(a)(1) Each carrier shall establish an internal appeal process for use by its members, its members' representatives, and health care providers to dispute coverage decisions made by the carrier.
(2) The carrier may use the internal grievance process established under Subtitle 10A of this title to comply with the requirement of paragraph (1) of this subsection.
Final decision in writing to member, member’s representative, and health care provider
(b) A carrier under this section shall render a final decision in writing to a member, a member's representative, and a health care provider acting on behalf of the member within 60 working days after the date on which the appeal is filed.
Exhaustion of internal appeals process prior to filing complaint with Commissioner
(c) Except as provided in subsection (d) of this section, the carrier's internal appeal process shall be exhausted prior to filing a complaint with the Commissioner under this subtitle.
Coverage decisions involving urgent medical conditions
(d) A member, a member's representative, or a health care provider filing a complaint on behalf of a member may file a complaint with the Commissioner without first filing an appeal with a carrier only if the coverage decision involves an urgent medical condition, as defined by regulation adopted by the Commissioner, for which care has not been rendered.
Notice of coverage decision
(e)(1) Within 30 calendar days after a coverage decision has been made, a carrier shall send a written notice of the coverage decision to the member and the member's representative, if any, and, in the case of a health maintenance organization, the treating health care provider.
(2) Notice of the coverage decision required to be sent under paragraph (1) of this subsection shall:
(i) state in detail in clear, understandable language, the specific factual bases for the carrier's decision; and
(ii) include the following information:
1. that the member, the member's representative, or a health care provider acting on behalf of the member has a right to file an appeal with the carrier;
2. that the member, the member's representative, or a health care provider acting on behalf of the member may file a complaint with the Commissioner without first filing an appeal, if the coverage decision involves an urgent medical condition for which care has not been rendered;
3. the Commissioner's address, telephone number, and facsimile number;
4. that the Health Advocacy Unit is available to assist the member or the member's representative in both mediating and filing an appeal under the carrier's internal appeal process; and
5. the address, telephone number, facsimile number, and electronic mail address of the Health Advocacy Unit.
Notice of appeal decision
(f)(1) Within 30 calendar days after the appeal decision has been made, each carrier shall send to the member, the member's representative, and the health care provider acting on behalf of the member a written notice of the appeal decision.
(2) Notice of the appeal decision required to be sent under paragraph (1) of this subsection shall:
(i) state in detail in clear, understandable language the specific factual bases for the carrier's decision; and
(ii) include the following information:
1. that the member, the member's representative, or a health care provider acting on behalf of the member has a right to file a complaint with the Commissioner within 4 months after receipt of a carrier's appeal decision;
2. the Commissioner's address, telephone number, and facsimile number;
3. a statement that the Health Advocacy Unit is available to assist the member in filing a complaint with the Commissioner; and
4. the address, telephone number, facsimile number, and electronic mail address of the Health Advocacy Unit.
Consent form authorizing release of member’s medical records
(g) 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.
Burden of persuasion relating to coverage or appeal decision
(h)(1) A carrier shall have the burden of persuasion that its coverage decision or appeal decision, as applicable, is correct:
(i) during the review of a complaint by the Commissioner or a designee of the Commissioner; and
(ii) in any hearing held in accordance with Title 10, Subtitle 2 of the State Government Article to contest a final decision of the Commissioner made and issued under this subtitle.
(2) As part of the review of a complaint, the Commissioner or a designee of the Commissioner may consider all of the facts of the case and any other evidence that the Commissioner or designee of the Commissioner considers appropriate.
Final decisions made by Commissioner
(i) The Commissioner shall:
(1) make and issue in writing a final decision on all complaints filed with the Commissioner under this subtitle that are within the Commissioner's jurisdiction; and
(2) provide notice in writing to all parties to a complaint of the opportunity and time period for requesting a hearing to be held in accordance with Title 10, Subtitle 2 of the State Government Article to contest a final decision of the Commissioner made and issued under this subtitle.
Credits
Added by Acts 2000, c. 371, § 2, eff. Jan. 1, 2001. Amended by Acts 2001, c. 29, § 1, eff. April 10, 2001; Acts 2003, c. 21, § 1, eff. April 8, 2003; Acts 2004, c. 415, § 1, eff. July 1, 2004; Acts 2011, c. 3, § 1, eff. July 1, 2011; Acts 2011, c. 4, § 1, eff. July 1, 2011.
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.
