Code of Maryland Regulations
Title 31 - MARYLAND INSURANCE ADMINISTRATION
Subtitle 10 - HEALTH INSURANCE-GENERAL
Chapter 31.10.18 - Denials of Coverage Based on Medical Necessity
Section 31.10.18.11 - Demonstration of Compelling Reason to File Complaint
Current through Register Vol. 51, No. 19, September 20, 2024
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 exhausts the internal grievance process and obtains a final decision under the grievance process could result in:
B. A member is considered to be in danger to self or others if the member is unable to function in activities of daily living or care for self without imminent dangerous consequences.
C. In a case involving a retrospective denial, there is no compelling reason to allow a member, a member's representative, or a health care provider on behalf of a member to file a complaint without first exhausting the internal grievance process of a carrier.
