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<section article="gin" article_name="Insurance" number="15-10A-04" title_number="15" title_name="Health Insurance" subtitle_number="10A" subtitle_name="Complaint Process for Adverse Decisions or Grievances">
  <level label="a">
    <text>The Commissioner shall:</text>
    <level label="1">
      <text>notwithstanding the provisions of § 15–10A–03(c)(1)(ii) of this subtitle, for the purpose of making final decisions on complaints, prioritize complaints regarding pending health care services over complaints regarding health care services already delivered;</text>
    </level>
    <level label="2">
      <text>make and issue in writing a final decision on all complaints filed with the Commissioner under this subtitle that are within the Commissioner’s jurisdiction; and</text>
    </level>
    <level label="3">
      <text>provide notice in writing to all parties to a complaint of the available remedy to the party described under subsection (e) of this section and the time period for requesting the remedy.</text>
    </level>
  </level>
  <level label="b">
    <level label="1">
      <text>For emergency cases, the Commissioner shall send written notification of the Commissioner’s final decision within 1 working day after the Commissioner or the Commissioner’s designee has informed the member or a health care provider who filed the complaint on behalf of the member of the final decision through an oral communication.</text>
    </level>
    <level label="2">
      <text>The Commissioner shall include in the notice the information required under subsection (a)(3) of this section.</text>
    </level>
  </level>
  <level label="c">
    <level label="1">
      <text>It is a violation of this subtitle for a carrier to fail to fulfill the carrier’s obligations to provide or reimburse for health care services specified in the carrier’s policies or contracts with members.</text>
    </level>
    <level label="2">
      <text>If, in rendering an adverse decision or grievance decision, a carrier fails to fulfill the carrier’s obligations to provide or reimburse for health care services specified in the carrier’s policies or contracts with members, the Commissioner may:</text>
      <level label="i">
        <text>issue an administrative order that requires the carrier to:</text>
        <level label="1">
          <text>cease inappropriate conduct or practices by the carrier or any of the personnel employed or associated with the carrier;</text>
        </level>
        <level label="2">
          <text>fulfill the carrier’s contractual obligations;</text>
        </level>
        <level label="3">
          <text>provide a health care service or payment that has been denied improperly; or</text>
        </level>
        <level label="4">
          <text>take appropriate steps to restore the carrier’s ability to provide a health care service or payment that is provided under a contract; or</text>
        </level>
      </level>
      <level label="ii">
        <text>impose any penalty or fine or take any action as authorized:</text>
        <level label="1">
          <text>for an insurer, nonprofit health service plan, or dental plan organization, under this article; or</text>
        </level>
        <level label="2">
          <text>for a health maintenance organization, under the Health – General Article or under this article.</text>
        </level>
      </level>
    </level>
    <level label="3">
      <text>In addition to paragraph (1) of this subsection, it is a violation of this subtitle, if the Commissioner, in consultation with an independent review organization, medical expert, the Department, or other appropriate entity, determines that the criteria and standards used by a health maintenance organization to conduct utilization review are not in accordance with § 15–10B–05 of this title.</text>
    </level>
  </level>
  <level label="d">
    <text>The Commissioner may refer complaints not within the Commissioner’s jurisdiction to the Health Advocacy Unit or any other appropriate federal or State government agency or unit for disposition or resolution.</text>
  </level>
  <level label="e">
    <level label="1">
      <text>A final decision of the Commissioner made on a complaint under this subtitle:</text>
      <level label="i">
        <text>is not subject to a request for a hearing under this subtitle for a carrier; and</text>
      </level>
      <level label="ii">
        <text>is subject to a right to file a petition for judicial review under § 2–215 of this article for a carrier or a member.</text>
      </level>
    </level>
    <level label="2">
      <text>Unless prohibited under federal law, a member may request a hearing to be held in accordance with § 2–210 of this article of a final decision of the Commissioner made on a complaint under this subtitle.</text>
    </level>
  </level>
</section>
