Maryland

If your insurer denies your claim, you have the right to submit an internal grievance with your health insurer.^[1] This means you can ask your insurer to conduct a full and fair review of its decision. To file a grievance, you should do the following:

• Review the determination letter. Your insurer should have sent you a determination letter to tell you that it would not cover your claim. Review this document to understand why your insurer denied your claim and how to file a grievance regarding the denial.
• Collect information. In addition to the determination letter, collect all the documents your insurer sent to you, including your insurance policy and your insurer’s medical necessity criteria. “Medical necessity criteria” refers to your insurer’s policy for determining whether a treatment or service is necessary for your condition.
• Request documents. If your insurer did not send you the determination letter, your policy, the medical necessity criteria, or instructions and forms for filing a grievance, call your insurer and request these documents.
• Call your health care provider’s office. Contact your health care provider’s office to ask for help with the grievance process. Someone in his or her office might help you fill out the forms to file a grievance and draft a strong appeal letter.
• Seek assistance from the state. If you would like additional help with the grievance process, you can contact the Maryland Attorney General’s Health Care Education and Advocacy Unit (“Unit”). The Unit will assist you, free-of-charge, with filing your appeal. You can reach the Unit at (877) 261-8807.^[2]
• Submit the appeal request. You or someone in your health care provider’s office should submit the grievance forms along with the letter from your health care provider and any additional information that your insurer requested. This should be done within six months from the date the claim was denied. Be sure to follow your insurer’s instructions closely and make a copy for your own records of all documents you or your health care provider submitted to the insurer.
• Ask for an expedited procedure, if applicable. You can request an expedited internal grievance procedure in emergency situations.^[3] Your situation is an emergency situation if your life or health would be in serious jeopardy or you would be a danger to yourself or others if you do not receive the requested treatment immediately.^[4]
• Follow up. Follow up with your insurer regularly until you hear back. Be sure to keep a record of the name of any representative you speak with about the appeal, the date and time you spoke with that person, a confirmation number for the call, and a summary of your discussion.

The internal grievance process should take a maximum of 30 business days if you have not yet received the requested treatment or service. It should take a maximum of 45 business days if you have received the requested service but payment has been denied. If you choose to do so, you can give your insurer an extension of up to an additional 30 business days.^[5]

If you request an expedited procedure, the process should take no more than 24 hours from the time you filed your request.^[6]

During an external review, an independent third party reviews your insurer’s decision.^[7] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim.

 You are entitled to an external review in the following circumstances:

• Your insurer denies your coverage after an internal appeal because your insurer determined your claim was not medically necessary, medically inappropriate, or is considered cosmetic, experimental or investigational; or
• Your medical situation is urgent and waiting would jeopardize your life or ability to function.

Please note that if your situation is urgent, you do not need to wait for a decision from your insurer on the internal grievance. You can request an expedited external review while you request an expedited internal grievance from your insurer.

You should submit your request for external review to the Maryland Insurance Administration (“Administration”) within 120 days from the date that the claim was denied.^[8]

How to submit a standard external review request. You should mail a written request to the Administration. You should include any new information and documentation that you did not previously include with your internal grievance request. For information on properly submitting a request, you should contact:^[9]

Maryland Insurance Administration
Attn: Appeals and Grievance Unit
200 St. Paul Place, Suite 2700
Baltimore, MD 21202
(410) 468-2000 or 1-800-492-6116

How to submit an expedited external review request. If you are requesting a standard external review for urgent care, you should contact your health insurer at the phone number on the back of your insurance card. You can also contact the Administration by phone at (410) 468-2000 or (800) 492-6116, by fax at (410) 468-2270, or at the following address to request assistance:

Maryland Insurance Administration
Attn: Appeals and Grievance Unit
200 St. Paul Place, Suite 2700
Baltimore, MD 21202^[10]

The external review process should take no more than 60 days. If you requested an expedited external review, the process should take no longer than four business days after your request is received.^[11]

If your insurer denied your claim because your plan does not cover the treatment or service, and you do not qualify for an external review, you still have another option. You can contact the Employee Benefits Division (“Division”) to request an additional review of your health insurer’s decision.^[12] The Employee Benefits Division can be reached by phone at (410) 767-4775 or (800) 307-8283, by fax at (410) 333-7104, or by mail at the following address:

Employee Benefits Division
Attn: Adverse Determinations
301 West Preston Street, Room 510
Baltimore, MD 21201^[13]

The Administration protects consumers from illegal insurance practices.^[14] If you are a Maryland resident and you believe your insurer did something illegal, you can file a complaint with the Administration.

Information. You can find a copy of the complaint form here. Your complaint should include the following information:

• The name, address, email address, telephone number, and relationship to insured/patient of the person filing the complaint (“Complainant”);
• The name, address, email address, and telephone number of the insured/patient, if different than Complainant;
• The name of the insurance company;
• If a group plan, the name of the group policyholder;
• Policy or member identification number, claim number, date of claim;
• If an employer-provided policy, the name and address of the employer;
• The name, address, and telephone number of the treating health care provider;
• A brief explanation of the problem; and
• What you consider a fair resolution.^[15]

Supporting documents. You should include the following supporting documents with your complaint:

• A signed medical record release form (included with the complaint packet);
• A copy of your insurance card;
• Copies of coverage denials or adverse benefit determinations from your insurer;
• Copies of any determinations made by internal and external reviewers;
• Any materials submitted with prior appeals and complaints;
• Supporting documentation from your health care provider;
• A copy of your insurance policy; and
• All responses from your insurer.^[16]

 How to submit. You should submit your complaint and the supporting documents by fax to (410) 468-2260 or by mail to:^[17]

Maryland Insurance Administration
Attn.: Consumer Complaint Investigation
200 St. Paul Place, Suite 2700
Baltimore, MD 21202

After the Administration receives your complaint, a representative will investigate. The process can take a few months to complete.^[18] At the end of the representative’s investigation, the Commissioner of Insurance may require the health insurer to stop inappropriate conduct, fulfill its contractual obligations, or provide the service or treatment that was denied. The Commissioner can also require the insurer to pay a penalty or fine.^[19]

If you file a complaint with the Administration, you can reach the agency at (410) 468-2000 or (800) 492-6116. The Administration is open from 8:00 a.m. to 5:00 p.m., Monday through Friday. You can also reach the agency after hours if you have an emergency medical situation.

You can also file a complaint with the Maryland Attorney General’s Office, either at the same time you file a complaint with the Maryland Insurance Administration or in lieu of filing a complaint with the Administration.

Complaint information. You can find a copy of the complaint form here. Your complaint should include the following information:

• The name, address, email address, telephone number, and date of birth of the patient;
• The name, address, email address, telephone number, and relationship to patient of the person filing the complaint (“Complainant”);
• The name of the insured individual, if different than the Complainant;
• The name of insurance company;
• The group name or number, membership number, and date appeal was filed with your health insurer;
• The name, business address, telephone number, and email address of your health care provider;
• The name, address, telephone number, and email address of any other health care providers involved in your case;
• Whether the patient has received service or care;
• A description of the complaint; and
• What you consider to be a fair resolution of the complaint.^[20]

Supporting documents. You should submit the following supporting documents with your complaint:

• Signed authorization to release medical information (in the complaint packet);
• A copy of the confirmation page you received after submitting your complaint online (if you submitted your complaint online);
• A copy of any bills, records, or correspondence related to your complaint;
• A copy of any correspondence from the health insurer related to the complaint;
• A copy of your insurance card;
• Copies of coverage denials or adverse benefit determinations from your insurer;
• Copies of any determinations made by internal and external reviewers;
• Any materials submitted with prior appeals and complaints;
• Supporting documentation from your health care provider;
• A copy of your insurance policy; and
• All responses from your insurer.^[21]

How to submit. The complaint may be submitted online here, faxed to (410) 576-6571, or mailed to the following address:

Office of the Attorney General
Consumer Protection Division
Health Education and Advocacy Unit
200 St. Paul Place, 16^th Floor
Baltimore, MD 21202^[22]

Once the Attorney General’s Office receives your complaint, the representative will review the complaint and ensure that it is the best agency to handle it.^[23] If the Attorney General’s Office determines that your complaint would be better handled by another agency, it will forward your complaint to that agency.^[24] Otherwise, the Attorney General’s Health Education and Advocacy Unit will assign your complaint to a mediator who will then mediate the issues between you and your health insurer.^[25] During the mediation process, the Attorney General’s Office cannot compel your health insurer to take any action.^[26] If you are unable to come to an agreement during mediation, you can agree to submit to binding arbitration or file a complaint in state court.^[27]

You can contact the Maryland Attorney General’s Office at (410) 528-1840 or (877) 261-8807. The Office is open from 9:00 a.m. to 4:30 p.m. Monday through Friday.