availability of its online process; and

(3) Provide information to insureds or enrollees on the availability of the step therapy or fail-first protocol within its network.

E. A payor that becomes authorized to provide benefits or services within the State of Maryland after October 1, 2012, shall meet each benchmark within this chapter within 3 months of the payor's offering of services or benefits within the State and shall thereafter maintain the processes or actions required by each benchmark.

Md. Code Regs. 10.25.17.03

Regulation .03 amended effective 42:20 Md. R. 1265, eff.10/12/2015; amended effective 49:27 Md. R. 1110, eff. 1/9/2023