Chapter 09. Maryland Medicaid Managed Care Program: MCO Dispute Resolution Procedures
Regulation .01 MCO Enrollee Services.LinkCopy Citation
An MCO shall:
A.
Maintain a member services unit that operates an enrollee services line at least during normal business hours;
B.
Operate its enrollee services line as a triage device to handle or properly refer enrollees' questions or complaints; and
C.
Provide information in the member handbook about how to use the MCO enrollee services line to obtain information and assistance.
Regulation .02 MCO Enrollee Complaint Process.LinkCopy Citation
A.
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.
B.
An MCO shall:
(1)
Submit its written internal complaint procedures to the Department for its approval;
(2)
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;
(3)
Prepare the document describing the MCO’s internal complaint process:
(a)
In a culturally sensitive manner;
(b)
At an appropriate reading comprehension level; and
(c)
In the prevalent non-English languages, identified by the State;
(4)
Deliver a copy of the MCO’s complaint procedures to each enrollee:
(a)
With the MCO’s initial contact with a new enrollee; and
(b)
At any time upon an enrollee’s request;
(5)
Maintain an accurate and accessible record of grievances and appeals for monitoring by the State and CMS, which includes, at a minimum:
(a)
A general description of the reason for the appeal or grievance;
(b)
The date received;
(c)
The date of each review or, if applicable, review meeting;
(d)
Resolution at each level of the appeal or grievance, if applicable;
(e)
Date of resolution at each level, if applicable; and
(f)
Name of the enrollee for whom the appeal or grievance was filed; and
(6)
Provide in its written procedures that an enrollee may file appeals and grievances orally or in writing.
C.
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:
(1)
Includes a specific standard for grievance decisions, monitored by the MCO for compliance, directing that:
(a)
The decision time for emergency medically related grievances may not exceed 24 hours;
(b)
The decision time for nonemergency medically related grievances may not exceed 5 days; and
(c)
For administrative grievances, the decision time may not exceed 30 days;
(2)
Includes participation by the provider, if appropriate;
(3)
Allows participation by the ombudsman, if appropriate;
(4)
Ensures the participation of individuals within the MCO who have the authority to require corrective action;
(5)
Requires documentation of the substance of the grievances and steps taken;
(6)
Includes a procedure for the aggregation and analysis of appeals and grievance data and use of the data for quality improvement;
(7)
Includes a documented procedure for reporting:
(a)
Appeals and grievances received by the MCO to:
(i)
The provider involved;
(ii)
Appropriate quality assurance committees and departments within the MCO;
(iii)
The MCO's consumer advisory board; and
(iv)
The Department as requested; and
(b)
The quarterly appeal and grievance analysis performed by the MCO as specified in COMAR 10.67.04.15D(1)(b);
(8)
Includes a documented procedure for written notification of the MCO's determination:
(a)
To the enrollee who filed the grievance; and
(b)
To those individuals and entities required to be notified of the grievance pursuant to §C(7) of this regulation;
(9)
Ensures that decision makers on appeals and grievances:
(a)
Were not involved in previous levels of decision-making;
(b)
Are not subordinates of people involved in previous levels of decision-making;
(c)
Are healthcare professionals with clinical expertise in treating the enrollee’s condition or disease, if any of the following apply:
(i)
The appeal is a denial based on lack of medical necessity;
(ii)
The grievance is regarding denial of expedited resolution of an appeal; or
(iii)
The appeal or grievance involves clinical issues; and
(d)
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.
Regulation .02-1 Member Complaints — Time Frames for MCOs to Respond to the Department.LinkCopy Citation
An MCO shall:
A.
Acknowledge an enrollee appeal or grievance reported to it by the Department’s complaint resolution unit within 1 business day;
B.
Respond to the Department’s request for information regarding disputed nonemergency medical care actions within 3 business days;
C.
Provide updates in a time frame specified by the Department;
D.
Provide medical records within 5 days of the request; and
E.
Provide a corrective action plan upon request and within the time frame specified, but not later than 10 days from the date of the request.
Regulation .03 MCO Provider Complaint Process.LinkCopy Citation
A.
An MCO shall have a complaint procedure for providers that is:
(1)
Documented in writing;
(2)
Disseminated in writing to all of the MCO's providers at the time they join the MCO's provider panel, and furnished to a provider at any time, upon request; and
(3)
Linked to the MCO's internal quality assurance program.
B.
An MCO shall include in its provider complaint process at least the following elements:
(1)
Procedures for registering and responding to provider grievances in a timely fashion, including standards for timeliness that recognize the need for expedited determinations in situations that are time-sensitive, that is, when an enrollee's treatment outcome may be significantly affected by the promptness of treatment, as set forth in Regulation .02C(1)(a) and (b) of this chapter apply;
(2)
Notification to the provider of an MCO's determination that affects the provider or that provider's patient, which includes a description of how to file an internal appeal with the MCO;
(3)
Documentation of the substance of complaints and steps taken;
(4)
Procedures to ensure the timely resolution of the complaint and response by the MCO to the provider;
(5)
Procedures for the termination or withdrawal of a provider from the MCO's provider panel, including:
(a)
At least 90 days prior notice to the primary care providers in the MCO's provider panel of the MCO's termination of a specialty services provider when the reason for the termination is unrelated to fraud, patient abuse, incompetency, or loss of licensure status;
(b)
If possible, at least 90 days prior notice to the primary care providers in the MCO's provider panel of a specialty services provider's withdrawal from the MCO's provider panel; and
(c)
Notices to primary care providers informing them of the enrollee’s right to change MCOs as described in COMAR 10.67.02.06A(1)(e).
(6)
Mechanisms to aggregate and analyze appeal and grievance data and to use the data for quality improvement;
(7)
An appeal process which:
(a)
Is available when the provider's appeal or grievance is not resolved to the provider's satisfaction, or when the MCO acts to reduce, suspend, or terminate provider's privileges with the MCO;
(b)
Acknowledges receipt of provider appeals within 5 business days of receipt by the MCO;
(c)
Allows providers 90 business days from the date of a denial to file an initial appeal;
(d)
Allows providers at least 15 business days from the date of denial to file each subsequent level of appeal;
(e)
Resolves appeals, regardless of the number of appeal levels allowed by the MCO, within 90 business days of receipt of the initial appeal by the MCO;
(f)
Pays claim within 30 days of the appeal decision when a claim denial is overturned;
(g)
Provides at its final level an opportunity for the provider to be heard by the MCO's chief executive officer, or the chief executive officer's designee;
(h)
Provides timely written notice to the provider of the results of the internal appeal; and
(i)
Provides for written notice of the substance of the dispute and the result of the internal appeal to appropriate quality assurance committees and departments within the MCO; and
(8)
A protocol for transmitting provider appeal and grievance reports and aggregate provider grievance and appeal data to the Department when requested.
C.
An MCO may not take any punitive action against a provider for utilizing the MCO provider complaint process, for supporting an enrollee's appeal, or for requesting expedited resolution for an enrollee's appeal.
D.
An MCO or its pharmacy benefits manager shall resolve pharmacy appeals concerning drug pricing within 21 days of the receipt of a request.
Regulation .03-1 Independent Review Organization (IRO).LinkCopy Citation
For provider disputes involving medical necessity, an MCO shall participate in the IRO process as specified in COMAR 10.67.13.
Regulation .03-2 Provider Complaints — Time Frames for MCOs to Respond to the Department.LinkCopy Citation
An MCO shall:
A.
Acknowledge provider grievances within 3 business days;
B.
Provide findings to the Department within 5 days; and
C.
Provide a corrective action plan to the Department within 10 days from the date of the request.
Regulation .04 MCO Actions and Decisions.LinkCopy Citation
A.
For certain services to enrollees that require preauthorization the following conditions apply:
(1)
For standard authorization decisions, the MCO shall make a determination within 2 business days of receipt of necessary clinical information, but not later than 14 calendar days from the date of the initial request so as not to adversely affect the health of the enrollee;
(2)
For expedited authorization decisions, the MCO shall make a determination and provide notice no later than 72 hours after receipt of the request for service if the provider indicates or the MCO determines that the standard time frame stated in §A(1) of this regulation could jeopardize:
(a)
The enrollee’s life;
(b)
The enrollee’s health; or
(c)
The enrollee’s ability to attain, maintain, or regain maximum function;
(3)
For all covered outpatient drug authorization decisions, the MCO shall provide notice by telephone or other telecommunication device within 24 hours of a preauthorization request in accordance with section 1927(d)(5)(A) of the Social Security Act;
(4)
Standard and expedited authorization decisions may be extended up to 14 calendar days, if the following conditions are met:
(a)
The enrollee or the provider requests an extension; or
(b)
The MCO justifies to the Department, upon request, a need for additional information and how the extension is in the enrollee’s interest; and
(5)
If the MCO successfully justifies extending the standard service authorization decision time frame, the MCO shall:
(a)
Give the enrollee written notice of the reason for the decision to extend the time frame;
(b)
Inform the enrollee of the right to file a grievance if he or she disagrees with the extension decision; and
(c)
Issue and carry out the MCO’s determination as expeditiously as the enrollee’s health condition requires but not later than the date the extension expires.
B.
Any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested:
(1)
Shall be made by a health care professional who has appropriate clinical expertise in treating the enrollee's condition or disease; and
(2)
May not be based solely on diagnosis, type of illness, or condition.
C.
An MCO shall ensure that compensation to individuals or entities that conduct utilization management activities is not structured to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any enrollee.
D.
Notices of a decision to deny a standard authorization shall be provided to the enrollee and the requesting provider within 72 hours from the date of determination.
E.
An MCO shall give an enrollee written notice of any action within the following time frames:
(1)
At least 10 days before the action for termination, suspension, or reduction of a previously authorized covered service;
(2)
The notice period is reduced to 5 days if probable enrollee fraud has been verified;
(3)
By the date of the action for the following:
(a)
The MCO has factual information confirming the death of an enrollee;
(b)
A signed written enrollee statement requesting service termination or giving information requiring termination or reduction of services, where the enrollee understands that this is the result of supplying that information;
(c)
The enrollee's admission to an institution where they are ineligible for further services;
(d)
The enrollee's address is unknown and mail directed to the enrollee has no forwarding address;
(e)
The enrollee has been accepted for Medicaid services by another jurisdiction;
(f)
The enrollee's physician prescribes a change in the level of medical care; or
(g)
An adverse determination made with regard to the preadmission screening requirements for nursing facility admissions; and
(4)
As soon as practicable for nursing facility transfers or discharges when:
(a)
The safety or health of individuals in the facility would be endangered;
(b)
The enrollee’s health improves sufficiently to allow a more immediate transfer or discharge; or
(c)
An immediate transfer or discharge is required by the enrollee’s urgent medical needs; and
(5)
For denial of payment, at the time of any action affecting the claim.
F.
A notice of adverse action shall:
(1)
Be in writing;
(2)
Meet the following requirements:
(a)
Be translated for enrollees who speak prevalent non-English languages;
(b)
Include language clarifying that oral interpretation is available for all languages and how to access it;
(c)
Be written in an easily understood language and format that takes into consideration enrollees with special needs;
(d)
Be available in alternative formats; and
(e)
Inform enrollees that information is available in alternative formats and how to access those formats; and
(3)
Contain the following information:
(a)
The action the MCO has made or intends to make;
(b)
The reasons for the action, including the right for the enrollee to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the MCO’s action, including:
(i)
Medical necessity criteria; and
(ii)
Any processes, strategies, or evidentiary standards used in setting coverage limits;
(c)
The enrollee’s right to request an appeal of the MCO’s action, including information on:
(i)
Exhausting the MCO’s one level of appeal; and
(ii)
The right to request a State fair hearing;
(d)
The procedures for exercising the rights described;
(e)
The circumstances under which an appeal process can be expedited and how to request it;
(f)
The enrollee’s right to have benefits continue pending resolution of the appeal;
(g)
How to request that benefits be continued; and
(h)
The circumstances under which the enrollee may be required to pay the costs of the services.
G.
If an MCO does not make an authorization decision within the times specified in §A of this regulation, the untimely decision is considered a denial and thus an adverse action subject to the notice requirements in §§C and E of this regulation.
Regulation .05 MCO Appeal Process for Enrollees.LinkCopy Citation
A.
An MCO's appeal process shall:
(1)
Require that an enrollee, or a provider acting on the enrollee’s behalf, file an appeal within 60 days from the date on the MCO’s notice of action;
(2)
Include procedures for acknowledging receipt of appeals within 5 business days;
(3)
Permit an enrollee to request an appeal either orally or in writing;
(4)
Provide that oral requests for appeal are considered the initiation of the appeal to establish the earliest possible filing date;
(5)
Provide reasonable opportunity to present evidence and allegations of fact or law, in person as well as in writing, and in the case of expedited appeals, the MCO shall inform the enrollee of the limited time available for the enrollee to present this evidence;
(6)
Provide the case file upon request to the enrollee and the enrollee's representative, free of charge and sufficiently in advance of the resolution time frame for appeals, which includes:
(a)
Medical records;
(b)
Other documents and records; and
(c)
Any new or additional evidence considered, relied upon, or generated by the MCO in connection with the action.
(7)
Allow a provider or authorized representative acting on behalf of an enrollee to file an appeal with the enrollee’s written consent;
(8)
Consider the enrollee, the enrollee's representative, or the estate representative of a deceased enrollee as parties to the appeal;
(9)
Establish and maintain an expedited review process, when the MCO determines or the provider indicates that taking the time for a standard resolution could seriously jeopardize the enrollee’s life, physical or mental health, or ability to attain, maintain, or regain maximum function; and
(10)
Ensure that punitive action is not taken against a provider who requests an expedited resolution or supports an enrollee’s appeal.
B.
Resolution.
(1)
Except for expedited appeals as described in §C, an MCO shall resolve each appeal and provide notice of resolution, as expeditiously as the enrollee’s health condition requires, and unless extended pursuant to §B(2) of this regulation, within 30 days from the day the MCO receives the appeal.
(2)
The time frames in §B(1) of this regulation may be extended up to 14 calendar days if:
(a)
The enrollee requests the extension; or
(b)
The MCO shows, upon the Department's request, that there is a need for additional information and how the delay is in the enrollee's interest.
(3)
For any extension not requested by the enrollee, the MCO shall:
(a)
Give the enrollee written notice; and
(b)
Make reasonable efforts to give the enrollee verbal notice of the reason for the delay.
(4)
Continuation of Benefits. The MCO shall continue the enrollee’s benefits pending the outcome of the appeal if all of the following occur:
(a)
The enrollee timely files for continuation of benefits;
(b)
The appeal is filed timely, meaning on or before the later of the following:
(i)
Within 10 days of the MCO mailing the notice of action; or
(ii)
The intended effective date of the MCO's proposed action;
(c)
The appeal involves the termination, suspension, or reduction of a previously authorized service;
(d)
The services were ordered by an authorized provider; and
(e)
The authorization period has not expired.
(5)
If the MCO continues or reinstates the enrollee's benefits while the appeal is pending, the benefits shall continue until one of the following occurs:
(a)
The enrollee withdraws the appeal;
(b)
The enrollee fails to request a State fair hearing and continuation of benefits within 10 days after the MCO sends the notice of an adverse resolution to the enrollee’s appeal; or
(c)
A State fair hearing decision adverse to the enrollee is made.
(6)
If the MCO or State fair hearing officer reverses a decision to deny, limit, or delay services, the MCO shall authorize or provide the disputed services promptly and as expeditiously as the enrollee’s health condition requires but no later than 72 hours of the date the MCO receives the reversal.
C.
Expedited Appeals.
(1)
An expedited resolution may be approved when the MCO determines or the provider indicates that taking the time for a standard resolution could seriously jeopardize:
(a)
The enrollee’s life;
(b)
The enrollee’s physical or mental health; or
(c)
The enrollee’s ability to attain, maintain, or regain maximum function.
(2)
Expedited appeals shall be resolved as expeditiously as the enrollee’s health condition requires but no later than 72 hours after the MCO receives the appeal.
(3)
If the MCO denies a request for expedited resolution of an appeal, the MCO shall:
(a)
Transfer the appeal to the standard time frame of not longer than 30 days from the day the MCO receives the appeal with a possible 14-day extension as described in §B(2) of this regulation; and
(b)
Make reasonable efforts to give the enrollee prompt verbal notice of the denial of expedited resolution and provide a written notice within 2 calendar days.
D.
Notification.
(1)
The MCO shall provide written notice of resolution which includes:
(a)
The results and date of the appeal resolution;
(b)
The reasons for the action;
(c)
For decisions not wholly in the enrollee’s favor:
(i)
The right to request a State fair hearing;
(ii)
How to request a State fair hearing;
(iii)
The right to continue to receive benefits pending a hearing;
(iv)
How to request the continuation of benefits; and
(v)
A statement that the enrollee may be liable for the cost of any continued benefits if the MCO's action is upheld in a hearing.
(2)
For notice of an expedited resolution, in addition to requirements listed in §D(1) of this regulation, the MCO shall also make reasonable efforts to provide oral notice of the decision.
E.
If an MCO fails to adhere to the notice and timing requirements, as described in §§A—D of this regulation, the enrollee is deemed to have exhausted the MCO’s appeals process and may initiate a State fair hearing.
F.
State Fair Hearing.
(1)
An enrollee may exercise State fair hearing rights pursuant to the Department’s regulations and State Government Article, §10-201 et seq., Annotated Code of Maryland, subject to the requirements of this regulation.
(2)
An enrollee may request a State fair hearing for an MCO appeal resolution after first exhausting the MCO’s appeal process by appealing to the Office of Administrative Hearings using the process specified in COMAR 10.01.04.
(3)
An enrollee shall file for a State fair hearing within 120 days from the date the MCO provides on the written notice of appeal resolution.
(4)
The parties to an appeal to the Office of Administrative Hearings under this section are the:
(a)
MCO;
(b)
Enrollee; and
(c)
Enrollee’s representative or the personal representative of a deceased enrollee’s estate.
(5)
The MCO shall provide documentation regarding medical determinations to enrollees and the Office of Administrative Hearings as required by COMAR 10.01.04 and other applicable law.
(6)
The MCO shall continue the enrollee’s benefits pending the outcome of the State fair hearing if all of the following occur:
(a)
The enrollee files for continuation of benefits within 10 days of the MCO upholding its action;
(b)
The State fair hearing request is filed timely, meaning on or before the later of the following:
(i)
10 days from the date on the MCO’s notice of appeal resolution; or
(ii)
The intended effective date of the MCO's proposed action;
(c)
The State fair hearing involves the termination, suspension, or reduction of a previously authorized service;
(d)
The services were ordered by an authorized provider; and
(e)
The authorization period has not expired.
(7)
If the MCO continues or reinstates the enrollee's benefits while the State fair hearing is pending, the benefits shall continue until one of the following occurs:
(a)
The enrollee withdraws the State fair hearing; or
(b)
A State fair hearing decision adverse to the enrollee is issued by the Office of Administrative Hearings.
(8)
The final decision of the Office of Administrative Hearings is appealable to the circuit court, and is governed by State Government Article, §10-201 et seq., Annotated Code of Maryland, and the Maryland Rules.
G.
The Department may order an MCO to provide a benefit or service based on its evaluation of the MCO’s action.
Chapter annotations
Authority: Health-General Article, §15-103(b)(9)(i)(4), Annotated Code of Maryland
History: Effective date:
History: Regulations .01—.03 adopted as an emergency provision effective November 8, 1996 (23:25 Md. R. 1730); adopted permanently effective March 10, 1997 (24:5 Md. R. 408)
History: Regulation .01 amended as an emergency provision effective November 1, 2008 (35:24 Md. R. 2069); amended permanently effective February 23, 2009 (36:4 Md. R. 353); December 31, 2018 (45:26 Md. R. 1244)
History: Regulation .02 amended effective June 30, 2008 (35:13 Md. R. 1180); February 26, 2018 (45:4 Md. R. 205); December 31, 2018 (45:26 Md. R. 1244)
History: Regulation .02A, B amended effective October 5, 2009 (36:20 Md. R. 1528)
History: Regulation .02B, C amended as an emergency provision effective November 1, 2008 (35:24 Md. R. 2069); amended permanently effective February 23, 2009 (36:4 Md. R. 353)
History: Regulation .02C amended effective February 2, 2004 (31:2 Md. R. 82)
History: Regulation .02C amended as an emergency provision effective January 5, 2005 (32:6 Md. R. 634); amended permanently effective April 11, 2005 (32:7 Md. R. 679)
History: Regulation .02C amended effective April 19, 2010 (37:8 Md. R. 615)
History: Regulation .02-1 adopted effective December 31, 2018 (45:26 Md. R. 1244)
History: Regulation .03 amended effective June 30, 2008 (35:13 Md. R. 1180)
History: Regulation .03B amended as an emergency provision effective November 1, 2008 (35:24 Md. R. 2069); amended permanently effective February 23, 2009 (36:4 Md. R. 353)
History: Regulation .03B amended effective October 5, 2009 (36:20 Md. R. 1528); December 31, 2018 (45:26 Md. R. 1244)
History: Regulation .03-1 adopted effective April 28, 2014 (41:8 Md. R. 471)
History: Regulation .03-2 adopted effective December 31, 2018 (45:26 Md. R. 1244)
History: Regulation .04 adopted effective June 30, 2008 (35:13 Md. R. 1180)
History: Regulation .04 amended effective February 26, 2018 (45:4 Md. R. 205)
History: Regulation .04B amended effective December 31, 2018 (45:26 Md. R. 1244)
History: Regulation .04D amended effective October 5, 2009 (36:20 Md. R. 1528)
History: Regulation .05 adopted effective June 30, 2008 (35:13 Md. R. 1180)
History: Regulation .05 amended effective February 26, 2018 (45:4 Md. R. 205)
History: Regulation .05A amended as an emergency provision effective November 1, 2008 (35:24 Md. R. 2069); amended permanently effective February 23, 2009 (36:4 Md. R. 353)
History: Regulation .05A amended effective October 5, 2009 (36:20 Md. R. 1528)
History: Regulation .05A, B amended effective December 31, 2018 (45:26 Md. R. 1244)
History: Regulation .05F, G adopted effective December 31, 2018 (45:26 Md. R. 1244)
History: Chapter transferred from COMAR 10.09.71 effective November 1, 2019 (46:22 Md. R. 977)
History: Regulation .03D adopted effective May 18, 2020 (47:10 Md. R. 515)
History: Regulation .04A, D amended effective November 18, 2019 (46:23 Md. R. 1065)
History: Regulation .05A amended effective June 13, 2022 (49:12 Md. R. 641)