2013 Maryland Code
§ 15-1703 - Appeals process

MD Ins Code § 15-1703 (2013) What's This?


(a) A carrier that uses a physician rating system shall:

(1) establish an appeals process for physicians to use to contest their rating; and

(2) at least 45 days before making available to enrollees any new or revised quality of performance or cost-efficiency evaluations or any new or revised inclusions or exclusions from a physician rating system, provide each physician included in the physician rating system with:

(i) a notice of the proposed change;

(ii) an explanation of the data used to assess the physician and how the physician may access the data;

(iii) the methodology and measures used to assess the physician;

(iv) an explanation of the right to contest the rating of the physician through the appeals process of the carrier; and

(v) instructions on how to file a timely appeal with the carrier.

(b) If a physician files a timely appeal, as defined by the carrier, regarding the rating of the physician under a physician rating system, the carrier may not disclose the rating of the physician or make a change in the quality of performance or cost-efficiency ratings of the physician until the carrier completes its investigation and renders a decision on the appeal.

(c) A carrier shall post the following information prominently on the section of the carrier’s Web site that discloses the rating of a physician to enrollees or to the public:

(1) where an enrollee can find the physician performance ratings of the carrier;

(2) a disclosure that physician performance ratings are only a guide to choosing a physician because the ratings have a risk of error and should not be the sole basis for selecting a physician;

(3) an explanation of the physician rating system, including the basis on which physician performance is measured and the basis for determining that a physician is not currently rated due to insufficient data or a pending appeal;

(4) any limitations of the data that the carrier uses to measure physician performance;

(5) the factors and criteria used in the carrier’s physician rating system, including quality of performance measures and cost efficiency measures; and

(6) how a physician may appeal a physician rating.

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