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Ch. 371
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2000 LAWS OF MARYLAND
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"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) (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
(ii) if the grievance was filed on behalf of the member under
subsection (b)(2)(iii) of this section, the health care provider.
(2) [The] A notice REQUIRED TO BE SENT UNDER PARAGRAPH (1) OF
THIS SUBSECTION shall include the [information required under subsection (i)(2) of
this section] FOLLOWING:
(I) FOR AN ADVERSE DECISION, THE INFORMATION REQUIRED
UNDER SUBSECTION (F) OF THIS SECTION; AND
(II) FOR A GRIEVANCE DECISION, THE INFORMATION REQUIRED
UNDER SUBSECTION (I) OF THIS SECTION.
(k) Each carrier shall include the information required by subsections (f) and
[(i)(2)(iii)] (I) SUBSECTION (F)(2)(III), (IV), AND (V) of this section in the policy, plan,
certificate, enrollment materials, or other evidence of coverage that the carrier
provides to a member at the time of the member's initial coverage or renewal of
coverage.
SECTION 2. AND BE IT FURTHER ENACTED, That the Laws of Maryland
read as follows:
SUBTITLE 10D. COMPLAINT PROCESS FOR COVERAGE DECISIONS.
15-10D-01.
(A) IN THIS SUBTITLE THE FOLLOWING WORDS HAVE THE MEANINGS
INDICATED.
(B) "APPEAL" MEANS A PROTEST FILED BY A MEMBER OR A HEALTH CARE
PROVIDER WITH A CARRIER UNDER ITS INTERNAL APPEAL PROCESS REGARDING A
COVERAGE DECISION CONCERNING A MEMBER
(C) "APPEAL DECISION" MEANS A FINAL DETERMINATION BY A CARRIER THAT
ARISES FROM AN APPEAL FILED WITH THE CARRIER UNDER ITS APPEAL PROCESS
REGARDING A COVERAGE DECISION CONCERNING A MEMBER
(D) "CARRIER" MEANS A PERSON THAT OFFERS A HEALTH CARE SERVICES
BENEFIT PLAN AND IS:
(1) AN AUTHORIZED INSURER THAT PROVIDES HEALTH INSURANCE IN
THE STATE;
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