<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".02" citation="COMAR 10.67.09.02" title_num="10" subtitle_num="67" chapter_num="09" heading="MCO Enrollee Complaint Process.">
  <paragraph num="A.">
    <text>An MCO shall have written complaint procedures by which an enrollee who is dissatisfied with the MCO or its network providers, or decisions made by the MCO or a provider, may seek recourse verbally or in writing within the MCO at any time.</text>
  </paragraph>
  <paragraph num="B.">
    <text>An MCO shall:</text>
    <paragraph num="(1)">
      <text>Submit its written internal complaint procedures to the Department for its approval;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Give enrollees any reasonable assistance in completing forms and taking other procedural steps related to a grievance or appeal in a manner consistent with COMAR 10.67.05.01A;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Prepare the document describing the MCO’s internal complaint process:</text>
      <paragraph num="(a)">
        <text>In a culturally sensitive manner;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>At an appropriate reading comprehension level; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>In the prevalent non-English languages, identified by the State;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(4)">
      <text>Deliver a copy of the MCO’s complaint procedures to each enrollee:</text>
      <paragraph num="(a)">
        <text>With the MCO’s initial contact with a new enrollee; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>At any time upon an enrollee’s request;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(5)">
      <text>Maintain an accurate and accessible record of grievances and appeals for monitoring by the State and CMS, which includes, at a minimum:</text>
      <paragraph num="(a)">
        <text>A general description of the reason for the appeal or grievance;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The date received;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>The date of each review or, if applicable, review meeting;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Resolution at each level of the appeal or grievance, if applicable;</text>
      </paragraph>
      <paragraph num="(e)">
        <text>Date of resolution at each level, if applicable; and</text>
      </paragraph>
      <paragraph num="(f)">
        <text>Name of the enrollee for whom the appeal or grievance was filed; and</text>
      </paragraph>
    </paragraph>
    <paragraph num="(6)">
      <text>Provide in its written procedures that an enrollee may file appeals and grievances orally or in writing.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>An MCO shall submit for Department approval an internal complaint process detailing the procedures for registering and responding to appeals and grievances in a timely fashion, which:</text>
    <paragraph num="(1)">
      <text>Includes a specific standard for grievance decisions, monitored by the MCO for compliance, directing that:</text>
      <paragraph num="(a)">
        <text>The decision time for emergency medically related grievances may not exceed 24 hours;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The decision time for nonemergency medically related grievances may not exceed 5 days; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>For administrative grievances, the decision time may not exceed 30 days;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>Includes participation by the provider, if appropriate;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Allows participation by the ombudsman, if appropriate;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Ensures the participation of individuals within the MCO who have the authority to require corrective action;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Requires documentation of the substance of the grievances and steps taken;</text>
    </paragraph>
    <paragraph num="(6)">
      <text>Includes a procedure for the aggregation and analysis of appeals and grievance data and use of the data for quality improvement;</text>
    </paragraph>
    <paragraph num="(7)">
      <text>Includes a documented procedure for reporting:</text>
      <paragraph num="(a)">
        <text>Appeals and grievances received by the MCO to:</text>
        <paragraph num="(i)">
          <text>The provider involved;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Appropriate quality assurance committees and departments within the MCO;</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>The MCO's consumer advisory board; and</text>
        </paragraph>
        <paragraph num="(iv)">
          <text>The Department as requested; and</text>
        </paragraph>
      </paragraph>
      <paragraph num="(b)">
        <text>The quarterly appeal and grievance analysis performed by the MCO as specified in COMAR 10.67.04.15D(1)(b);</text>
      </paragraph>
    </paragraph>
    <paragraph num="(8)">
      <text>Includes a documented procedure for written notification of the MCO's determination:</text>
      <paragraph num="(a)">
        <text>To the enrollee who filed the grievance; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>To those individuals and entities required to be notified of the grievance pursuant to §C(7) of this regulation;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(9)">
      <text>Ensures that decision makers on appeals and grievances:</text>
      <paragraph num="(a)">
        <text>Were not involved in previous levels of decision-making;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Are not subordinates of people involved in previous levels of decision-making;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Are healthcare professionals with clinical expertise in treating the enrollee’s condition or disease, if any of the following apply:</text>
        <paragraph num="(i)">
          <text>The appeal is a denial based on lack of medical necessity;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>The grievance is regarding denial of expedited resolution of an appeal; or</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>The appeal or grievance involves clinical issues; and</text>
        </paragraph>
      </paragraph>
      <paragraph num="(d)">
        <text>Take into account all comments, documents, records, and other information submitted by the enrollee or their representative, without regard to whether such information was submitted or considered in the initial action.</text>
      </paragraph>
    </paragraph>
  </paragraph>
</regulation>