Ch. 415                                   2004 LAWS OF MARYLAND

[(d)] (E)    "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 offers a health

benefit plan subject to regulation by the State.

[(e)](F) "Complaint" means a protest filed with the Commissioner involving a
coverage decision other than that which is covered by Subtitle 10A of this title.

[(f)](G) (1) "Coverage decision" means an initial determination by a carrier
or a representative of the carrier that results in noncoverage of a health care service.

(2) "Coverage decision" includes nonpayment of all or any part of a claim.

(3) "Coverage decision" does not include an adverse decision as defined
in § 15-10A-01(b) of this title.

(H) (G) "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.

(I) (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 MAY:

(I) IN THE JUDGMENT OF A PRUDENT LAYPERSON WHO
POSSESSES AN AVERAGE KNOWLEDGE OF HEALTH AND MEDICINE, SERIOUSLY
JEOPARDIZE THE LIFE OR HEALTH OF THE MEMBER OR THE ABILITY OF THE
MEMBER TO REGAIN MAXIMUM FUNCTION; OR

(II) IN THE OPINION OF A PHYSICIAN WITH KNOWLEDGE OF THE
MEMBER'S MEDICAL CONDITION:

1. SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH OF THE
MEMBER OR THE ABILITY OF THE MEMBER TO REGAIN MAXIMUM FUNCTION; OR

2. SUBJECT THE MEMBER TO SEVERE 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
OF HEALTH CARE SERVICES.

[(g)] (J) (H) (1) "Health benefit plan" means:

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