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<section article="gin" article_name="Insurance" number="15-10A-06" title_number="15" title_name="Health Insurance" subtitle_number="10A" subtitle_name="Complaint Process for Adverse Decisions or Grievances">
  <level label="a">
    <level label="1">
      <text>On a quarterly basis, each carrier shall submit to the Commissioner, on the form the Commissioner requires, a report that describes the following information aggregated by zip code as required by the Commissioner:</text>
      <level label="i">
        <text>the number of members entitled to health care benefits under a policy, plan, or certificate issued or delivered in the State by the carrier;</text>
      </level>
      <level label="ii">
        <text>the number of clean claims for reimbursement processed by the carrier;</text>
      </level>
      <level label="iii">
        <text>the activities of the carrier under this subtitle, including:</text>
        <level label="1">
          <text>the outcome of each grievance filed with the carrier;</text>
        </level>
        <level label="2">
          <text>the number and outcomes of cases that were considered emergency cases under § 15–10A–02(b)(2)(i) of this subtitle;</text>
        </level>
        <level label="3">
          <text>the time within which the carrier made a grievance decision on each emergency case;</text>
        </level>
        <level label="4">
          <text>the time within which the carrier made a grievance decision on all other cases that were not considered emergency cases;</text>
        </level>
        <level label="5">
          <text>the number of grievances filed with the carrier that resulted from an adverse decision involving length of stay for inpatient hospitalization as related to the medical procedure involved;</text>
        </level>
        <level label="6">
          <text>the number of adverse decisions issued by the carrier under § 15–10A–02(f) of this subtitle, whether the adverse decision involved a prior authorization or step therapy protocol, the type of service at issue in the adverse decisions, and whether an artificial intelligence, algorithm, or other software tool was used in making the adverse decision;</text>
        </level>
        <level label="7">
          <text>the number of adverse decisions overturned after a reconsideration request under § 15–10B–06 of this title; and</text>
        </level>
        <level label="8">
          <text>the number of requests made and granted under § 15–831(c)(1) and (2) of this title; and</text>
        </level>
      </level>
      <level label="iv">
        <text>the number and outcome of all other cases that are not subject to activities of the carrier under this subtitle that resulted from an adverse decision involving the length of stay for inpatient hospitalization as related to the medical procedure involved.</text>
      </level>
    </level>
    <level label="2">
      <text>If the number of adverse decisions issued by a carrier for a type of service has grown by 10% or more in the immediately preceding calendar year or 25% or more in the immediately preceding 3 calendar years, the carrier shall submit in the report required under paragraph (1) of this subsection:</text>
      <level label="i">
        <text>a description of any changes in medical management contributing to the rise in adverse decisions for the type of service;</text>
      </level>
      <level label="ii">
        <text>any other known reasons for the increase; and</text>
      </level>
      <level label="iii">
        <text>a description of the carrier’s efforts and actions taken to determine the reason for the increase.</text>
      </level>
    </level>
  </level>
  <level label="b">
    <text>The Commissioner shall:</text>
    <level label="1">
      <text>compile an annual summary report based on the information provided:</text>
      <level label="i">
        <text>under subsection (a) of this section; and</text>
      </level>
      <level label="ii">
        <text>by the Secretary under § 19–705.2(e) of the Health – General Article;</text>
      </level>
    </level>
    <level label="2">
      <text>include in the summary report data on adverse decisions and grievances related to post–acute services, including adverse decisions and grievances relating to admissions to skilled nursing facilities and inpatient rehabilitation facilities;</text>
    </level>
    <level label="3">
      <text>report any violations or actions taken under § 15–10B–11 of this title; and</text>
    </level>
    <level label="4">
      <text>provide copies of the summary report to the Governor and, subject to § 2–1257 of the State Government Article, to the General Assembly.</text>
    </level>
  </level>
  <level label="c">
    <text>The Commissioner may use information provided under subsection (a) of this section as the basis for an examination under Title 2, Subtitle 2 of this article.</text>
  </level>
</section>
