Md. Code Regs. 31.10.20.03

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

Section 31.10.20.03 - 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.

Md. Code Regs. 31.10.20.03

Regulations .03 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 .03 recodified from .04 effective 43:9 Md. R. 532, eff. 5/9/2016; amended effective 45:17 Md. R. 804, eff. 8/27/2018