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PARRIS N. GLENDENING, Governor
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Ch. 371
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(I) STATE IN DETAIL IN CLEAR, UNDERSTANDABLE LANGUAGE
THE SPECIFIC FACTUAL BASES FOR THE CARRIER'S DECISION; AND
(II) INCLUDE THE FOLLOWING INFORMATION:
1. THAT THE MEMBER, OR A HEALTH CARE PROVIDER
ACTING ON BEHALF OF THE MEMBER HAS A RIGHT TO FILE A COMPLAINT WITH THE
COMMISSIONER WITHIN 60 WORKING DAYS AFTER RECEIPT OF A CARRIER'S APPEAL
DECISION; AND
2. THE COMMISSIONER'S ADDRESS, TELEPHONE NUMBER,
AND FACSIMILE NUMBER
(F) (G) THE COMMISSIONER MAY REQUEST THE MEMBER THAT FILED THE
COMPLAINT OR A LEGALLY AUTHORIZED DESIGNEE OF THE MEMBER TO SIGN A
CONSENT FORM AUTHORIZING THE RELEASE OF THE MEMBER'S MEDICAL RECORDS
TO THE COMMISSIONER OR THE COMMISSIONER'S DESIGNEE THAT ARE NEEDED IN
ORDER FOR THE COMMISSIONER TO MAKE A FINAL DECISION ON THE COMPLAINT.
(G) (H) (1) DURING THE REVIEW OF A COMPLAINT BY THE COMMISSIONER
OR A DESIGNEE OF THE COMMISSIONER, A CARRIER SHALL HAVE THE BURDEN OF
PERSUASION THAT ITS COVERAGE DECISION OR APPEAL DECISION, AS APPLICABLE,
IS CORRECT.
(2) AS PART OF THE REVIEW OF A COMPLAINT, THE COMMISSIONER OR
A DESIGNEE OF THE COMMISSIONER MAY CONSIDER ALL OF THE FACTS OF THE
CASE AND ANY OTHER EVIDENCE THAT THE COMMISSIONER OR DESIGNEE OF THE
COMMISSIONER CONSIDERS APPROPRIATE.
(H) (I) THE COMMISSIONER SHALL;
(1) MAKE AND ISSUE IN WRITING A FINAL DECISION ON ALL
COMPLAINTS FILED WITH THE COMMISSIONER UNDER THIS SUBTITLE THAT ARE
WITHIN THE COMMISSIONER'S JURISDICTION; AND
(2) PROVIDE NOTICE IN WRITING TO ALL PARTIES TO A COMPLAINT OF
THE OPPORTUNITY AND TIME PERIOD FOR REQUESTING A HEARING TO BE HELD IN
ACCORDANCE WITH TITLE 10 SUBTITLE 2 OF THE STATE GOVERNMENT ARTICLE TO
CONTEST A FINAL DECISION OF THE COMMISSIONER MADE AND ISSUED UNDER THIS
SUBTITLE.
15-10D-04. 15-10D-03.
(A) IT IS A VIOLATION OF THIS SUBTITLE FOR A CARRIER TO FAIL TO FULFILL
THE CARRIER'S OBLIGATIONS TO PROVIDE OR REIMBURSE FOR HEALTH CARE
SERVICES SPECIFIED IN THE CARRIER'S POLICIES OR CONTRACTS WITH MEMBERS.
(B) IF, IN RENDERING A COVERAGE DECISION OR APPEAL DECISION, A
CARRIER FAILS TO FULFILL THE CARRIERS POLICIES OR CONTRACTS WITH
MEMBERS, THE COMMISSIONER MAY:
(1) ISSUE AN ADMINISTRATIVE ORDER THAT REQUIRES THE CARRIER
TO:
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- 2111 -
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