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ROBERT L. EHRLICH, JR., Governor
Ch. 415
(3) FOR A COVERAGE DECISION INVOLVING AN EXTENSION OF A
COURSE OF TREATMENT BEYOND THE PERIOD OF TIME OR NUMBER OF
TREATMENTS PREVIOUSLY APPROVED BY THE CARRIER, THE CARRIER SHALL
COMPLY WITH § 15-10A-02(I)(3) OF THIS TITLE.
(4) FOR A COVERAGE DECISION INVOLVING AN EMERGENCY CASE, THE
CARRIER SHALL COMPLY WITH § 15-10A-02(I)(2) OF THIS TITLE.
[(2)] (5) Notice of the coverage decision required to be sent under
[paragraph (1)] PARAGRAPHS (1) THROUGH (4) 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, or a health care provider acting on
behalf of the member,] MEMBER OR THE AUTHORIZED REPRESENTATIVE has a right
to file an appeal with the carrier;
2. that the [member, or a health care provider acting on
behalf of the member,] MEMBER OR THE AUTHORIZED REPRESENTATIVE may file a
complaint with the Commissioner without first filing an appeal, if the coverage
decision involves an [urgent medical condition] EMERGENCY CASE 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 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;
(III) REFERENCE THE SPECIFIC HEALTH BENEFIT PLAN
PROVISIONS ON WHICH THE COVERAGE DECISION IS BASED;
(IV) INCLUDE A DESCRIPTION OF ANY ADDITIONAL MATERIAL OR
INFORMATION REQUIRED FROM THE MEMBER OR THE AUTHORIZED
REPRESENTATIVE AND AN EXPLANATION OF THE NECESSITY OF THE MATERIAL OR
INFORMATION;
(V) INCLUDE A DESCRIPTION OF THE CARRIER'S APPEAL
PROCEDURES AND THE TIME LIMITS APPLICABLE TO THE CARRIER'S APPEAL
PROCEDURES; AND
(VI) IF THE CARRIER USES AN INTERNAL RULE, GUIDELINE,
PROTOCOL, OR OTHER SIMILAR CRITERION TO MAKE THE COVERAGE DECISION:
1. PROVIDE THE INTERNAL RULE, GUIDELINE, PROTOCOL,
OR OTHER SIMILAR CRITERION; OR
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