Code of Maryland Regulations
Title 31 - MARYLAND INSURANCE ADMINISTRATION
Subtitle 10 - HEALTH INSURANCE-GENERAL
Chapter 31.10.29 - Complaint Process for Coverage Decisions
Section 31.10.29.03 - Exhaustion of Internal Appeal Process
Current through Register Vol. 51, No. 19, September 20, 2024
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.
