2016 Maryland Code
Insurance
Title 15 - Health Insurance
Subtitle 10A - Complaint Process for Adverse Decisions or Grievances
§ 15-10A-04. Decisions -- Final decision; notice; hearing; remedies for noncompliance

(a) Issuance of decisions. -- The Commissioner shall:

(1) notwithstanding the provisions of § 15-10A-03(c)(1)(ii) of this subtitle, for the purpose of making final decisions on complaints, prioritize complaints regarding pending health care services over complaints regarding health care services already delivered;

(2) make and issue in writing a final decision on all complaints filed with the Commissioner under this subtitle that are within the Commissioner's jurisdiction; and

(3) provide notice in writing to all parties to a complaint of the available remedy to the party described under subsection (e) of this section and the time period for requesting the remedy.

(b) Written notification. --

(1) For emergency cases, the Commissioner shall send written notification of the Commissioner's final decision within 1 working day after the Commissioner or the Commissioner's designee has informed the member or a health care provider who filed the complaint on behalf of the member of the final decision through an oral communication.

(2) The Commissioner shall include in the notice the information required under subsection (a)(3) of this section.

(c) Failure to fulfill obligations with members. --

(1) It is a violation of this subtitle for a carrier to fail to fulfill the carrier's obligations to provide or reimburse for health care services specified in the carrier's policies or contracts with members.

(2) If, in rendering an adverse decision or grievance decision, a carrier fails to fulfill the carrier's obligations to provide or reimburse for health care services specified in the carrier's policies or contracts with members, the Commissioner may:

(i) issue an administrative order that requires the carrier to:

1. cease inappropriate conduct or practices by the carrier or any of the personnel employed or associated with the carrier;

2. fulfill the carrier's contractual obligations;

3. provide a health care service or payment that has been denied improperly; or

4. take appropriate steps to restore the carrier's ability to provide a health care service or payment that is provided under a contract; or

(ii) impose any penalty or fine or take any action as authorized:

1. for an insurer, nonprofit health service plan, or dental plan organization, under this article; or

2. for a health maintenance organization, under the Health - General Article or under this article.

(3) In addition to paragraph (1) of this subsection, it is a violation of this subtitle, if the Commissioner, in consultation with an independent review organization, medical expert, the Department, or other appropriate entity, determines that the criteria and standards used by a health maintenance organization to conduct utilization review are not:

(i) objective;

(ii) clinically valid;

(iii) compatible with established principles of health care; or

(iv) flexible enough to allow deviations from norms when justified on a case by case basis.

(d) Complaints not within jurisdiction. -- The Commissioner may refer complaints not within the Commissioner's jurisdiction to the Health Advocacy Unit or any other appropriate federal or State government agency or unit for disposition or resolution.

(e) Effect of final decision; judicial hearing. --

(1) A final decision of the Commissioner made on a complaint under this subtitle:

(i) is not subject to a request for a hearing under this subtitle for a carrier; and

(ii) is subject to a right to file a petition for judicial review under § 2-215 of this article for a carrier or a member.

(2) Unless prohibited under federal law, a member may request a hearing to be held in accordance with § 2-210 of this article of a final decision of the Commissioner made on a complaint under this subtitle.