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PARRIS N. GLENDENING, Governor Ch. 329
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(1) DOCUMENT THE ADVERSE DECISION IN WRITING AFTER THE
CARRIER HAS PROVIDED ORAL COMMUNICATION OF THE DECISION TO THE MEMBER
OR THE HEALTH CARE PROVIDER ACTING ON BEHALF OF THE MEMBER; AND
(2) SEND, WITHIN 5 WORKING DAYS AFTER THE ADVERSE DECISION HAS
BEEN MADE, A WRITTEN NOTICE TO THE MEMBER AND THE A HEALTH. CARE
PROVIDER ACTING ON BEHALF OF THE MEMBER THAT:
(I) STATES IN DETAIL IN CLEAR, UNDERSTANDABLE LANGUAGE
THE SPECIFIC FACTUAL BASES FOR THE CARRIER'S DECISION:
(II) REFERENCES THE SPECIFIC CRITERIA AND STANDARDS,
INCLUDING INTERPRETIVE GUIDELINES, ON WHICH THE DECISION WAS BASED, AND
DOES NOT SOLELY USE GENERALIZED TERMS SUCH AS "EXPERIMENTAL PROCEDURE
NOT COVERED", "COSMETIC PROCEDURE NOT COVERED", "SERVICE INCLUDED
UNDER ANOTHER PROCEDURE". OR "NOT MEDICALLY NECESSARY';
(III) STATES THE NAME, BUSINESS ADDRESS, AND BUSINESS
TELEPHONE NUMBER OF:
1. THE MEDICAL DIRECTOR OR ASSOCIATE MEDICAL
DIRECTOR, AS APPROPRIATE, WHO MADE THE DECISION IF THE CARRIER IS A
HEALTH MAINTENANCE ORGANIZATION; OR
2. THE DESIGNATED EMPLOYEE OR REPRESENTATIVE OF
THE CARRIER WHO HAS RESPONSIBILITY FOR THE CARRIER'S INTERNAL GRIEVANCE
PROCESS IF THE CARRIER IS NOT A HEALTH MAINTENANCE ORGANIZATION;
(IV) GIVES WRITTEN DETAILS OF THE CARRIER'S INTERNAL
GRIEVANCE PROCESS AND PROCEDURES UNDER THIS SUBTITLE; AND
(V) INCLUDES THE FOLLOWING INFORMATION:
1. THAT THE MEMBER OR A HEALTH CARE PROVIDER ON
BEHALF OF THE MEMBER HAS A RIGHT TO FILE A COMPLAINT WITH THE
COMMISSIONER WITHIN 30 DAYS AFTER RECEIPT OF A CARRIER'S GRIEVANCE
DECISION;
2. THAT A COMPLAINT MAY BE FILED WITHOUT FIRST
FILING A GRIEVANCE IF THE MEMBER OR A HEALTH CARE PROVIDER FILING A
GRIEVANCE ON BEHALF OF THE MEMBER CAN DEMONSTRATE A COMPELLING
REASON TO DO SO AS DETERMINED BY THE COMMISSIONER:
3. THE COMMISSIONER'S ADDRESS, TELEPHONE NUMBER
AND FACSIMILE NUMBER;
4. A STATEMENT THAT THE HEALTH ADVOCACY UNIT IS
AVAILABLE TO ASSIST THE MEMBER IN BOTH MEDIATING AND FILING A GRIEVANCE
UNDER THE CARRIERS INTERNAL GRIEVANCE PROCESS: AND
4. 5. THE ADDRESS, TELEPHONE NUMBER FACSIMILE
NUMBER, AND E-MAIL ADDRESS OF THE HEALTH ADVOCACY UNIT; AND
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- 1973 -
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