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10.09.71.00.htm 10.09.71.00. Title 10 MARYLAND DEPARTMENT OF HEALTH Subtitle 09 MEDICAL CARE PROGRAMS Chapter 71 Maryland Medicaid Managed Care Program: MCO Dispute Resolution Procedures Authority: Health-General Article, §15-103(b)9)i)4) Annotated Code of Maryland
10.09.71.01.htm 10.09.71.01. 01 MCO Enrollee Services.. An MCO shall:. A. Maintain a member services unit that operates an enrollee services line at least during normal business hours;B. Operate its enrollee services line as a triage device to handle or properly refer enrollees' questions or complaints; andC. Provide information in the member handbook about how to use the MCO enrollee services line to obtain information and assistance.
10.09.71.02.htm 10.09.71.02. 02 MCO Enrollee Complaint Process.. A. An MCO shall have written complaint procedures by which an enrollee who is dissatisfied with the MCO or its network providers, or decisions made by the MCO or a provider, may seek recourse verbally or in writing within the MCO at any time.B. An MCO shall:. 1) Submit its written internal complaint procedures to the Department for its approval;. 2) Give enrollees any reasonable assistance in completing forms and taking other procedural steps re
10.09.71.02-1.htm 10.09.71.02-1. 02-1 Member Complaints ― Time Frames for MCOs to Respond to the Department.. An MCO shall:. A. Acknowledge an enrollee appeal or grievance reported to it by the Department’s complaint resolution unit within 1 business day;B. Respond to the Department’s request for information regarding disputed nonemergency medical care actions within 3 business days;C. Provide updates in a time frame specified by the Department;. D. Provide medical records within 5 days of the request; and.
10.09.71.03.htm 10.09.71.03. 03 MCO Provider Complaint Process.. A. An MCO shall have a complaint procedure for providers that is:. 1) Documented in writing;. 2) Disseminated in writing to all of the MCO's providers at the time they join the MCO's provider panel, and furnished to a provider at any time, upon request; and3) Linked to the MCO's internal quality assurance program.. B. An MCO shall include in its provider complaint process at least the following elements:. 1) Procedures for registe
10.09.71.03-1.htm 10.09.71.03-1. 03-1 Independent Review Organization (IRO). For provider disputes involving medical necessity, an MCO shall participate in the IRO process as specified in COMAR 10.09.86.
10.09.71.03-2.htm 10.09.71.03-2. 03-2 Provider Complaints ― Time Frames for MCOs to Respond to the Department.. An MCO shall:. A. Acknowledge provider grievances within 3 business days;. B. Provide findings to the Department within 5 days; and. C. Provide a corrective action plan to the Department within 10 days from the date of the request..
10.09.71.04.htm 10.09.71.04. 04 MCO Actions and Decisions.. A. For certain services to enrollees that require preauthorization the following conditions apply:. 1) For standard authorization decisions, the MCO shall make a determination within 2 business days of receipt of necessary clinical information, but not later than 14 calendar days from the date of the initial request so as not to adversely affect the health of the enrollee;2) For expedited authorization decisions, the MCO shall make a determinatio
10.09.71.05.htm 10.09.71.05. 05 MCO Appeal Process for Enrollees.. A. An MCO's appeal process shall:. 1) Require that an enrollee, or a provider acting on the enrollee’s behalf, file an appeal within 60 days from the date on the MCO’s notice of action;2) Include procedures for acknowledging receipt of appeals within 5 business days;. 3) Permit an enrollee to request an appeal either orally or in writing;. 4) Provide that oral requests for appeal are considered the initiation of the appeal to establish th
10.09.71.9999.htm 10.09.71.9999. Administrative History Effective date:. Regulations .01―03 adopted as an emergency provision effective November 8, 1996 (23:25 Md. R. 1730) adopted permanently effective March 10, 1997 (24:5 Md. R. 408)Regulation .01 amended as an emergency provision effective November 1, 2008 (35:24 Md. R. 2069) amended permanently effective February 23, 2009 (36:4 Md. R. 353) December 31, 2018 (45:26 Md. R. 1244)Regulation .02 amended effective June 30, 2008 (35:13 Md. R. 1180) February
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