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S.B. 164
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VETOES
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(2) "MEMBER" INCLUDES:
(I) A SUBSCRIBER; AND
(II) UNLESS PREEMPTED BY FEDERAL LAW, A MEDICARE
RECIPIENT.
(3) "MEMBER" DOES NOT INCLUDE A MEDICAID RECIPIENT.
15-10D-02.
THIS SUBTITLE APPLIES TO A CARRIER FOR ANY CONTRACT THAT;
(1) IS DELIVERED OR ISSUED IN THE STATE; OR
(2) COVERS INDIVIDUALS WHO RESIDE OR WORK IN THE STATE IF THE
CONTRACT IS DELIVERED OR ISSUED IN A STATE THAT THE COMMISSIONER
DETERMINES DOES NOT HAVE AN EXTERNAL COMPLAINT PROCESS FOR APPEALS
COMPARABLE TO THE COMPLAINT PROCESS ESTABLISHED IN THIS SUBTITLE.
15-10D-03.
(A) (1) IN ADDITION TO THE REQUIREMENTS OF SUBTITLE 10A OF THIS
TITLE, EACH CARRIER SHALL ESTABLISH AN INTERNAL APPEAL PROCESS FOR USE
BY ITS MEMBERS 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.
(B) (1) AN INTERNAL APPEAL PROCESS SHALL INCLUDE AN EXPEDITED
PROCEDURE FOR USE IN AN EMERGENCY CASE FOR PURPOSES OF RENDERING AN
APPEAL DECISION WITHIN 24 HOURS AFTER THE DATE AN APPEAL IS FILED WITH
THE CARRIER
(2) THE INTERNAL APPEAL PROCESS SHALL PROVIDE THAT A CARRIER
RENDER AN APPEAL DECISION IN WRITING.
(B) AN INTERNAL APPEAL PROCESS ESTABLISHED BY A CARRIER UNDER THIS
SECTION SHALL PROVIDE THAT A CARRIER RENDER A FINAL DECISION IN WRITING
TO A MEMBER AND A HEALTH CARE PROVIDER ACTING ON BEHALF OF THE MEMBER,
WITHIN 60 WORKING DAYS AFTER THE DATE ON WHICH THE APPEAL IS FILED.
(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.
(D) (1) A MEMBER 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 AND
RECEIVING AN APPEAL DECISION IF THE MEMBER OR THE HEALTH CARE PROVIDER
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- 3736 -
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