Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 1
Subtitle 07 - HOSPITALS
Chapter 10.07.11 - Health Maintenance Organizations
Section 10.07.11.11 - Complaint System for Quality of Care Issues
Universal Citation: MD Code Reg 10.07.11.11
Current through Register Vol. 51, No. 19, September 20, 2024
A. The HMO shall have a:
(1) Written procedure to assist and respond
to enrollees, families, and providers on complaints concerning quality of care
issues; and
(2) Designated
department to handle complaints.
B. Quality of care issues include, but are not necessarily limited to:
(1) Bad outcomes
related to poor care;
(2) Failure
to follow-up on diagnostic procedures;
(3) Failure to provide treatment for
presenting complaints consistent with standard of care;
(4) Failure to appropriately document medical
records;
(5) Confidentiality and
privacy issues related to medical records or provision of care;
(6) General dissatisfaction with
care;
(7) Qualifications of
individuals who are:
(a) Employees of the HMO;
or
(b) Under contract with the HMO
to provide services to enrollees;
(8) Misdiagnosis;
(9) Inappropriate referral to meet enrollees'
needs;
(10) Environmental issues
related to infection control and hazardous medical waste;
(11) Failure of a provider to perform
adequate medical screening, assessments, or timely care in emergency
situations;
(12) Failure to provide
an adequate internal enrollee complaint process concerning quality of care
issues;
(13) Failure to comply with
policies and procedures concerning delivery of care; or
(14) Inadequate credentialing and performance
appraisal for physicians.
C. The HMO shall:
(1) Submit the written procedure to the
Department for approval before distributing to enrollees;
(2) Obtain Departmental approval of any
revision to the written procedure before implementing the proposed change;
and
(3) Distribute the approved
written procedure to all enrollees.
D. The written complaint procedure shall include, at a minimum, the:
(1) Department of
the HMO that the enrollee or family member may contact if the enrollee wishes
to make a complaint or obtain information concerning a complaint;
(2) Complaint department's address and
telephone number;
(3) Procedure for
investigating the complaint;
(4)
Time frame in which the HMO shall provide a final response to or resolve the
enrollee's complaint, not to exceed 60 days; and
(5) Telephone number of the Maryland
Insurance Administration if the enrollee wishes to pursue a complaint regarding
quality of care issues outside of the HMO's complaint system.
E. The HMO shall treat the enrollee with dignity, courtesy, and due regard for the individual's privacy.
F. The HMO shall maintain a written record of complaints and responses for at least 5 years following the date the complaint was received by the HMO.
G. Investigation by the Department.
(1) The Maryland Insurance Administration is
the single point of entry for all complaints to State government filed by an
HMO enrollee. The Maryland Insurance Administration shall refer all quality of
care complaints, as defined in §B of this regulation, to the Department
for investigation.
(2) The
Department may:
(a) Refer a complaint directly
to an HMO for resolution; or
(b)
Conduct an independent investigation.
(3) If the Department refers the complaint to
an HMO, the HMO shall provide the following information in writing to the
Department within 30 days of receipt of the complaint:
(a) The results of the
investigation;
(b) Any change or
proposed change to HMO policies or procedures as a result of the investigation;
and
(c) The HMO's method to prevent
recurrence of the problem.
(4) If the HMO has not completed the
investigation within 30 days, the HMO shall send the Department an interim
report with a summary of the investigation to date and the expected date of
completion. The expected date of completion may not be longer than 60 days from
receipt of the complaint.
Disclaimer: These regulations may not be the most recent version. Maryland may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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