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PARRIS N. GLENDENING, Governor
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S.B. 164
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(ii) 2. [reference] REFERENCES the specific criteria and
standards, including interpretive guidelines, on which the [adverse decision or]
grievance decision was based;
(iii) 3. [state] STATES the name, business address, and business
telephone number of:
1. A. the medical director or associate medical director, as
appropriate, who made the [adverse decision or] grievance decision if the carrier is a
health maintenance organization; or
2. B. 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; and
(iv) 4. [include] INCLUDES the following information:
1. A. that the member has a right to file a complaint with
the Commissioner within 30 days after receipt of a carrier's grievance decision; AND
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; and
3. B. the Commissioner's address, telephone number, and
facsimile number.
[(3)] (2) A carrier may not use solely in a notice sent under paragraph
(1) of this subsection generalized terms such as "experimental procedure not covered",
"cosmetic procedure not covered", "service included under another procedure", or "not
medically necessary" to satisfy the requirements of [paragraph (2)(i) or (ii) of] this
subsection.
(j) (1) For an emergency case under subsection (b)(2)(i) of this section,
within 1 day after a decision has been orally communicated to the member or health
care provider, the carrier shall send notice in writing of any adverse decision or
grievance decision to:
(i) the member; and
(ii) if the grievance was filed on behalf of the member under
subsection (b)(2)(iii) of this section, the health care provider.
(2) [The] A notice REQUIRED TO BE SENT UNDER PARAGRAPH (1) OF
THIS SUBSECTION shall include the [information required under subsection (i)(2) of
this section] FOLLOWING:
(I) FOR AN ADVERSE DECISION, THE INFORMATION REQUIRED
UNDER SUBSECTION (F) OF THIS SECTION; AND
(II) FOR A GRIEVANCE DECISION, THE INFORMATION REQUIRED
UNDER SUBSECTION (I) OF THIS SECTION.
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- 3733 -
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