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31.10.18.00.htm 31.10.18.00. Title 31 MARYLAND INSURANCE ADMINISTRATION Subtitle 10 HEALTH INSURANCE ― GENERAL Chapter 18 Denials of Coverage Based on Medical Necessity Authority: Insurance Article, §2-109 and Title 15, Subtitle 10A, Annotated Code of Maryland
31.10.18.01.htm 31.10.18.01. 01 Scope.. This chapter applies to carriers and to private review agents to whom the internal grievance process has been delegated by a carrier.
31.10.18.02.htm 31.10.18.02. 02 Definitions.. A. In this chapter, the following terms have the meanings indicated.. B. Terms Defined.. 1) Adverse Decision.. a) "Adverse decision" means a utilization review determination by a private review agent, a carrier, or a health care provider acting on behalf of a carrier that:i) A proposed or delivered health care service which would otherwise be covered under the member's contract is not or was not medically necessary, appropriate, or efficient; and
31.10.18.03.htm 31.10.18.03. 03 Repealed..
31.10.18.04.htm 31.10.18.04. 04 Health Advocacy Unit Information in Notice of Adverse Decision.. A carrier shall include in each notice of adverse decision the following disclosure in at least 12-point typeface, with the first sentence in bold capital typeface:THERE IS HELP AVAILABLE TO YOU IF YOU WISH TO DISPUTE THE DECISION OF THE PLAN ABOUT PAYMENT FOR HEALTH CARE SERVICES. You may contact the Health Advocacy Unit of Maryland's Consumer Protection Division at (phone number, address, fax, e-mail)
31.10.18.05.htm 31.10.18.05. 05 Procedures for Emergency Cases.. A. An expedited review of an adverse decision in accordance with this regulation is required if the:. 1) Adverse decision is rendered for health care services that are proposed but have not been delivered; and2) Services are necessary to treat a condition or illness that, without immediate medical attention, would:a) Seriously jeopardize the life or health of the member of the member’s ability to regain maximum functions;
31.10.18.06.htm 31.10.18.06. 06 Establishment, Filing, and Reporting of Internal Grievance Process.. A. Each carrier shall establish an internal grievance process.. B. Each carrier shall:. 1) File with the Commissioner its internal grievance process not more than 30 days after the effective date of this chapter;2) File with the Commissioner each amendment to its internal process at least 30 days before its intended use;3) Include with the filing the circumstances, if any, under which the inter
31.10.18.07.htm 31.10.18.07. 07 Requirements for Internal Grievance Process.. An internal grievance process shall:. A. Meet the requirements established under this chapter; and. B. Include an expedited procedure for use in an emergency case for purposes of rendering a grievance decision within 24 hours after filing the grievance pursuant to the carrier's internal grievance process, that includes an explanation about:1) Who will make the determination whether an emergency case exists when a
31.10.18.08.htm 31.10.18.08. 08 Time for Rendering Final Decisions Resulting from Internal Grievance Process.. A. Except as otherwise provided in this regulation, a carrier shall render a final decision on a grievance that involves a:1) Prospective denial in a nonemergency case within 30 working days after the filing date; and. 2) Retrospective denial within 45 working days after the filing date.. B. With the written consent of the member, member’s representative, or health care provider who file
31.10.18.09.htm 31.10.18.09. 09 Repealed..
31.10.18.10.htm 31.10.18.10. 10 Repealed..
31.10.18.11.htm 31.10.18.11. 11 Demonstration of Compelling Reason to File Complaint.. A. A member, a member’s representative, or a health care provider on behalf of a member may file a complaint without first exhausting the internal grievance process of a carrier if the complaint demonstrates to the satisfaction of the Commissioner a compelling reason to do so. A compelling reason includes showing that the potential delay in receipt of a health care service until after the member or health care provider ex
31.10.18.12.htm 31.10.18.12. 12 General Procedures for Complaints.. A. Consent Form.. 1) For services rendered on or after January 1, 1999, the Commissioner shall request the signed consent of the member that filed the complaint, or a legally authorized designee of the member, 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.2) The Commissioner may r
31.10.18.9999.htm 31.10.18.9999. Administrative History Effective date:. Regulations .01―15 adopted as an emergency provision effective January 1, 1999 (26:2 Md. R. 104) adopted permanently effective March 22, 1999 (26:6 Md. R. 490) ―Chapter revised effective April 11, 2005 (32:7 Md. R. 686) ―. Chapter revised effective April 16, 2012 (39:7 Md. R. 496). Regulation .05A amended effective July 30, 2018 (45:15 Md. R. 728). Regulation .11 amended effective July 30, 2018 (45:15 Md. R. 728).
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