COMAR 31.10.29 · Chapter 29 Complaint Process for Coverage Decisions

Administrative History Effective date: June 10, 2002 (29:11 Md. R. 891) Regulation .02B amended effective April 16, 2012 (39:7 Md. R. 497) Regulation .03B , C amended effective April 16, 2012 (39:7 Md. R. 497) Authority Insurance Article, §§ 15-10 D- 02 (d) and 15-10 D-04, Annotated Code of Maryland

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.01 Scope. This chapter applies to carriers and representatives of carriers making coverage decisions.

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.02 Definitions. A. In this chapter, the following terms have the meaning indicated. B. Terms Defined. (1) "Appeal" means a protest filed by a member, a member’s representative, or a health care provider with a carrier under its internal appeal process regarding a coverage decision concerning a member. (2) "Appeal decision" means a final determination by a carrier that arises from an appeal filed with the carrier under its appeal process regarding a coverage decision concerning a member. (3) "Carrier" means a person that offers a health benefit plan and is: (a) An authorized insurer that provides health insurance in the State; (b) A nonprofit health service plan; (c) A health maintenance organization; (d) A dental plan organization; or (e) Except for a managed care organization, as defined in Health-General Article, Title 15, Subtitle 1, Annotated Code of Maryland, any other person that offers a health benefit plan subject to regulation by the State. (4) "Complaint" means a protest filed with the Commissioner involving a coverage decision other than that which is covered by Insurance Article, Title 15, Subtitle 10A, Annotated Code of Maryland . (5) "Coverage decision" has the meaning stated in Insurance Article, §15-10 D-01, Annotated Code of Maryland. (6) Health Benefit Plan. (a) "Health benefit plan" means: (i) A hospital or medical policy or contract, including a policy or contract issued under a multiple employer trust or association; (ii) A hospital or medical policy or contract issued by a nonprofit health service plan; (iii) A health maintenance organization contract; or (iv) A dental plan organization contract. (b) "Health benefit plan" does not include one or more, or any combination, of the following: (i) Long-term care insurance; (ii) Disability insurance; (iii) Accidental travel and accident death and dismemberment insurance; (iv) Credit health insurance; (v) A health benefit plan issued by a managed care organization, as defined in Health-General Article, Title 15, Subtitle 1, Annotated Code of Maryland; (vi) Disease-specific insurance; or (vii) Fixed indemnity insurance. (7) "Health care provider" means: (a) An individual who is licensed under the Health Occupations Article, Annotated Code of Maryland , to provide health care services in the ordinary course of business or practice of a profession and is a treating provider of the member; or (b) A hospital, as defined in Health-General Article, §19-301, Annotated Code of Maryland. (8) "Health care service" means a health or medical care procedure or service rendered by a health care provider that: (a) Provides testing, diagnosis, or treatment of a human disease or dysfunction; or (b) Dispenses drugs, medical devices, medical appliances, or medical goods for the treatment of a human disease or dysfunction. (9) "Internal appeal process" means the appeal process required by Insurance Article, Title 15, Subtitle 10D, Annotated Code of Maryland , to be adopted by the carrier for use by its members and health care providers to dispute coverage decisions made by the carrier or a representative of the carrier. (10) Member. (a) "Member" means a person entitled to health care services under a policy, plan, or contract issued or delivered in the State by a carrier. (b) "Member" includes: (i) A subscriber; and (ii) Unless preempted by federal law, a Medicare recipient. (c) "Member" does not include a Medicaid recipient. (11) “Member’s representative” has the meaning stated in Insurance Article, §15-10 D-01, Annotated Code of Maryland. (12) "Urgent medical condition" means a condition that satisfies either of the following: (a) A medical condition, including a physical condition, a mental condition, or a dental condition, where the absence of medical attention within 72 hours could reasonably be expected by an individual, acting on behalf of a carrier, applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine, to result in: (i) Placing the member's life or health in serious jeopardy; (ii) The inability of the member to regain maximum function; (iii) Serious impairment to bodily function; (iv) Serious dysfunction of any bodily organ or part; or (v) The member remaining seriously mentally ill with symptoms that cause the member to be a danger to self or others; or (b) A medical condition, including a physical condition, a mental health condition, or a dental condition, where the absence of medical attention within 72 hours in the opinion of a health care provider with knowledge of the member's medical condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the coverage decision. (13) "Retrospective denial" means a coverage decision which is made by the carrier after the health care service has been rendered to the member.

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.03 Exhaustion of Internal Appeal Process. A. Except as provided in §B of this regulation , the carrier's internal appeal process shall be exhausted before filing a complaint with the Commissioner under this chapter. B. In a case involving a prospective denial, a member, a member’s representative, or a health care provider filing a complaint on behalf of a member may file a complaint with the Commissioner without first filing an appeal with a carrier and receiving a final decision on the appeal if the member, the member’s representative, or the health care provider gives sufficient information and supporting documentation in the complaint that demonstrates an urgent medical condition exists as defined under this chapter. C. In a case involving a retrospective denial, an urgent medical condition is not deemed to exist to allow a member, a member’s representative, or a health care provider on behalf of a member to file to a complaint without first exhausting the internal appeal process of a carrier.

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Previous Chapter 28 Individual Health Insurance Contracts — Standard Provisions and Exclusions

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Next Chapter 30 Disability Benefit Claims Procedures

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