|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S.B. 164
|
|
|
|
|
|
VETOES
|
|
|
|
|
|
|
|
|
|
|
|
|
|
RESOLUTION TO YOUR DISPUTE. THE HEALTH ADVOCACY UNIT IS NOT AVAILABLE
TO REPRESENT OR ACCOMPANY YOU DURING ANY PROCEEDING OF THE INTERNAL
GRIEVANCE PROCESS.
ADDITIONALLY, YOU MAY FILE A COMPLAINT WITH THE MARYLAND
INSURANCE ADMINISTRATION, WITHOUT HAVING TO FIRST FILE A GRIEVANCE WITH
THE PLAN, IF:
(1) THE PLAN HAS DENIED AUTHORIZATION FOR A HEALTH CARE
SERVICE NOT YET PROVIDED TO YOU; AND
(2) YOU OR YOUR PROVIDER CAN SHOW A COMPELLING REASON TO FILE
A COMPLAINT, INCLUDING THAT A DELAY IN RECEIVING THE HEALTH CARE SERVICE
COULD RESULT IN LOSS OF LIFE, SERIOUS IMPAIRMENT TO A BODILY FUNCTION, OR
SERIOUS DYSFUNCTION OF A BODILY ORGAN OR PART, OR THE MEMBER REMAINING
SERIOUSLY MENTALLY ILL WITH SYMPTOMS THAT CAUSE THE MEMBER TO BE A
DANCER TO SELF OR OTHERS. INFORMATION DESCRIBED IN THIS NOTICE MAY ALSO
BE FOUND IN (CITE POLICY, PLAN, CERTIFICATE, ENROLLMENT MATERIALS, OR
OTHER EVIDENCE OF COVERAGE)".
(i) [(1) For nonemergency cases, each carrier's internal grievance process
established under subsection (a) of this section shall include a provision that requires
the carrier to:
(i) document in writing any adverse decision or grievance decision
made by the carrier after the carrier has provided oral communication of the decision
to the member or the health care provider who filed the grievance on behalf of the
member; and
(ii) within 5 working days after the decision has been made, send
notice of the adverse decision or grievance decision to:
1. the member; and
2. if the grievance was filed on behalf of the member under
subsection (b)(2)(iii) of this section, the health care provider.
(2) Notice of the adverse decision or grievance decision required to be
sent under paragraph (1) of this subsection shall:]
(1) FOR NONEMERGENCY CASES, WHEN A CARRIER RENDERS A
GRIEVANCE DECISION, THE CARRIER SHALL:
(I) DOCUMENT THE GRIEVANCE 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
(II) SEND, WITHIN 5 WORKING DAYS AFTER THE GRIEVANCE
DECISION HAS BEEN MADE, A WRITTEN NOTICE TO THE MEMBER AND A HEALTH
CARE PROVIDER ACTING ON BEHALF OF THE MEMBER THAT:
(i) 1. [state] STATES in detail in clear, understandable
language the specific factual bases for the carrier's decision;
|
|
|
|
|
|
|
|
|
|
- 3732 -
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
 |
