Ch. 415                                    2004 LAWS OF MARYLAND

2. INFORM 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.

[(f)] (H) [(1) Within 30 calendar days after the appeal decision has been
made, each carrier shall send to the member, and the health care provider acting on
behalf of the member, a written notice of the appeal decision.

(2)] Notice of [the] AN appeal decision [required to be sent under
paragraph (1) of this subsection] shall:

[(i)] (1) state in detail in clear, understandable language the
specific factual bases for the carrier's decision; [and]

[(ii)] (2) include the following information:

[1.](I) that the [member, or a health-care provider acting on
behalf of the member,] MEMBER OR AUTHORIZED REPRESENTATIVE has a right to
file a complaint with the Commissioner within 60 working days after receipt of a
carrier's appeal decision; and

[2.](II) the Commissioner's address, telephone number, and
facsimile [number.] NUMBER;

(3) REFERENCE THE SPECIFIC PLAN PROVISIONS ON WHICH THE
APPEAL DECISION IS BASED;

(4) INCLUDE A STATEMENT THAT THE MEMBER OR THE AUTHORIZED
REPRESENTATIVE IS ENTITLED TO RECEIVE, FREE OF CHARGE, REASONABLE
ACCESS TO AND COPIES OF ALL DOCUMENTS, RECORDS, AND OTHER INFORMATION
RELEVANT TO THE APPEAL DECISION; AND

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

(I) PROVIDE THE INTERNAL RULE, GUIDELINE, PROTOCOL, OR
OTHER SIMILAR CRITERION; OR

(II) INFORM THE MEMBER OR 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.

[(g)](I) The Commissioner may request the member that filed the complaint
or [a legally] AN authorized [designee] REPRESENTATIVE of the member 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.

[(h)](J) (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
coverage decision or appeal decision, as applicable, is correct:

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