§ 15-10A-03. Filing of complaint after receipt of grievance decision
West's Annotated Code of MarylandInsuranceEffective: July 1, 2011
Effective: July 1, 2011
MD Code, Insurance, § 15-10A-03
§ 15-10A-03. Filing of complaint after receipt of grievance decision
(a)(1) Within 4 months after the date of receipt of an adverse decision or a grievance decision, a member, a member's representative, or a health care provider, who filed the grievance on behalf of the member under § 15-10A-02(b)(2)(iii) of this subtitle, may file a complaint with the Commissioner.
(3) Except for an emergency case under subsection (b)(1)(ii) of this section, the carrier that is the subject of a complaint filed under paragraph (1) of this subsection shall provide to the Commissioner any information requested by the Commissioner no later than 7 working days from the date the carrier receives the request for information.
(b)(1) In developing procedures to be used in reviewing and deciding complaints, the Commissioner shall:
(c)(1) Except as provided in paragraph (2) of this subsection and except for an emergency case under subsection (b)(1)(ii) of this section, the Commissioner shall make a final decision on a complaint:
(d) The Commissioner shall seek advice from an independent review organization or medical expert, as provided in § 15-10A-05 of this subtitle, for complaints filed with the Commissioner under this subtitle that involve a question of whether a health care service provided or to be provided to a member is medically necessary.
(e)(1) A carrier shall have the burden of persuasion that its adverse decision or grievance decision, as applicable, is correct:
(3) As required under § 15-10A-02(i) of this subtitle, the carrier's adverse decision or grievance decision shall state in detail in clear, understandable language the factual bases for the decision and reference the specific criteria and standards, including interpretive guidelines on which the decision was based.
(f) The Commissioner may request the member that filed the complaint or a legally authorized designee of the member to sign a consent form authorizing the release of the member's medical records to the Commissioner or the Commissioner's designee that are needed in order for the Commissioner to make a final decision on the complaint.
Credits
Added by Acts 1998, c. 111, § 2, eff. Jan. 1, 1999; Acts 1998, c. 112, § 2, eff. Jan. 1, 1999. Amended by Acts 2001, c. 173, § 1, eff. Oct. 1, 2001; Acts 2004, c. 415, § 1, eff. July 1, 2004; Acts 2005, c. 25, § 1, eff. April 12, 2005; Acts 2011, c. 3, § 1, eff. July 1, 2011; Acts 2011, c. 4, § 1, eff. July 1, 2011.
MD Code, Insurance, § 15-10A-03, MD INSURANCE § 15-10A-03
Current through legislation effective through April 9, 2023, from the 2024 Regular Session of the General Assembly. Some statute sections may be more current, see credits for details.
End of Document |