|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
PARRIS N. GLENDENING, Governor
|
|
|
|
|
|
Ch. 329
|
|
|
|
|
|
|
|
|
|
|
|
|
|
(ii) 2. reference REFERENCES the specific criteria and
standards, including interpretive guidelines, on which the adverse decision or
grievance decision was based;
(iii) 3. state STATES the name, business address, and business
telephone number of:
1. A. the medical director or associate medical director, as
appropriate, who made the adverse decision or grievance decision if the carrier is a
health maintenance organization; or
2. B. 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; and
(iv) 4. include INCLUDES the following information:
1. THAT THE MEMBER HAS A RIGHT TO APPEAL THE
ADVERSE DECISION THROUGH THE CARRIER'S INTERNAL GRIEVANCE PROCESS;
2. THE DETAILS OF THE CARRIER'S INTERNAL GRIEVANCE
PROCESS AND PROCEDURES UNDER THE PROVISIONS OF THIS SUBTITLE;
3. A STATEMENT THAT THE HEALTH ADVOCACY UNIT IS
AVAILABLE TO ASSIST THE MEMBER IN BOTH MEDIATING AND FILING A GRIEVANCE
UNDER THE CARRIER'S INTERNAL GRIEVANCE PROCESS;
4. THE ADDRESS, TELEPHONE NUMBER, FACSIMILE
NUMBER, AND E-MAIL ADDRESS OF THE HEALTH ADVOCACY UNIT;
[1.] A. 5. that the member has a right to file a complaint
with the Commissioner within 30 days after receipt of a carrier's grievance decision;
AND
[2.]. 6. 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; and
[3.] 7. 2. B. the Commissioner's address, telephone number,
and facsimile number.
(3) (2) A carrier may not use solely in a notice sent under paragraph
(1) of this subsection generalized terms such as "experimental procedure not covered",
"cosmetic procedure not covered", "service included under another procedure", or "not
medically necessary" to satisfy the requirements of paragraph (2)(i) or (ii) of this
subsection.
[(j)] (I) (1) For an emergency case under subsection (b)(2)(i) of this section,
within 1 day after a decision has been orally communicated to the member or health
care provider, the carrier shall send notice in writing of any adverse decision or
grievance decision to:
(i) the member; and
|
|
|
|
|
|
|
|
|
|
- 1975 -
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
 |
