Sec. 10.67.09.02. MCO Enrollee Complaint Process

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.