Ch. 415                                    2004 LAWS OF MARYLAND

(d)     In cases considered appropriate by the Commissioner, the Commissioner
may seek advice from an independent review organization or medical expert, as
provided in § 15-10A-05 of this subtitle, for complaints filed with the Commissioner
under this subtitle that involve a question of whether a health care service provided
or to be provided to a member is medically necessary.

(e)     (1) During the review of a complaint by the Commissioner or a designee
of the Commissioner, a A carrier shall have the burden of persuasion that its adverse
decision or grievance decision, as applicable, is correct:

(I)      DURING THE REVIEW OF A COMPLAINT BY THE COMMISSIONER
OR A DESIGNEE OF THE COMMISSIONER; AND

(II)     IN ANY HEARING HELD IN ACCORDANCE WITH § 2-210 OF THIS
ARTICLE.

(2)     As part of the review of a complaint, the Commissioner or a designee
of the Commissioner may consider all of the facts of the case and any other evidence
that the Commissioner or designee of the Commissioner considers appropriate.

(3)     As required under § [15-10A-02(i)] 15-10A-02(H) of this subtitle, the
carrier's adverse decision or grievance decision shall state in detail in clear,
understandable language the factual bases for the decision and reference the specific
criteria and standards, including interpretive guidelines on which the decision was
based.

(4)     (i) Except as provided in subparagraph (ii) of this paragraph, in
responding to a complaint, a carrier may not rely on any basis not stated in its
adverse decision or grievance decision.

(ii) The Commissioner may allow a carrier, a member, or fa health
care provider] AN AUTHORIZED REPRESENTATIVE filing a complaint on behalf of a
member to provide additional information as may be relevant for the Commissioner to
make a final decision on the complaint.

(iii) The Commissioner's use of additional information may not
delay the Commissioner's decision on the complaint by more than [5 working] 7 days.

(f) The Commissioner may request the member that filed the complaint or [a
legally authorized designee of the member] AN AUTHORIZED REPRESENTATIVE to
sign a consent form authorizing the release of the member's medical records to the
Commissioner or the Commissioner's designee that are needed in order for the
Commissioner to make a final decision on the complaint.

(G) ON REQUEST OF THE COMMISSIONER, THE PATIENT, OR THE AUTHORIZED
REPRESENTATIVE, A CARRIER SHALL PROVIDE THE NAMES OF THE REVIEWING
PHYSICIANS OR OTHER HEALTH CARE SERVICE REVIEWERS, INCLUDING THE
MEDICAL SPECIALTY OF THE PHYSICIAN OR HEALTH CARE SERVICE REVIEWER WHO
MADE A PARTICULAR ADVERSE DECISION OR GRIEVANCE DECISION.

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