Common use of FILING OF COMPLAINT AFTER RECEIPT OF NOTIFICATION OF GRIEVANCE DECISIONS OR APPEAL DECISIONS Clause in Contracts

FILING OF COMPLAINT AFTER RECEIPT OF NOTIFICATION OF GRIEVANCE DECISIONS OR APPEAL DECISIONS. 1. Within 4 months after the date of receipt of an Appeal Decision or a Grievance Decision, a Member, the Member’s Representative or Health Care Provider acting on behalf of the Member may file a Complaint with the Commissioner for review of the Grievance Decision or Appeal Decision. 2. A Member, the Member’s Representative or Health Care Provider acting on behalf of the Member may file a Complaint without first exhausting the Plan’s internal Grievance or Appeals process if: a. In the case of an Adverse Decision: SAMPLE i. The Plan or the Plan’s Designee waives the requirement that the internal Grievance process be exhausted before filing a Complaint with the Commissioner; ii. The Plan or the Plan’s Designee has failed to comply with any of the requirements of the internal Grievance process; iii. The Member, the Member’s Representative or Health Care Provider acting on behalf of the Member provides sufficient information and supporting documentation in the Complaint to demonstrate a Compelling Reason. b. In the case of a Coverage Decision, the Complaint involves an Urgent Medical Condition for which care has not been rendered. 3. The remaining provisions of this paragraph K. apply to Complaints regarding Adverse Decisions and Grievance Decisions. a. The Commissioner shall notify the Plan or the Plan’s Designee of the Complaint within five working days after the date the Complaint is filed with the Commissioner. b. Except for an Emergency Case (Claim Involving Urgent Care), the Plan or the Plan’s Designee shall provide to the Commissioner any information requested by the Commissioner no later than seven working days from the date the Plan or the Plan’s Designee receives the request for information. 4. a. Except as provided in paragraph K.4.b below, the Commissioner shall make a final decision on a Complaint: i. Within 45 days after a Complaint is filed regarding a Pre-Service Claim; ii. Within 45 days after a Complaint is filed regarding a Post-Service Claim; and iii. Within 24 hours after a Complaint is filed regarding a Claim Involving Urgent Care.

FILING OF COMPLAINT AFTER RECEIPT OF NOTIFICATION OF GRIEVANCE DECISIONS OR APPEAL DECISIONS. 1. Within 4 months after the date of receipt of an Appeal Decision or a Grievance Decision, a Member, the Member’s Representative or Health Care Provider acting on behalf of the Member may file a Complaint with the Commissioner for review of the Grievance Decision or Appeal Decision. 2. A Member, the Member’s Representative or Health Care Provider acting on behalf of the Member may file a Complaint without first exhausting the Plan’s internal Grievance or Appeals process if: a. In the case of an Adverse Decision: SAMPLE: i. The Plan or the Plan’s Designee waives the requirement that the internal Grievance process be exhausted before filing a Complaint with the Commissioner; ii. The Plan or the Plan’s Designee has failed to comply with any of the requirements of the internal Grievance process; iii. The Member, the Member’s Representative or Health Care Provider acting on behalf of the Member provides sufficient information and supporting documentation in the Complaint to demonstrate a Compelling Reason. b. In the case of a Coverage Decision, the Complaint involves an Urgent Medical Condition for which care has not been rendered. 3. The remaining provisions of this paragraph K. apply to Complaints regarding Adverse Decisions and Grievance Decisions. a. The Commissioner shall notify the Plan or the Plan’s Designee of the Complaint within five working days after the date the Complaint is filed with the Commissioner. b. Except for an Emergency Case (Claim Involving Urgent Care), the Plan or the Plan’s Designee shall provide to the Commissioner any information requested by the Commissioner no later than seven working days from the date the Plan or the Plan’s Designee receives the request for information. 4. a. Except as provided in paragraph K.4.b below, the Commissioner shall make a final decision on a Complaint: i. a. Within 45 days after a Complaint is filed regarding a Pre-Service Claim; ii. b. Within 45 days after a Complaint is filed regarding a Post-Service Claim; and iii. c. Within 24 hours after a Complaint is filed regarding a Claim Involving Urgent Care. The Commissioner may extend the period within which a final decision is to be made under paragraph.K.4.a. for up to an additional 30 working days if: a. the Commissioner has not yet received information requested by the Commissioner; and b. the information requested is necessary for the Commissioner to render a final decision on the Complaint. 5. The Commissioner shall seek advice from an independent review organization or medical expert for Complaints filed with the Commissioner that involve a question of whether a Pre-Service Claim or a Post-Service Claim is Medically Necessary. The Commissioner shall select an independent review organization or medical expert to advise on the Complaint in the manner set forth in Section 15-10A-05 of the Insurance Article. 6. The Plan shall have the burden of persuasion that its Adverse Decision or Grievance Decision, as applicable, is correct during the review of a Complaint by the Commissioner or Designee of the Commissioner, and in any hearing held regarding the Complaint. 7. As part of the review of a Complaint, the Commissioner or Designee of the Commissioner may consider all of the facts of the case and any other evidence deemed Relevant. 8. Except as provided below, in responding to a Complaint, the Plan may not rely on any basis not stated in its Adverse Benefit Determination. a. The Commissioner may allow the Plan, a Member, the Member’s Representative or Health Care Provider acting on behalf of the Member to provide additional information as may be relevant for the Commissioner to make a final decision on the Complaint. b. The Commissioner shall allow the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member at least 5 working days to provide the additional information. c. The Commissioner’s use of additional information may not delay the Commissioner’s decision on the Complaint by more than five working days. 9. The Commissioner may request the Member 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 Designee of the Commissioner that are needed in order for the Commissioner to make a final decision on the Complaint. 10. Subject to paragraphs H, a Member, the Member’s Representative or Health Care Provider acting on behalf of the Member may file a Complaint with the Commissioner if the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member does not receive the Plan’s Grievance Decision within the following timeframes: a. Within 30 days after the filing date of a Grievance regarding a Pre-Service Claim; b. Within 45 working days after the filing date of a Grievance regarding a Post- Service Claim; and c. Within 24 hours after the receipt of a Grievance regarding a Claim Involving Urgent Care. Note: the Health Advocacy Unit is available to assist the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member in both mediating and filing a Grievance. Contact the Health Advocacy Unit at: E-mail: xxxx@xxx.xxxxx.xx.xx

FILING OF COMPLAINT AFTER RECEIPT OF NOTIFICATION OF GRIEVANCE DECISIONS OR APPEAL DECISIONS. 1. Within 4 months after the date of receipt of an Appeal Decision or a Grievance Decision, a Member, the Member’s 's Representative or Health Care Provider acting on behalf of the Member may file a Complaint with the Commissioner for review of the Grievance Decision or Appeal Decision. 2. A Member, the Member’s 's Representative or Health Care Provider acting on behalf of the Member may file a Complaint without first exhausting the Plan’s 's internal Grievance or Appeals process if: a. In the case of an Adverse Decision: SAMPLE: i. The Plan or the Plan’s 's Designee waives the requirement that the internal Grievance process be exhausted before filing a Complaint with the Commissioner; ii. The Plan or the Plan’s 's Designee has failed to comply with any of the requirements of the internal Grievance process; iii. The Member, the Member’s 's Representative or Health Care Provider acting on behalf of the Member provides sufficient information and supporting documentation in the Complaint to demonstrate a Compelling Reason. b. In the case of a Coverage Decision, the Complaint involves an Urgent Medical Condition for which care has not been rendered. 3. The remaining provisions of this paragraph K. apply to Complaints regarding Adverse Decisions and Grievance Decisions. a. The Commissioner shall notify the Plan or the Plan’s 's Designee of the Complaint within five working days after the date the Complaint is filed with the Commissioner. b. Except for an Emergency Case (Claim Involving Urgent Care), the Plan or the Plan’s 's Designee shall provide to the Commissioner any information requested by the Commissioner no later than seven working days from the date the Plan or the Plan’s 's Designee receives the request for information. 4. a. Except as provided in paragraph K.4.b below, the Commissioner shall make a final decision on a Complaint: i. Within 45 days after a Complaint is filed regarding a Pre-Service Claim; ii. Within 45 days after a Complaint is filed regarding a Post-Service Claim; and iii. Within 24 hours after a Complaint is filed regarding a Claim Involving Urgent Care.

FILING OF COMPLAINT AFTER RECEIPT OF NOTIFICATION OF GRIEVANCE DECISIONS OR APPEAL DECISIONS. 1. Within 4 months after the date of receipt of an Appeal Decision or a Grievance Decision, a Member, the Member’s 's Representative or Health Care Provider acting on behalf of the Member may file a Complaint with the Commissioner for review of the Grievance Decision or Appeal Decision.. SAMPLE 2. A Member, the Member’s 's Representative or Health Care Provider acting on behalf of the Member may file a Complaint without first exhausting the Plan’s 's internal Grievance or Appeals process if: a. In the case of an Adverse Decision: SAMPLE: i. The Plan or the Plan’s 's Designee waives the requirement that the internal Grievance process be exhausted before filing a Complaint with the Commissioner; ii. The Plan or the Plan’s 's Designee has failed to comply with any of the requirements of the internal Grievance process; iii. The Member, the Member’s 's Representative or Health Care Provider acting on behalf of the Member provides sufficient information and supporting documentation in the Complaint to demonstrate a Compelling Reason. b. In the case of a Coverage Decision, the Complaint involves an Urgent Medical Condition for which care has not been rendered. 3. The remaining provisions of this paragraph K. apply to Complaints regarding Adverse Decisions and Grievance Decisions. a. The Commissioner shall notify the Plan or the Plan’s 's Designee of the Complaint within five working days after the date the Complaint is filed with the Commissioner. b. Except for an Emergency Case (Claim Involving Urgent Care), the Plan or the Plan’s 's Designee shall provide to the Commissioner any information requested by the Commissioner no later than seven working days from the date the Plan or the Plan’s 's Designee receives the request for information. 4. a. Except as provided in paragraph K.4.b below, the Commissioner shall make a final decision on a Complaint: : i. Within 45 days after a Complaint is filed regarding a Pre-Service Claim; ii. Within 45 days after a Complaint is filed regarding a Post-Service Claim; and iii. Within 24 hours after a Complaint is filed regarding a Claim Involving Urgent Care.