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PARRIS N. GLENDENING, Governor Ch. 371
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(4) the address, telephone number, and facsimile number of the
Commissioner; and
(5) information on where the information required by this subsection can
be found in the member's policy, plan, certificate, enrollment materials, or other
evidence of coverage.]
FOR NONEMERGENCY CASES, WHEN A CARRIER RENDERS AN ADVERSE
DECISION, THE CARRIER SHALL:
(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 A HEALTH CARE PROVIDER
ACTING ON BEHALF OF THE MEMBER THAT:
(1) (I) STATES IN DETAIL IN CLEAR, UNDERSTANDABLE LANGUAGE
THE SPECIFIC FACTUAL BASES FOR THE CARRIER'S DECISION;
(2) (II) REFERENCES THE SPECIFIC CRITERIA AND STANDARDS,
INCLUDING INTERPRETIVE GUIDELINES, ON WHICH THE DECISION WAS BASED, AND
MAY NOT SOLELY USE GENERALIZED TERMS SUCH AS "EXPERIMENTAL PROCEDURE
NOT COVERED", "COSMETIC PROCEDURE NOT COVERED", "SERVICE INCLUDED
UNDER ANOTHER PROCEDURE", OR "NOT MEDICALLY NECESSARY";
(3) (III) STATES THE NAME, BUSINESS ADDRESS, AND BUSINESS
TELEPHONE NUMBER OF:
(I) 1. THE MEDICAL DIRECTOR OR ASSOCIATE MEDICAL DIRECTOR,
AS APPROPRIATE, WHO MADE THE DECISION IF THE CARRIER IS A HEALTH
MAINTENANCE ORGANIZATION; OR
(II) 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;
(4) (IV) GIVES WRITTEN DETAILS OF THE CARRIER'S INTERNAL
GRIEVANCE PROCESS AND PROCEDURES UNDER THIS SUBTITLE; AND
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(5) (V) INCLUDES THE FOLLOWING INFORMATION:
(I) 1. THAT THE MEMBER OR A 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;
(II) 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; AND
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- 2103 -
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