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PARRIS N. GLENDENING, Governor
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Ch. 371
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(B) (1) AN INTERNAL APPEAL PROCESS SHALL INCLUDE AN EXPEDITED
PROCEDURE FOR USE IN AN EMERGENCY CASE FOR PURPOSES OF RENDERING AN
APPEAL DECISION WITHIN 31 HOURS AFTER THE DATE AN APPEAL IS FILED WITH
THE CARRIER.
(2) THE INTERNAL APPEAL PROCESS SHALL PROVIDE THAT A CARRIER
RENDER AN APPEAL DECISION IN WRITING.
(B) AN INTERNAL APPEAL PROCESS ESTABLISHED BY A CARRIER UNDER THIS
SECTION SHALL PROVIDE THAT A CARRIER RENDER A FINAL DECISION IN WRITING
TO A MEMBER AND A HEALTH CARE PROVIDER ACTING ON BEHALF OF THE MEMBER
WITHIN 60 WORKING DAYS AFTER THE DATE ON WHICH THE APPEAL IS FILED.
(C) EXCEPT AS PROVIDED IN SUBSECTION (D) OF THIS SECTION, THE
CARRIER'S INTERNAL APPEAL PROCESS SHALL BE EXHAUSTED PRIOR TO FILING A
COMPLAINT WITH THE COMMISSIONER UNDER THIS SUBTITLE.
(D) (1) A MEMBER OR A HEALTH CARE PROVIDER FILING A COMPLAINT ON
BEHALF OF A MEMBER MAY FILE A COMPLAINT WITH THE COMMISSIONER WITHOUT
FIRST FILING AN APPEAL WITH A CARRIER ONLY IF THE COVERAGE DECISION
INVOLVES AN URGENT MEDICAL CONDITION, AS DEFINED BY REGULATION ADOPTED
BY THE COMMISSIONER FOR WHICH CARE HAS NOT BEEN RENDERED AND
RECEIVING AN APPEAL DECISION IF THE MEMBER OR THE HEALTH CARE PROVIDER
PROVIDES SUFFICIENT INFORMATION AND SUPPORTING DOCUMENTATION IN THE
COMPLAINT THAT DEMONSTRATES A COMPELLING REASON TO DO SO.
(2) THE COMMISSIONER SHALL DEFINE BY REGULATION THE
STANDARDS THAT THE COMMISSIONER SHALL USE TO DECIDE WHAT
DEMONSTRATES A COMPELLING REASON UNDER PARAGRAPH (1) OF THIS
SUBSECTION.
(E) (1) FOR NONEMERGENCY CASES, EACH CARRIER'S INTERNAL APPEAL
PROCESS ESTABLISHED UNDER SUBSECTION (A) OF THIS SECTION SHALL INCLUDE A
PROVISION THAT REQUIRES THE CARRIER TO:
(I) DOCUMENT IN WRITING ANY COVERAGE DECISION OR APPEAL
DECISION MADE BY THE CARRIER; AND
(II) WITHIN 5 WORKING DAYS AFTER THE DECISION HAS BEEN
MADE, SEND NOTICE OF THE COVERAGE DECISION OR APPEAL DECISION TO:
1. THE MEMBER; AND
2. IF THE GRIEVANCE WAS FILED ON BEHALF OF THE
MEMBER, THE HEALTH-CARE PROVIDER
(2) NOTICE OF THE COVERAGE DECISION OR APPEAL DECISION
REQUIRED TO BE SENT UNDER PARAGRAPH (1) OF THIS SUBSECTION SHALL:
(I) STATE IN DETAIL IN CLEAR, UNDERSTANDABLE LANGUAGE
THE SPECIFIC FACTUAL BASES FOR THE CARRIER'S DECISION;
(II) INCLUDE THE FOLLOWING INFORMATION;
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- 2109 -
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