(a) In this subtitle the following words have the meanings indicated. (b) (1) “Adverse decision” means: (i) a utilization review determination by a private review agent, a carrier, or a health care provider acting on behalf of a carrier that: 1. a proposed or delivered health care service covered under the member’s contract is or was not medically necessary, appropriate, […]
This subtitle applies to a health benefit plan that: (1) is delivered or issued in the State; or (2) covers individuals who reside or work in the State if the health benefit plan is delivered or issued in a state that the Commissioner determines does not have an external complaint process for adverse decisions or grievances comparable […]
(a) Each carrier shall establish an internal grievance process for its members. (b) (1) An internal grievance process shall meet the same requirements established under Subtitle 10B of this title. (2) In addition to the requirements of Subtitle 10B of this title, an internal grievance process established by a carrier under this section shall: (i) include an expedited procedure for […]
(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. (2) Whenever the Commissioner receives a complaint under […]
(a) The Commissioner shall: (1) notwithstanding the provisions of § 15–10A–03(c)(1)(ii) of this subtitle, for the purpose of making final decisions on complaints, prioritize complaints regarding pending health care services over complaints regarding health care services already delivered; (2) make and issue in writing a final decision on all complaints filed with the Commissioner under this subtitle that […]
(a) For a complaint filed with the Commissioner under this subtitle that involves a question of whether the health care service provided or to be provided to a member is medically necessary, the Commissioner: (1) shall select an independent review organization or medical expert to advise on the complaint; and (2) may accept and base the final decision […]
(a) On a quarterly basis, each carrier shall submit to the Commissioner, on the form the Commissioner requires, a report that describes: (1) the activities of the carrier under this subtitle, including: (i) the outcome of each grievance filed with the carrier; (ii) the number and outcomes of cases that were considered emergency cases under § 15-10A-02(b)(2)(i) of this […]
On a quarterly basis, the Health Advocacy Unit shall submit a report to the Commissioner that: (1) describes activities it performed on behalf of members that have participated in an internal grievance process of a carrier established under this subtitle; (2) describes its efforts to mediate cases that involve an adverse decision; (3) names each carrier involved in […]
(a) On or before November 1, 1999, and each November 1 thereafter, the Health Advocacy Unit shall publish an annual summary report and provide copies of the report to the Governor and, subject to § 2-1257 of the State Government Article, the General Assembly. (b) (1) The annual summary report required under subsection (a) of this section shall […]
(a) The Commissioner shall adopt regulations to carry out this subtitle. (b) In addition to the requirements of subsection (a) of this section, the Commissioner shall adopt by regulation a requirement that each carrier provide a mechanism in a form and manner that the Commissioner may require to enable a member to: (1) be informed of the member’s […]
A carrier shall provide the notices required to be provided to members under this subtitle in a culturally and linguistically appropriate manner as described in the Affordable Care Act.
