ROBERT L. EHRLICH, JR., Governor Ch. 415
(2) "AUTHORIZED REPRES ENTATIVE" INCLUDES, IN AN EMERGENCYS
CASE, A HEALTH CARE PROVIDER WITH KNOWLEDGE OF THE MEMBER'
[(c)] (D) "Carrier" means a person that offers a health benefit plan and is:
(1) an authorized insurer that provides health insurance in the State;
(2) a nonprofit health service plan;
(3) a health maintenance organization;
(4) a dental plan organization; or
(5) except for a managed care organization as defined in Title 15,—
Subtitle 1 of the Health
General Article, any other person that provides health
benefit plans subject to regulation by the State.
[(d)] (E) "Complaint" means a protest filed with the Commissioner involving
an adverse decision or grievance decision concerning the member.
(F) (E) "DESIGNEE OF THE COMMISSIONER" MEANS ANY PERSON TO WHOM
THE COMMISSIONER HAS DELEGATED THE AUTHORITY TO REVIEW AND DECIDE
COMPLAINTS FILED UNDER THIS SUBTITLE, INCLUDING AN ADMINISTRATIVE LAW
JUDGE TO WHOM THE AUTHORITY TO CONDUCT A HEARING HAS BEEN DELEGATED
FOR RECOMMENDED OR FINAL DECISION.
(G) (1) "EMERGENCY CASE" MEANS ANY CLAIM OR REQUEST FOR MEDICAL
CARE OR TREATMENT IN WHICH THE APPLICATION OF THE TIME PERIODS FOR
MAKING NONEMERGENCY CASE DETERMINATIONS:
(I) IN THE JUDGMENT OF A PRUDENT LAYPERSON WHO
POSSESSES AN AVERAGE KNOWLEDGE OF HEALTH AND MEDICINE, MAY SERIOUSLY
JEOPARDIZE THE LIFE OR HEALTH OF THE MEMBER OR THE ABILITY OF THE
MEMBER TO REGAIN MAXIMUM FUNCTIONS; OR
(H) IN THE OPINION OF A PHYSICIAN WITH KNOWLEDGE OF THE
MEMBER'S MEDICAL CONDITION:
1. MAY SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH OF
THE MEMBER OR THE ABILITY OF THE MEMBER TO REGAIN MAXIMUM FUNCTION; OR
2. MAY SUBJECT THE MEMBER TO S EVERE PAIN THAT
CANNOT BE ADEQUATELY MANAGED WITHOUT THE CARE OR TREATMENT THAT IS
THE SUBJECT OF THE CLAIM OR REQUEST.
(2) "EMERGENCY CASE" DOES NOT INCLUDE A RETROSPECTIVE DENIAL S
OF HEALTH CARE
(H) (F) "Grievance" means a protest filed by a member or [a health
care provider on behalf of a member
] AN AUTHORIZED REPRESENTATIVE with a
carrier through the carrier's internal grievance process regarding an adverse decision
concerning the member.
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