Ch. 415

2004 LAWS OF MARYLAND

1. NOTIFY THE MEMBER AND THE AUTHORIZED

REPRESENTATIVE IN WRITING WITHIN 30 DAYS AFTER RECEIPT OF THE REQUEST
FOR PAYMENT OF HEALTH CARE SERVICES OF THE SPECIFIC INFORMATION
NECESSARY TO MAKE THE DECISION;

2. ALLOW THE MEMBER OR THE AUTHORIZED

REPRESENTATIVE ACTING ON BEHALF OF THE MEMBER AT LEAST 45 DAYS TO
PROVIDE THE SPECIFIC INFORMATION; AND

3. PROVIDE WRITTEN NOTICE OF THE CARRIER'S DECISION
TO THE MEMBER AND THE AUTHORIZED REPRESENTATIVE WITHIN THE EARLIER OF;

A. 15 DAYS AFTER RECEIPT OF THE SPECIFIC INFORMATION
REQUIRED IN ITEM 1 OF THIS SUBPARAGRAPH; OR

B. 15 DAYS AFTER THE DATE THE SPECIFIC INFORMATION
WAS REQUIRED TO BE PROVIDED TO THE CARRIER.

(III) THE CARRIER MAY BE ALLOWED A 15-DAY EXTENSION IF THE
CARRIER:

1. DETERMINES THE EXTENSION IS NECESSARY DUE TO
CIRCUMSTANCES BEYOND THE CONTROL OF THE CARRIER; AND

2. PROVIDES NOTICE TO THE MEMBER AND THE
AUTHORIZED REPRESENTATIVE BEFORE THE EXPIRATION OF THE INITIAL 30 DAY
PERIOD OF;

A. THE CIRCUMSTANCES REQUIRING THE EXTENSION OF
TIME; AND

B. THE DATE BY WHICH THE CARRIER EXPECTS TO RENDER
A DECISION.

[(k)] (J) Each carrier shall include the information required by subsection
[(f)(2)(iii)] (G)(2)(III), (iv), and (v) of this section in the policy, HEALTH BENEFIT plan,
certificate, enrollment materials, or other evidence of coverage that the carrier
provides to a member at the time of the member's initial coverage or renewal of
coverage.

[(l)] (K) (1) Nothing in this subtitle prohibits a carrier from delegating its
internal grievance process to a private review agent that has a certificate issued
under Subtitle 10B of this title and is acting on behalf of the carrier.

(2) If a carrier delegates its internal grievance process to a private
review agent, the carrier shall be:

(i) bound by the grievance decision made by the private review
agent acting on behalf of the carrier; and

(ii) responsible for a violation of any provision of this subtitle
regardless of the delegation made by the carrier under paragraph (1) of this
subsection.

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