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

A. that the member OR THE AUTHORIZED REPRESENTATIVE
has a right to file a complaint with the Commissioner within [30 working] 45 days
after receipt of a carrier's grievance decision; and

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

5. STATES THAT THE MEMBER AND THE AUTHORIZED
REPRESENTATIVE ARE ENTITLED TO RECEIVE, FREE OF CHARGE, REASONABLE
ACCESS TO, AND COPIES OF, ALL DOCUMENTS, RECORDS, AND OTHER INFORMATION
RELEVANT TO THE GRIEVANCE DECISION;

6. IF THE CARRIER USES AN INTERNAL RULE, GUIDELINE,
PROTOCOL, OR OTHER SIMILAR CRITERION TO MAKE THE GRIEVANCE DECISION:

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

B. 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
FROM THE MEMBER OR AUTHORIZED REPRESENTATIVE; AND

7. PROVIDES AN EXPLANATION OF THE SCIENTIFIC OR
CLINICAL JUDGMENT FOR THE GRIEVANCE DECISION, IF THE GRIEVANCE DECISION
IS A RESULT OF MEDICAL REVIEW OF EXPERIMENTAL OR INVESTIGATIONAL
TREATMENTS OR SERVICES.

(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 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) A notice required to be sent under paragraph (1) of this subsection
shall include the 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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