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PARRIS N. GLENDENING, Governor
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S.B. 164
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(II) REFERENCES THE SPECIFIC CRITERIA AND STANDARDS,
INCLUDING INTERPRETIVE GUIDELINES, ON WHICH THE DECISION WAS BASED, AND
MAY NOT SOLELY USE GENERALIZED TERMS SUCH AS "EXPERIMENTAL PROCEDURE
NOT COVERED", "COSMETIC PROCEDURE NOT COVERED", "SERVICE INCLUDED
UNDER ANOTHER PROCEDURE", OR "NOT MEDICALLY NECESSARY";
(3) (III) STATES THE NAME, BUSINESS ADDRESS, AND BUSINESS
TELEPHONE NUMBER OF:
(I) 1. THE MEDICAL DIRECTOR OR ASSOCIATE MEDICAL
DIRECTOR, AS APPROPRIATE, WHO MADE THE DECISION IF THE CARRIER IS A
HEALTH MAINTENANCE ORGANIZATION; OR
(II) 2. 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;
(4) (IV) GIVES WRITTEN DETAILS OF THE CARRIER'S INTERNAL
GRIEVANCE PROCESS AND PROCEDURES UNDER THIS SUBTITLE; AND
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(5) (V) INCLUDES THE FOLLOWING INFORMATION:
(I) 1. THAT THE MEMBER OR A PROVIDER ON BEHALF OF THE
MEMBER HAS A RIGHT TO FILE A COMPLAINT WITH THE COMMISSIONER WITHIN 30
DAYS AFTER RECEIPT OF A CARRIER'S GRIEVANCE DECISION;
(II) 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 AS DETERMINED BY THE COMMISSIONER; AND
(III) 3. THE COMMISSIONER'S ADDRESS, TELEPHONE NUMBER,
AND FACSIMILE NUMBER; AND
4. A STATEMENT THAT THE HEALTH ADVOCACY UNIT IS
AVAILABLE TO ASSIST THE MEMBER IN BOTH MEDIATING AND FILING A GRIEVANCE
UNDER THE CARRIER'S INTERNAL GRIEVANCE PROCESS; AND
5. THE ADDRESS, TELEPHONE NUMBER, FACSIMILE
NUMBER, AND EMAIL ADDRESS OF THE HEALTH ADVOCACY UNIT.
(6) INCLUDES THE FOLLOWING DISCLOSURE IN AT LEAST 12-POINT
TYPEFACE, WITH THE FIRST SENTENCE IN BOLD CAPITAL TYPEFACE:
"THERE IS HELP AVAILABLE TO YOU IF YOU WISH TO DISPUTE THE DECISION
OF THE PLAN ABOUT PAYMENT FOR HEALTH CARE SERVICES. YOU MAY CONTACT
THE HEALTH ADVOCACY UNIT OF MARYLAND'S CONSUMER PROTECTION DIVISION
AT (PHONE NUMBER, ADDRESS, FAX, E MAIL).
THE HEALTH ADVOCACY UNIT CAN HELP YOU AND YOUR HEALTH CARE
PROVIDER PREPARE A GRIEVANCE TO FILE UNDER THE CARRIER'S INTERNAL GRIEVANCE PROCEDURE. THAT UNIT CAN ALSO ATTEMPT TO MEDIATE A
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- 3731 -
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