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S.B. 164
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VETOES
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15-10A-02:
(f) [Except for an emergency case under subsection (b)(2)(i) of this section, at
the time a member first contacts a carrier about an adverse decision, the carrier shall
send in writing to the member within 2 working days after the initial contact:
(1) the details of its internal grievance process and procedures under the
provisions of this subtitle;
(2) information stating that:
(i) the Health Advocacy Unit:
1. is available to assist the member with filing a grievance
under the carrier's internal grievance process; but
2. is not available to represent or accompany the member
during the proceedings of the internal grievance process;
(ii) the Health Advocacy Unit can assist the member in mediating a
resolution of the adverse decision with the carrier, but that any time during the
mediation, the member or a health care provider on behalf of the member may file a
grievance; and
(iii) the member or a health care provider on behalf of the member
may file a complaint with the Commissioner without first filing a grievance if
sufficient information and supporting documentation is filed with the complaint that
demonstrates a compelling reason to do so;
(3) the address, telephone number, facsimile number, and e-mail
address of the Health Advocacy Unit;
(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;
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- 3730 -
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