|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
PARRIS N. GLENDENING, Governor
|
|
|
|
|
|
Ch. 371
|
|
|
|
|
|
|
|
|
|
|
|
|
|
1. the member; and
2. if the grievance was filed on behalf of the member under
subsection (b)(2)(iii) of this section, the health care provider.
(2) Notice of the adverse decision or grievance decision required to be
sent under paragraph (1) of this subsection shall:]
(1) FOR NONEMERGENCY CASES, WHEN A CARRIER RENDERS A
GRIEVANCE DECISION, THE CARRIER SHALL:
(I) DOCUMENT THE GRIEVANCE 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
(II) SEND, WITHIN 5 WORKING DAYS AFTER THE GRIEVANCE
DECISION HAS BEEN MADE, A WRITTEN NOTICE TO THE MEMBER AND A HEALTH
CARE PROVIDER ACTING ON BEHALF OF THE MEMBER THAT:
(i) 1. [state] STATES in detail in clear, understandable language the
specific factual bases for the carrier's decision;
(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. A. 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. 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. 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",
|
|
|
|
|
|
|
|
|
|
- 2105 -
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
 |
