Maryland HB 523 (2023) requires health insurers to respond to standard prior authorization requests within 2 business days and urgent requests within 24 hours. HB 978 (October 1, 2023) mandates human clinical review for all PA adverse determinations, banning AI-only denials.
Prior Authorization Timelines
Maryland establishes two decision timelines for PA requests:
| Request Type | Timeline |
|---|---|
| Standard PA | 2 business days |
| Expedited (urgent) | 24 hours |
These timelines apply to all state-regulated health plans. Emergency services are not subject to PA requirements; retrospective review is permitted after emergency care delivery.
Electronic Prior Authorization Portals
Maryland Insurance Code ยง15-10B-01 requires all insurers to support electronic PA submission portals by 2024. Electronic PA requests receive the same decision timelines as paper submissions. Insurers must acknowledge receipt and provide status updates.
Denial Requirements and Clinical Review
PA denials must include: (1) specific clinical criteria cited, (2) clinical rationale for denial, and (3) appeals instructions. HB 978 prohibits AI-only decisions. Every PA denial requires review and sign-off by a qualified healthcare provider with relevant clinical expertise.
Internal and External Appeals
Patients and providers have 30 days from PA denial to file an internal appeal. The insurer must respond to internal appeals within 15 days. External review through the Maryland Insurance Administration is available if the internal appeal is denied.
Enforcement and Compliance
The Maryland Insurance Administration monitors PA compliance and can take enforcement action against insurers that miss timelines or violate HB 978 human review requirements. Violations are documented during market conduct examinations.
Track prior authorization timelines and human review compliance with Altair's PA management system.
Frequently Asked Questions
Can a Maryland insurer deny prior auth using only an AI system?
No. Maryland HB 978 (effective October 1, 2023) prohibits AI-only PA denials. All prior authorization denials require human clinical review by a qualified healthcare provider.
How long does Maryland give for expedited PA decisions?
Maryland HB 523 requires expedited (urgent) PA decisions within 24 hours of submission. Standard PA decisions must be made within 2 business days.
Related Resources
- Maryland Timely Filing Requirements
- Maryland Surprise Billing Protection Act
- All State Billing Laws
- Prior Authorization Rules Overview