Maryland's Appeals and Grievances Law

 

You have the right to appeal denial decisions.

Maryland law gives Maryland consumers the right to appeal a decision that denies you coverage for medically necessary treatment. If your doctor has determined that certain medical treatment is needed, but your HMO or health insurer does not agree, this law allows you to appeal. Under the appeals and grievances law, the Maryland Insurance Commissioner has the authority to overturn your health plan's decision if your treatment is determined to be medically necessary.

How the Appeals and Grievances Process Works

 

Step One

When an HMO or health insurer denies coverage for treatment, it must do so in writing. After an adverse decision or denial, your health plan must give you the details of its internal grievance process so that you can file an appeal with your health plan if you choose.

If you decide to file an appeal, the Maryland Attorney General's Health Care Education and Advocacy Unit will assist you, free-of-charge, in filing your appeal. The Health Education and Advocacy Unit may be reached toll-free at 1-877-261-8807.

Step Two

After you have exhausted your health plan's internal grievance process and if you are still not satisfied with the result, you or your authorized representative may seek assistance from the Maryland Insurance Administration within four months after your health plan's grievance decision. In its written decision, your health plan must provide details on filing a complaint with the Insurance Administration.

Please file your appeals and grievances complaint in writing (see How to File below) and provide copies of all documentation relevant to your case (e.g. denial letter from health plan, medical records, etc.). The Insurance Administration has medical experts who will review your case.

Once the Insurance Administration has concluded its investigation, you will be notified promptly of the final decision. In emergency cases, a decision must be provided within 24 hours.

How to File an Appeals and Grievance Complaint

 

Complaints must be submitted in writing and include a signed consent form. File a complaint to the MIA in writing in one of two ways:

 

Download Forms to be Completed by Hand

These forms should be as complete and detailed as possible and accompanied by copies of any relevant documentation of your complaint. They may be mailed or faxed to the agency as directed below:

  • Life and Health/Appeals and Grievances
    (Includes an Authorization for the release of Medical Information). This is required so that doctors, insurers, and other relevant parties can share your medical information with our investigator in order to make a determination in your case.

Submit a Written Letter
If you choose to just send a letter, please include or provide the following:

  • Your name, address, daytime and evening phone number
  • Name of your insurance company, type of insurance (auto, homeowners, fire, etc.), policy number and claim number (if applicable)
  • Name of any other insurance company, agent, adjuster, etc. involved in your problem (provide as many names and phone numbers as possible)
  • A copy of your health insurance card or your policy.
  • A completed and signed Medical Records Release form (which can be printed above).
  • A detailed explanation of the problem or situation
  • Copies of any documents that you think are important for the investigator to review. Do not send originals.

Mail or fax this information to:

Maryland Insurance Administration
Attn: Consumer Complaint Investigation
Life and Health/Appeals and Grievance
200 St. Paul Place, Suite 2700
Baltimore, MD 21202
Telephone: 410-468-2000 or 1-800-492-6116 TTY: 1-800-735-2258
Fax: 410-468-2270 or 410-468-2260 (Life and Health/Appeals and Grievance)

If you need help filling out these forms or would like to submit them to an agency representative, please visit us at one of our Consumer Outreach locations.

 

The Maryland Insurance Administration's Jurisdiction