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PARRIS N. GLENDENING, Governor
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S.B. 164
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PROVIDES SUFFICIENT INFORMATION AND SUPPORTING DOCUMENTATION IN THE
COMPLAINT THAT DEMONSTRATES A COMPELLING REASON TO DO SO.
(2) THE COMMISSIONER SHALL DEFINE BY REGULATION THE
STANDARDS THAT THE COMMISSIONER SHALL USE TO DECIDE WHAT
DEMONSTRATES A COMPELLING REASON UNDER PARAGRAPH (1) OF THIS
SUBSECTION.
(E) (1) FOR NONEMERGENCY CASES, EACH CARRIER'S INTERNAL APPEAL
PROCESS ESTABLISHED UNDER SUBSECTION (A) OF THIS SECTION SHALL INCLUDE A
PROVISION THAT REQUIRES THE CARRIER TO:
(I) DOCUMENT IN WRITING ANY COVERAGE DECISION OR APPEAL
DECISION MADE BY THE CARRIER; AND
(II) WITHIN 5 WORKING DAYS AFTER THE DECISION HAS BEEN
MADE, SEND NOTICE OF THE COVERAGE DECISION OR APPEAL DECISION TO;
1. THE MEMBER; AND
2. IF THE GRIEVANCE WAS FILED ON BEHALF OF THE
MEMBER, THE HEALTH CARE PROVIDER.
(2) NOTICE OF THE COVERAGE DECISION OR 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;
(II) INCLUDE THE FOLLOWING INFORMATION:
1. THAT THE MEMBER HAS A RIGHT TO FILE A COMPLAINT
WITH THE COMMISSIONER WITHIN 30 DAYS AFTER RECEIPT OF A CARRIER'S APPEAL
DECISION;
2. THAT A COMPLAINT MAY BE FILED WITHOUT FIRST
FILING AN APPEAL IF THE MEMBER OR A HEALTH CARE PROVIDER FILING AN
APPEAL ON BEHALF OF THE MEMBER CAN DEMONSTRATE A COMPELLING REASON
TO DO SO; AND
3. THE COMMISSIONER'S ADDRESS, TELEPHONE NUMBER,
AND FACSIMILE NUMBER.
(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, 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
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- 3737 -
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