§ 15-10A-02

(a) Each carrier shall establish an internal grievance process for its members.

(b) (1) An internal grievance process shall meet the same requirements established under Subtitle 10B of this title.

(2) In addition to the requirements of Subtitle 10B of this title, an internal grievance process established by a carrier under this section shall:

(i) include an expedited procedure for use in an emergency case for purposes of rendering a grievance decision within 24 hours of the date a grievance is filed with the carrier;

(ii) provide that a carrier render a final decision in writing on a grievance within 30 working days after the date on which the grievance is filed unless:

1. the grievance involves an emergency case under item (i) of this paragraph;

2. the member, the member’s representative, or a health care provider filing a grievance on behalf of a member agrees in writing to an extension for a period of no longer than 30 working days; or

3. the grievance involves a retrospective denial under item (iv) of this paragraph;

(iii) allow a grievance to be filed on behalf of a member by a health care provider or the member’s representative;

(iv) provide that a carrier render a final decision in writing on a grievance within 45 working days after the date on which the grievance is filed when the grievance involves a retrospective denial; and

(v) for a retrospective denial, allow a member, the member’s representative, or a health care provider on behalf of a member to file a grievance for at least 180 days after the member receives an adverse decision.

(3) For purposes of using the expedited procedure for an emergency case that a carrier is required to include under paragraph (2)(i) of this subsection, the carrier shall initiate the expedited procedure for an emergency case if the member or the member’s representative requests the expedited review or the health care provider or the member or the member’s representative attests that:

(i) the adverse decision was rendered for health care services that are proposed but have not been provided; and

(ii) the services are necessary to treat a condition or illness that, without immediate medical attention, would:

1. seriously jeopardize the life or health of the member or the member’s ability to regain maximum functions;

2. cause the member to be in danger to self or others; or

3. cause the member to continue using intoxicating substances in an imminently dangerous manner.

(c) Except as provided in subsection (d) of this section, the carrier’s internal grievance process shall be exhausted prior to filing a complaint with the Commissioner under this subtitle.

(d) (1) (i) A member, the 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 a grievance with a carrier and receiving a final decision on the grievance if:

1. the carrier waives the requirement that the carrier’s internal grievance process be exhausted before filing a complaint with the Commissioner;

2. the carrier has failed to comply with any of the requirements of the internal grievance process as described in this section; or

3. the member, the member’s representative, or the health care provider provides sufficient information and supporting documentation in the complaint that demonstrates a compelling reason to do so.

(ii) The Commissioner shall define by regulation the standards that the Commissioner shall use to decide what demonstrates a compelling reason under subparagraph (i) of this paragraph.

(2) Subject to subsections (b)(2)(ii) and (h) of this section, a member, a member’s representative, or a health care provider may file a complaint with the Commissioner if the member, the member’s representative, or the health care provider does not receive a grievance decision from the carrier on or before the 30th working day on which the grievance is filed.

(3) Whenever the Commissioner receives a complaint under paragraph (1) or (2) of this subsection, the Commissioner shall notify the carrier that is the subject of the complaint within 5 working days after the date the complaint is filed with the Commissioner.

(e) Each carrier shall:

(1) file for review with the Commissioner and submit to the Health Advocacy Unit a copy of its internal grievance process established under this subtitle; and

(2) file any revision to the internal grievance process with the Commissioner and the Health Advocacy Unit at least 30 days before its intended use.

(f) (1) For nonemergency cases, when a carrier renders an adverse decision, the carrier shall:

(i) inform the member, the member’s representative, or the health care provider acting on behalf of the member of the adverse decision:

1. orally by telephone; or

2. with the affirmative consent of the member, the member’s representative, or the health care provider acting on behalf of the member, by text, facsimile, e–mail, an online portal, or other expedited means; and

(ii) send, within 5 working days after the adverse decision has been made, a written notice to the member, the member’s representative, and a health care provider acting on behalf of the member that:

1. states at the top in prominent bold print:

A. that the notice is a denial of a requested health care service;

B. that the member may file an appeal;

C. the telephone number and e–mail address required to be available under § 15–10B–05(e) of this title; and

D. that the notice includes additional information on how to file and receive assistance for filing a complaint;

2. states in detail in clear, understandable language the specific factual bases for the carrier’s decision and the reasoning used to determine that the health care service is not medically necessary and did not meet the carrier’s criteria and standards used in conducting the utilization review;

3. provides the specific reference, language, or requirements from the criteria and standards, including any interpretive guidelines, on which the decision was based, and may not solely use:

A. generalized terms such as “experimental procedure not covered”, “cosmetic procedure not covered”, “service included under another procedure”, or “not medically necessary”; or

B. language directing the member to review the additional coverage criteria in the member’s policy or plan documents;

4. includes a unique identifier for and the business address and business telephone number of:

A. if the carrier is a health maintenance organization, the medical director or associate medical director, as appropriate, who made the decision; or

B. if the carrier is not a health maintenance organization, the designated employee or representative of the carrier who has responsibility for the carrier’s internal grievance process and the physician who is required to make all adverse decisions as required in § 15–10B–07(a) of this title;

5. gives written details of the carrier’s internal grievance process and procedures under this subtitle; and

6. includes the following information:

A. that the member, the member’s representative, or a health care provider on behalf of the member has a right to file a complaint with the Commissioner within 4 months after receipt of a carrier’s grievance decision;

B. that a complaint may be filed without first filing a grievance if the member, the member’s representative, or a health care provider filing a grievance on behalf of the member can demonstrate a compelling reason to do so as determined by the Commissioner;

C. the Commissioner’s address, telephone number, and facsimile number;

D. a statement that the Health Advocacy Unit is available to assist the member or the member’s representative in both mediating and filing a grievance under the carrier’s internal grievance process; and

E. the address, telephone number, facsimile number, and electronic mail address of the Health Advocacy Unit.

(2) The business telephone number included in the notice as required under paragraph (1)(ii)4 of this subsection must be a dedicated number for adverse decisions and may not be the general customer call number for the carrier.

(g) If within 5 working days after a member, the member’s representative, or a health care provider, who has filed a grievance on behalf of a member, files a grievance with the carrier, and if the carrier does not have sufficient information to complete its internal grievance process, the carrier shall:

(1) after confirming through a complete review of any information already submitted by the health care provider:

(i) notify the member, the member’s representative, or the health care provider that it cannot proceed with reviewing the grievance unless additional information is provided;

(ii) request the specific information, including any lab or diagnostic test or other medical information that must be submitted to complete the internal grievance process; and

(iii) provide the specific reference, language, or requirements from the criteria and standards used by the carrier to support the need for the additional information; and

(2) assist the member, the member’s representative, or the health care provider in gathering the necessary information without further delay.

(h) A carrier may extend the 30–day or 45–day period required for making a final grievance decision under subsection (b)(2)(ii) of this section with the written consent of the member, the member’s representative, or the health care provider who filed the grievance on behalf of the member.

(i) (1) For nonemergency cases, when a carrier renders a grievance decision, the carrier shall:

(i) document the grievance decision in writing after the carrier has provided oral communication of the decision to the member, the member’s representative, or the health care provider acting on behalf of the member; and

(ii) send, within 5 working days after the grievance decision has been made, a written notice to the member, the member’s representative, and a health care provider acting on behalf of the member that:

1. states at the top in prominent bold print:

A. that the notice is a denial of a requested health care service;

B. that the member may file a complaint with the Commissioner;

C. the telephone number and e–mail address required to be available under § 15–10B–05(e) of this title; and

D. that the notice includes additional information on how to file and receive assistance for an appeal;

2. states in detail in clear, understandable language the specific factual bases for the carrier’s decision and the reasoning used to determine that the health care service is not medically necessary and did not meet the carrier’s criteria and standards used in conducting utilization review;

3. provides the specific reference, language, or requirements from the criteria and standards, including any interpretive guidelines used by the carrier, on which the grievance decision was based;

4. includes a unique identifier for and the business address and business telephone number of:

A. if the carrier is a health maintenance organization, the medical director or associate medical director, as appropriate, who made the grievance decision; or

B. if the carrier is not a health maintenance organization, the designated employee or representative of the carrier who has responsibility for the carrier’s internal grievance process and the designated employee or representative’s title and clinical specialty; and

5. includes the following information:

A. that the member or the member’s representative has a right to file a complaint with the Commissioner within 4 months after receipt of a carrier’s grievance decision;

B. the Commissioner’s address, telephone number, and facsimile number;

C. a statement that the Health Advocacy Unit is available to assist the member or the member’s representative in filing a complaint with the Commissioner; and

D. the address, telephone number, facsimile number, and electronic mail address of the Health Advocacy Unit.

(2) The business telephone number included in the notice as required under paragraph (1)(ii)4 of this subsection must be a dedicated number for grievance decisions and may not be the general customer call number for the carrier.

(3) To satisfy the requirements of this subsection, a carrier may not use solely in the written notice sent under paragraph (1) of this subsection:

(i) generalized terms such as “experimental procedure not covered”, “cosmetic procedure not covered”, “service included under another procedure”, or “not medically necessary”; or

(ii) language directing the member to review the additional coverage criteria in the member’s policy or plan documents.

(j) (1) For an emergency case under subsection (b)(2)(i) of this section, within 1 day after a decision has been orally communicated to the member, the member’s representative, or the health care provider, the carrier shall send notice in writing of any adverse decision or grievance decision to:

(i) the member and the member’s representative, if any; and

(ii) if the grievance was filed on behalf of the member under subsection (b)(2)(iii) of this section, the health care provider.

(2) A notice required to be sent under paragraph (1) of this subsection shall include the following:

(i) for an adverse decision, the information required under subsection (f) of this section; and

(ii) for a grievance decision, the information required under subsection (i) of this section.

(k) (1) Each carrier shall include the information required by subsection (f)(1)(ii)3, 4, and 5 of this section in the policy, plan, certificate, enrollment materials, or other evidence of coverage that the carrier provides to a member at the time of the member’s initial coverage or renewal of coverage.

(2) Each carrier shall include as part of the information required by paragraph (1) of this subsection a statement indicating that, when filing a complaint with the Commissioner, the member or the member’s representative will be required to authorize the release of any medical records of the member that may be required to be reviewed for the purpose of reaching a decision on the complaint.

(l) (1) Nothing in this subtitle prohibits a carrier from delegating its internal grievance process to a private review agent that has a certificate issued under Subtitle 10B of this title and is acting on behalf of the carrier.

(2) If a carrier delegates its internal grievance process to a private review agent, the carrier shall be:

(i) bound by the grievance decision made by the private review agent acting on behalf of the carrier; and

(ii) responsible for a violation of any provision of this subtitle regardless of the delegation made by the carrier under paragraph (1) of this subsection.