ROBERT L. EHRLICH, JR., Governor                            Ch. 415

1. the medical director or associate medical director, as
appropriate, who made the decision if the carrier is a health maintenance
organization; or

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;

(iv) gives written details of the carrier's internal grievance process
and procedures under this subtitle; [and]

(v) includes the following information:

1. that the member or [a health care provider] THE
AUTHORIZED REPRESENTATIVE ACTING on behalf of the member has a right to file a
complaint with the Commissioner within [30 working] 45 days after receipt of a
carrier's grievance decision;

2. that a complaint may be filed without first filing a
grievance if the member or [a health care provider] THE AUTHORIZED
REPRESENTATIVE filing a grievance on behalf of the member can demonstrate a
compelling reason to do so as determined by the Commissioner;

3. the Commissioner's address, telephone number, and
facsimile number;

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
electronic mail address of the Health Advocacy [Unit.] UNIT;

(VI) IF A CARRIER USES AN INTERNAL RULE, GUIDELINE,
PROTOCOL, OR OTHER SIMILAR CRITERION TO MAKE THE ADVERSE DECISION;

1. PROVIDES THE INTERNAL RULE, GUIDELINE, PROTOCOL,
OR OTHER SIMILAR CRITERION; OR

2. INFORMS THE MEMBER AND THE AUTHORIZED
REPRESENTATIVE THAT A COPY OF THE INTERNAL RULE, GUIDELINE, PROTOCOL, OR
OTHER SIMILAR CRITERION WILL BE PROVIDED FREE OF CHARGE ON REQUEST OF
THE MEMBER OR THE AUTHORIZED REPRESENTATIVE;

(VII) PROVIDES AN EXPLANATION OF THE SCIENTIFIC OR CLINICAL
JUDGMENT FOR THE ADVERSE DECISION, IF THE ADVERSE DECISION IS A RESULT OF
MEDICAL REVIEW OF EXPERIMENTAL OR INVESTIGATIONAL TREATMENTS OR
SERVICES; AND

(VIII) IF A CARRIER REQUIRES ADDITIONAL INFORMATION;

- 1505 -