Title 15. Health Insurance — Subtitle 10A. Complaint Process for Adverse Decisions or Grievances
Statutes in effect as of October 1, 2026.
Md. Code Ann., Ins. § 15-10A-01 (2026)
Title 15. Health Insurance
Subtitle 10A. Complaint Process for Adverse Decisions or Grievances
§ 15–10A-01LinkCopy Citation
(a)
In this subtitle the following words have the meanings indicated.
(b)
(1)
“Adverse decision” means:
(i)
a utilization review determination by a private review agent, a carrier, or a health care provider acting on behalf of a carrier that:
(1)
a proposed or delivered health care service covered under the member’s contract is or was not medically necessary, appropriate, or efficient; and
(2)
may result in noncoverage of the health care service; or
(ii)
a denial by a carrier of a request by a member for an alternative standard or a waiver of a standard to satisfy the requirements of a wellness program under § 15–509 of this title.
(2)
“Adverse decision” includes a utilization review determination based on a prior authorization or step therapy requirement.
(3)
“Adverse decision” does not include a decision concerning a subscriber’s status as a member.
(c)
“Carrier” means a person that offers a health benefit plan and is:
(1)
an authorized insurer that provides health insurance in the State;
(2)
a nonprofit health service plan;
(3)
a health maintenance organization;
(4)
a dental plan organization;
(5)
a self–funded student health plan operated by an independent institution of higher education, as defined in § 10–101 of the Education Article, that provides health care to its students and their dependents; or
(6)
except for a managed care organization as defined in Title 15, Subtitle 1 of the Health – General Article, any other person that provides health benefit plans subject to regulation by the State.
(d)
“Complaint” means a protest filed with the Commissioner involving an adverse decision or grievance decision concerning the member.
(e)
“Designee of the Commissioner” means any person to whom the Commissioner has delegated the authority to review and decide complaints filed under this subtitle, including an administrative law judge to whom the authority to conduct a hearing has been delegated for recommended or final decision.
(f)
“Grievance” means a protest filed by a member, a member’s representative, or a health care provider on behalf of a member with a carrier through the carrier’s internal grievance process regarding an adverse decision concerning the member.
(g)
“Grievance decision” means a final determination by a carrier that arises from a grievance filed with the carrier under its internal grievance process regarding an adverse decision concerning a member.
(h)
“Health Advocacy Unit” means the Health Education and Advocacy Unit in the Division of Consumer Protection of the Office of the Attorney General established under Title 13, Subtitle 4A of the Commercial Law Article.
(i)
“Health benefit plan” has the meaning stated in § 2–112.2(a) of this article.
(j)
“Health care provider” means:
(1)
an individual who is licensed under the Health Occupations Article to provide health care services in the ordinary course of business or practice of a profession and is a treating provider of the member; or
(2)
a hospital, as defined in § 19–301 of the Health – General Article.
(k)
“Health care service” means a health or medical care procedure or service rendered by a health care provider that:
(1)
provides testing, diagnosis, or treatment of a human disease or dysfunction;
(2)
dispenses drugs, medical devices, medical appliances, or medical goods for the treatment of a human disease or dysfunction; or
(3)
provides any other care, service, or treatment of disease or injury, the correction of defects, or the maintenance of physical or mental well–being of individuals.
(l)
(1)
“Member” means a person entitled to health care benefits under a policy, plan, or certificate issued or delivered in the State by a carrier.
(2)
“Member” includes:
(i)
a subscriber; and
(ii)
unless preempted by federal law, a Medicare recipient.
(3)
“Member” does not include a Medicaid recipient.
(m)
“Member’s representative” means an individual who has been authorized by the member to file a grievance or a complaint on the member’s behalf.
(n)
“Private review agent” has the meaning stated in § 15–10B–01 of this title.
Md. Code Ann., Ins. § 15-10A-01.1 (2026)
Title 15. Health Insurance
Subtitle 10A. Complaint Process for Adverse Decisions or Grievances
§ 15–10A-01.1LinkCopy Citation
This subtitle applies to a health benefit plan that:
(1)
is delivered or issued in the State; or
(2)
covers individuals who reside or work in the State if the health benefit plan is delivered or issued in a state that the Commissioner determines does not have an external complaint process for adverse decisions or grievances comparable to the complaint process established in this subtitle.
Md. Code Ann., Ins. § 15-10A-02 (2026)
Title 15. Health Insurance
Subtitle 10A. Complaint Process for Adverse Decisions or Grievances
§ 15–10A-02LinkCopy Citation
(a)
Each carrier shall establish an internal grievance process for its members.
(b)
(1)
An internal grievance process shall meet the same requirements established under Subtitle 10B of this title.
(2)
In addition to the requirements of Subtitle 10B of this title, an internal grievance process established by a carrier under this section shall:
(i)
include an expedited procedure for use in an emergency case for purposes of rendering a grievance decision within 24 hours of the date a grievance is filed with the carrier;
(ii)
provide that a carrier render a final decision in writing on a grievance within 30 working days after the date on which the grievance is filed unless:
(1)
the grievance involves an emergency case under item (i) of this paragraph;
(2)
the member, the member’s representative, or a health care provider filing a grievance on behalf of a member agrees in writing to an extension for a period of no longer than 30 working days; or
(3)
the grievance involves a retrospective denial under item (iv) of this paragraph;
(iii)
allow a grievance to be filed on behalf of a member by a health care provider or the member’s representative;
(iv)
provide that a carrier render a final decision in writing on a grievance within 45 working days after the date on which the grievance is filed when the grievance involves a retrospective denial; and
(v)
for a retrospective denial, allow a member, the member’s representative, or a health care provider on behalf of a member to file a grievance for at least 180 days after the member receives an adverse decision.
(3)
For purposes of using the expedited procedure for an emergency case that a carrier is required to include under paragraph (2)(i) of this subsection, the carrier shall initiate the expedited procedure for an emergency case if the member or the member’s representative requests the expedited review or the health care provider or the member or the member’s representative attests that:
(i)
the adverse decision was rendered for health care services that are proposed but have not been provided; and
(ii)
the services are necessary to treat a condition or illness that, without immediate medical attention, would:
(1)
seriously jeopardize the life or health of the member or the member’s ability to regain maximum functions;
(2)
cause the member to be in danger to self or others; or
(3)
cause the member to continue using intoxicating substances in an imminently dangerous manner.
(c)
Except as provided in subsection (d) of this section, the carrier’s internal grievance process shall be exhausted prior to filing a complaint with the Commissioner under this subtitle.
(d)
(1)
(i)
A member, the 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 a grievance with a carrier and receiving a final decision on the grievance if:
(1)
the carrier waives the requirement that the carrier’s internal grievance process be exhausted before filing a complaint with the Commissioner;
(2)
the carrier has failed to comply with any of the requirements of the internal grievance process as described in this section; or
(3)
the member, the member’s representative, or the health care provider provides sufficient information and supporting documentation in the complaint that demonstrates a compelling reason to do so.
(ii)
The Commissioner shall define by regulation the standards that the Commissioner shall use to decide what demonstrates a compelling reason under subparagraph (i) of this paragraph.
(2)
Subject to subsections (b)(2)(ii) and (h) of this section, a member, a member’s representative, or a health care provider may file a complaint with the Commissioner if the member, the member’s representative, or the health care provider does not receive a grievance decision from the carrier on or before the 30th working day on which the grievance is filed.
(3)
Whenever the Commissioner receives a complaint under paragraph (1) or (2) of this subsection, the Commissioner shall notify the carrier that is the subject of the complaint within 5 working days after the date the complaint is filed with the Commissioner.
(e)
Each carrier shall:
(1)
file for review with the Commissioner and submit to the Health Advocacy Unit a copy of its internal grievance process established under this subtitle; and
(2)
file any revision to the internal grievance process with the Commissioner and the Health Advocacy Unit at least 30 days before its intended use.
(f)
(1)
For nonemergency cases, when a carrier renders an adverse decision, the carrier shall:
(i)
inform the member, the member’s representative, or the health care provider acting on behalf of the member of the adverse decision:
(1)
orally by telephone; or
(2)
with the affirmative consent of the member, the member’s representative, or the health care provider acting on behalf of the member, by text, facsimile, e–mail, an online portal, or other expedited means; and
(ii)
send, within 5 working days after the adverse decision has been made, a written notice to the member, the member’s representative, and a health care provider acting on behalf of the member that:
(1)
states at the top in prominent bold print:
(A)
that the notice is a denial of a requested health care service;
(B)
that the member may file an appeal;
(C)
the telephone number and e–mail address required to be available under § 15–10B–05(e) of this title; and
(D)
that the notice includes additional information on how to file and receive assistance for filing a complaint;
(2)
states in detail in clear, understandable language the specific factual bases for the carrier’s decision and the reasoning used to determine that the health care service is not medically necessary and did not meet the carrier’s criteria and standards used in conducting the utilization review;
(3)
provides the specific reference, language, or requirements from the criteria and standards, including any interpretive guidelines, on which the decision was based, and may not solely use:
(A)
generalized terms such as “experimental procedure not covered”, “cosmetic procedure not covered”, “service included under another procedure”, or “not medically necessary”; or
(B)
language directing the member to review the additional coverage criteria in the member’s policy or plan documents;
(4)
includes a unique identifier for and the business address and business telephone number of:
(A)
if the carrier is a health maintenance organization, the medical director or associate medical director, as appropriate, who made the decision; or
(B)
if the carrier is not a health maintenance organization, the designated employee or representative of the carrier who has responsibility for the carrier’s internal grievance process and the physician who is required to make all adverse decisions as required in § 15–10B–07(a) of this title;
(5)
gives written details of the carrier’s internal grievance process and procedures under this subtitle; and
(6)
includes the following information:
(A)
that the member, the member’s representative, or a health care provider on behalf of the member has a right to file a complaint with the Commissioner within 4 months after receipt of a carrier’s grievance decision;
(B)
that a complaint may be filed without first filing a grievance if the member, the member’s representative, or a health care provider filing a grievance on behalf of the member can demonstrate a compelling reason to do so as determined by the Commissioner;
(C)
the Commissioner’s address, telephone number, and facsimile number;
(D)
a statement that the Health Advocacy Unit is available to assist the member or the member’s representative in both mediating and filing a grievance under the carrier’s internal grievance process; and
(E)
the address, telephone number, facsimile number, and electronic mail address of the Health Advocacy Unit.
(2)
The business telephone number included in the notice as required under paragraph (1)(ii)4 of this subsection must be a dedicated number for adverse decisions and may not be the general customer call number for the carrier.
(g)
If within 5 working days after a member, the member’s representative, or a health care provider, who has filed a grievance on behalf of a member, files a grievance with the carrier, and if the carrier does not have sufficient information to complete its internal grievance process, the carrier shall:
(1)
after confirming through a complete review of any information already submitted by the health care provider:
(i)
notify the member, the member’s representative, or the health care provider that it cannot proceed with reviewing the grievance unless additional information is provided;
(ii)
request the specific information, including any lab or diagnostic test or other medical information that must be submitted to complete the internal grievance process; and
(iii)
provide the specific reference, language, or requirements from the criteria and standards used by the carrier to support the need for the additional information; and
(2)
assist the member, the member’s representative, or the health care provider in gathering the necessary information without further delay.
(h)
A carrier may extend the 30–day or 45–day period required for making a final grievance decision under subsection (b)(2)(ii) of this section with the written consent of the member, the member’s representative, or the health care provider who filed the grievance on behalf of the member.
(i)
(1)
For nonemergency cases, when a carrier renders a grievance decision, the carrier shall:
(i)
document the grievance decision in writing after the carrier has provided oral communication of the decision to the member, the member’s representative, or the health care provider acting on behalf of the member; and
(ii)
send, within 5 working days after the grievance decision has been made, a written notice to the member, the member’s representative, and a health care provider acting on behalf of the member that:
(1)
states at the top in prominent bold print:
(A)
that the notice is a denial of a requested health care service;
(B)
that the member may file a complaint with the Commissioner;
(C)
the telephone number and e–mail address required to be available under § 15–10B–05(e) of this title; and
(D)
that the notice includes additional information on how to file and receive assistance for an appeal;
(2)
states in detail in clear, understandable language the specific factual bases for the carrier’s decision and the reasoning used to determine that the health care service is not medically necessary and did not meet the carrier’s criteria and standards used in conducting utilization review;
(3)
provides the specific reference, language, or requirements from the criteria and standards, including any interpretive guidelines used by the carrier, on which the grievance decision was based;
(4)
includes a unique identifier for and the business address and business telephone number of:
(A)
if the carrier is a health maintenance organization, the medical director or associate medical director, as appropriate, who made the grievance decision; or
(B)
if the carrier is not a health maintenance organization, the designated employee or representative of the carrier who has responsibility for the carrier’s internal grievance process and the designated employee or representative’s title and clinical specialty; and
(5)
includes the following information:
(A)
that the member or the member’s representative has a right to file a complaint with the Commissioner within 4 months after receipt of a carrier’s grievance decision;
(B)
the Commissioner’s address, telephone number, and facsimile number;
(C)
a statement that the Health Advocacy Unit is available to assist the member or the member’s representative in filing a complaint with the Commissioner; and
(D)
the address, telephone number, facsimile number, and electronic mail address of the Health Advocacy Unit.
(2)
The business telephone number included in the notice as required under paragraph (1)(ii)4 of this subsection must be a dedicated number for grievance decisions and may not be the general customer call number for the carrier.
(3)
To satisfy the requirements of this subsection, a carrier may not use solely in the written notice sent under paragraph (1) of this subsection:
(i)
generalized terms such as “experimental procedure not covered”, “cosmetic procedure not covered”, “service included under another procedure”, or “not medically necessary”; or
(ii)
language directing the member to review the additional coverage criteria in the member’s policy or plan documents.
(j)
(1)
For an emergency case under subsection (b)(2)(i) of this section, within 1 day after a decision has been orally communicated to the member, the member’s representative, or the health care provider, the carrier shall send notice in writing of any adverse decision or grievance decision to:
(i)
the member and the member’s representative, if any; and
(ii)
if the grievance was filed on behalf of the member under subsection (b)(2)(iii) of this section, the health care provider.
(2)
A notice required to be sent under paragraph (1) of this subsection shall include the following:
(i)
for an adverse decision, the information required under subsection (f) of this section; and
(ii)
for a grievance decision, the information required under subsection (i) of this section.
(k)
(1)
Each carrier shall include the information required by subsection (f)(1)(ii)3, 4, and 5 of this section in the policy, plan, certificate, enrollment materials, or other evidence of coverage that the carrier provides to a member at the time of the member’s initial coverage or renewal of coverage.
(2)
Each carrier shall include as part of the information required by paragraph (1) of this subsection a statement indicating that, when filing a complaint with the Commissioner, the member or the member’s representative will be required to authorize the release of any medical records of the member that may be required to be reviewed for the purpose of reaching a decision on the complaint.
(l)
(1)
Nothing in this subtitle prohibits a carrier from delegating its internal grievance process to a private review agent that has a certificate issued under Subtitle 10B of this title and is acting on behalf of the carrier.
(2)
If a carrier delegates its internal grievance process to a private review agent, the carrier shall be:
(i)
bound by the grievance decision made by the private review agent acting on behalf of the carrier; and
(ii)
responsible for a violation of any provision of this subtitle regardless of the delegation made by the carrier under paragraph (1) of this subsection.
Md. Code Ann., Ins. § 15-10A-03 (2026)
Title 15. Health Insurance
Subtitle 10A. Complaint Process for Adverse Decisions or Grievances
§ 15–10A-03LinkCopy Citation
(a)
(1)
Within 4 months after the date of receipt of an adverse decision or a grievance decision, a member, a member’s representative, or a health care provider, who filed the grievance on behalf of the member under § 15–10A–02(b)(2)(iii) of this subtitle, may file a complaint with the Commissioner.
(2)
Whenever the Commissioner receives a complaint under this subsection, the Commissioner shall notify the carrier that is the subject of the complaint within 5 working days after the date the complaint is filed with the Commissioner.
(3)
Except for an emergency case under subsection (b)(1)(ii) of this section, the carrier that is the subject of a complaint filed under paragraph (1) of this subsection shall provide to the Commissioner any information requested by the Commissioner no later than 7 working days from the date the carrier receives the request for information.
(b)
(1)
In developing procedures to be used in reviewing and deciding complaints, the Commissioner shall:
(i)
allow a health care provider to file a complaint on behalf of a member; and
(ii)
establish an expedited procedure for use in an emergency case for the purpose of making a final decision on a complaint within 24 hours after the complaint is filed with the Commissioner.
(2)
For purposes of using the expedited procedure for an emergency case under paragraph (1)(ii) of this subsection, the Commissioner shall define by regulation the standards required for a grievance to be considered an emergency case.
(c)
(1)
Except as provided in paragraph (2) of this subsection and except for an emergency case under subsection (b)(1)(ii) of this section, the Commissioner shall make a final decision on a complaint:
(i)
within 45 days after a complaint regarding a pending health care service is filed; and
(ii)
within 45 days after a complaint is filed regarding a retrospective denial of services already provided.
(2)
The Commissioner may extend the period within which a final decision is to be made under paragraph (1) of this subsection for up to an additional 30 working days if:
(i)
the Commissioner has not yet received information requested by the Commissioner; and
(ii)
the information requested is necessary for the Commissioner to render a final decision on the complaint.
(d)
The Commissioner shall seek advice from an independent review organization or medical expert, as provided in § 15–10A–05 of this subtitle, for complaints filed with the Commissioner under this subtitle that involve a question of whether a health care service provided or to be provided to a member is medically necessary.
(e)
(1)
A carrier shall have the burden of persuasion that its adverse decision or grievance decision, as applicable, is correct:
(i)
during the review of a complaint by the Commissioner or a designee of the Commissioner; and
(ii)
in any hearing held in accordance with § 2–210 of this article.
(2)
As part of the review of a complaint, the Commissioner or a designee of the Commissioner may consider all of the facts of the case and any other evidence that the Commissioner or designee of the Commissioner considers appropriate.
(3)
As required under § 15–10A–02(i) of this subtitle, the carrier’s adverse decision or grievance decision shall state in detail in clear, understandable language the factual bases for the decision and reference the specific criteria and standards, including interpretive guidelines on which the decision was based.
(4)
(i)
Except as provided in subparagraph (ii) of this paragraph, in responding to a complaint, a carrier may not rely on any basis not stated in its adverse decision or grievance decision.
(ii)
The Commissioner may allow a carrier, a member, a member’s representative, or a health care provider filing a complaint on behalf of a member to provide additional information as may be relevant for the Commissioner to make a final decision on the complaint.
(iii)
The Commissioner shall allow the member, the member’s representative, or the health care provider filing a complaint on behalf of the member at least 5 working days to provide the additional information described in subparagraph (ii) of this paragraph.
(iv)
The Commissioner’s use of additional information may not delay the Commissioner’s decision on the complaint by more than 5 working days.
(f)
The Commissioner may request the member that filed the complaint or a legally authorized designee of the member to sign a consent form authorizing the release of the member’s medical records to the Commissioner or the Commissioner’s designee that are needed in order for the Commissioner to make a final decision on the complaint.
Md. Code Ann., Ins. § 15-10A-04 (2026)
Title 15. Health Insurance
Subtitle 10A. Complaint Process for Adverse Decisions or Grievances
§ 15–10A-04LinkCopy Citation
(a)
The Commissioner shall:
(1)
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;
(2)
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
(3)
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.
(b)
(1)
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.
(2)
The Commissioner shall include in the notice the information required under subsection (a)(3) of this section.
(c)
(1)
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.
(2)
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:
(i)
issue an administrative order that requires the carrier to:
(1)
cease inappropriate conduct or practices by the carrier or any of the personnel employed or associated with the carrier;
(2)
fulfill the carrier’s contractual obligations;
(3)
provide a health care service or payment that has been denied improperly; or
(4)
take appropriate steps to restore the carrier’s ability to provide a health care service or payment that is provided under a contract; or
(ii)
impose any penalty or fine or take any action as authorized:
(1)
for an insurer, nonprofit health service plan, or dental plan organization, under this article; or
(2)
for a health maintenance organization, under the Health – General Article or under this article.
(3)
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.
(d)
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.
(e)
(1)
A final decision of the Commissioner made on a complaint under this subtitle:
(i)
is not subject to a request for a hearing under this subtitle for a carrier; and
(ii)
is subject to a right to file a petition for judicial review under § 2–215 of this article for a carrier or a member.
(2)
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.
Md. Code Ann., Ins. § 15-10A-05 (2026)
Title 15. Health Insurance
Subtitle 10A. Complaint Process for Adverse Decisions or Grievances
§ 15–10A-05LinkCopy Citation
(a)
For a complaint filed with the Commissioner under this subtitle that involves a question of whether the health care service provided or to be provided to a member is medically necessary, the Commissioner:
(1)
shall select an independent review organization or medical expert to advise on the complaint; and
(2)
may accept and base the final decision on the complaint on the professional judgment of an independent review organization or medical expert.
(b)
To ensure access to advice when needed, the Commissioner, in consultation with the Secretary of Health and carriers, shall compile a list of independent review organizations and medical experts.
(c)
Any expert reviewer assigned by an independent review organization or medical expert shall be a physician or other appropriate health care provider who meets the following minimum requirements:
(1)
be an expert in the treatment of the member’s medical condition, and knowledgeable about the recommended health care service or treatment through actual clinical experience;
(2)
hold:
(i)
a nonrestricted license in a state of the United States; and
(ii)
in addition, for physicians, a current certification by a recognized American medical specialty board in the area or areas appropriate to the subject of review; and
(3)
have no history of disciplinary actions or sanctions, including loss of staff privileges or participation restrictions that have been taken or are pending by any hospital, governmental agency or unit, or regulatory body that the Commissioner, in accordance with regulations adopted by the Commissioner, considers relevant in meeting the requirements of this subsection.
(d)
An independent review organization may not be a subsidiary of, or in any way owned or controlled by, a health benefit plan, or a trade association of health benefit plans, or a trade association of health care providers.
(e)
In addition to subsection (d) of this section, to be included on the list compiled under subsection (b) of this section, an independent review organization shall submit to the Commissioner the following information:
(1)
if the independent review organization is a publicly held organization, the names of all stockholders and owners of more than 5% of any stock or options of the independent review organization;
(2)
the names of all holders of bonds or notes in excess of $100,000, if any;
(3)
the names of all corporations and organizations that the independent review organization controls or is affiliated with, and the nature and extent of any ownership or control, including the affiliated organization’s type of business;
(4)
the names of all directors, officers, and executives of the independent review organization as well as a statement regarding any relationships the directors, officers, and executives may have with any carrier or health care provider group; and
(5)
evidence, in the form required by the Commissioner, that the independent review organization is accredited by a nationally recognized private accrediting organization.
(f)
An expert reviewer assigned by an independent review organization or the independent review organization or medical expert selected by the Commissioner under this section may not have a material professional, familial, or financial conflict of interest with any of the following:
(1)
the carrier that is the subject of the complaint;
(2)
any officer, director, or management employee of the carrier that is the subject of the complaint;
(3)
the health care provider, the health care provider’s medical group, or the independent practice association that rendered or is proposing to render the health care service that is under review;
(4)
the health care facility at which the health care service was provided or will be provided; or
(5)
the developer or manufacturer of the principal drug, device, procedure, or other therapy that is being proposed for the member.
(g)
For any independent review organization selected by the Commissioner under subsection (a) of this section, the independent review organization shall have a quality assurance mechanism in place that ensures:
(1)
the timeliness and quality of the reviews;
(2)
the qualifications and independence of the expert reviewers; and
(3)
the confidentiality of medical records and review materials.
(h)
(1)
The carrier that is the subject of the complaint shall be responsible for paying the reasonable expenses of the independent review organization or medical expert selected by the Commissioner in accordance with subsection (a) of this section.
(2)
The independent review organization or medical expert shall:
(i)
present to the carrier for payment a detailed account of the expenses incurred by the independent review organization or medical expert; and
(ii)
provide a copy of the detailed account of expenses to the Commissioner.
(3)
The carrier that is the subject of the complaint may not pay and an independent review organization or medical expert may not accept any compensation in addition to the payment for reasonable expenses under paragraph (1) of this subsection.
Md. Code Ann., Ins. § 15-10A-06 (2026)
Title 15. Health Insurance
Subtitle 10A. Complaint Process for Adverse Decisions or Grievances
§ 15–10A-06LinkCopy Citation
(a)
(1)
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:
(i)
the number of members entitled to health care benefits under a policy, plan, or certificate issued or delivered in the State by the carrier;
(ii)
the number of clean claims for reimbursement processed by the carrier;
(iii)
the activities of the carrier under this subtitle, including:
(1)
the outcome of each grievance filed with the carrier;
(2)
the number and outcomes of cases that were considered emergency cases under § 15–10A–02(b)(2)(i) of this subtitle;
(3)
the time within which the carrier made a grievance decision on each emergency case;
(4)
the time within which the carrier made a grievance decision on all other cases that were not considered emergency cases;
(5)
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;
(6)
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;
(7)
the number of adverse decisions overturned after a reconsideration request under § 15–10B–06 of this title; and
(8)
the number of requests made and granted under § 15–831(c)(1) and (2) of this title; and
(iv)
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.
(2)
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:
(i)
a description of any changes in medical management contributing to the rise in adverse decisions for the type of service;
(ii)
any other known reasons for the increase; and
(iii)
a description of the carrier’s efforts and actions taken to determine the reason for the increase.
(b)
The Commissioner shall:
(1)
compile an annual summary report based on the information provided:
(i)
under subsection (a) of this section; and
(ii)
by the Secretary under § 19–705.2(e) of the Health – General Article;
(2)
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;
(3)
report any violations or actions taken under § 15–10B–11 of this title; and
(4)
provide copies of the summary report to the Governor and, subject to § 2–1257 of the State Government Article, to the General Assembly.
(c)
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.
Md. Code Ann., Ins. § 15-10A-07 (2026)
Title 15. Health Insurance
Subtitle 10A. Complaint Process for Adverse Decisions or Grievances
§ 15–10A-07LinkCopy Citation
On a quarterly basis, the Health Advocacy Unit shall submit a report to the Commissioner that:
(1)
describes activities it performed on behalf of members that have participated in an internal grievance process of a carrier established under this subtitle;
(2)
describes its efforts to mediate cases that involve an adverse decision;
(3)
names each carrier involved in the cases described in the report;
(4)
states the number and outcome of each grievance considered an emergency case under § 15-10A-02(b)(2)(i) of this subtitle described in the report, including the time within which the carrier made a grievance decision on each emergency case; and
(5)
states the number and outcome of each case described in the report that was not considered an emergency case, including the time within which the carrier made a grievance decision on the case.
Md. Code Ann., Ins. § 15-10A-08 (2026)
Title 15. Health Insurance
Subtitle 10A. Complaint Process for Adverse Decisions or Grievances
§ 15–10A-08LinkCopy Citation
(a)
On or before November 1, 1999, and each November 1 thereafter, the Health Advocacy Unit shall publish an annual summary report and provide copies of the report to the Governor and, subject to § 2–1257 of the State Government Article, the General Assembly.
(b)
(1)
The annual summary report required under subsection (a) of this section shall be on the grievances and complaints filed with or referred to a carrier, the Commissioner, the Health Advocacy Unit, or any other federal or State government agency or unit under this subtitle during the previous fiscal year.
(2)
In consultation with the Commissioner and any affected State government agency or unit, the Health Advocacy Unit shall:
(i)
evaluate the effectiveness of the internal grievance process and complaint process available to members; and
(ii)
include in the annual summary report the results of the evaluation and any proposed changes to the law that it considers necessary to ensure compliance with the purposes of the law.
Md. Code Ann., Ins. § 15-10A-09 (2026)
Title 15. Health Insurance
Subtitle 10A. Complaint Process for Adverse Decisions or Grievances
§ 15–10A-09LinkCopy Citation
(a)
The Commissioner shall adopt regulations to carry out this subtitle.
(b)
In addition to the requirements of subsection (a) of this section, the Commissioner shall adopt by regulation a requirement that each carrier provide a mechanism in a form and manner that the Commissioner may require to enable a member to:
(1)
be informed of the member’s right to challenge a decision made by a carrier that resulted in the nonpayment of a health care service; and
(2)
access the Consumer Education and Advocacy Program in the Administration.
Md. Code Ann., Ins. § 15-10A-10 (2026)
Title 15. Health Insurance
Subtitle 10A. Complaint Process for Adverse Decisions or Grievances
§ 15–10A-10LinkCopy Citation
A carrier shall provide the notices required to be provided to members under this subtitle in a culturally and linguistically appropriate manner as described in the Affordable Care Act.