Md. Code Regs. 31.10.30.05

Current through Register Vol. 51, No. 24, December 2, 2024

Section 31.10.30.05 - Timing and Notice of an Appeal Determination

A. An insurer shall give written or electronic notice that complies with the standards imposed by 29 CFR § 2520.104b-1(c)(1)(i), (iii), and (iv), of an appeal determination to a covered individual within a reasonable period of time, but not later than 45 days after receipt of an appeal of an adverse benefit determination, unless the 45-day period is extended in accordance with this regulation.

B. Subject to §E of this regulation, the period of time within which an appeal determination shall be made begins at the time an appeal is received, without regard to whether all the information necessary to make an appeal determination accompanies the filing.

C. The initial 45-day time period under §A of this regulation may be extended for a period not to exceed 45 days if the insurer:

(1) Determines that the extension is necessary due to special circumstances; and

(2) Provides the notice required under §D of this regulation to the covered individual prior to the expiration of the initial 45-day period.

D. The notice of an extension under §C of this regulation shall be in writing and include:

(1) A description of the special circumstances requiring the extension of time; and

(2) The date by which the insurer plans to render a decision.

E. If the period of time within which an appeal determination is required to be made is extended under §C of this regulation due to a covered individual's failure to submit information necessary to decide the appeal, the period for making the appeal determination shall be tolled (temporarily suspended) from the date on which the notice of the extension is sent to the covered individual until the date on which the covered individual responds to the request for additional information.

F. The notice of an adverse appeal determination shall include:

(1) The specific reason or reasons for the adverse appeal determination;

(2) A reference to the specific policy provisions on which the adverse appeal determination is based;

(3) A statement that the covered individual is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the covered individual's claim for benefits; and

(4) If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse appeal determination, either:

(a) The specific rule, guideline, protocol, or other similar criterion; or

(b) A statement that:

(i) An internal rule, guideline, protocol, or other similar criterion was relied on in making the adverse appeal determination; and

(ii) A copy of the rule, guideline, protocol, or other similar criterion will be provided on request free of charge to the covered individual;

(5) The address, telephone number, and facsimile number of the Commissioner; and

(6) A discussion of the decision, including an explanation of the basis for disagreeing with or not following:

(a) The views presented by the covered individual to the insurer of health care professionals treating the covered individual and vocational professionals who evaluated the covered individual;

(b) The views of medical or vocational experts whose advice was obtained on behalf of the insurer in connection with a covered individual's adverse appeal determination, without regard to whether the advice was relied upon in making the appeal determination; and

(c) A disability determination regarding the covered individual presented by the covered individual to the insurer made by the Social Security Administration.

G. An insurer shall provide access to, and copies of, documents, records, and other information described in §F(3) and (4) of this regulation.

H. The notice of an adverse appeal determination shall be provided in a culturally and linguistically appropriate manner.

I. An insurer is considered to provide relevant notices in a culturally and linguistically appropriate manner if:

(1) The insurer provides oral language services, such as a telephone customer assistance hotline, that include answering questions in any applicable non-English language and providing assistance with filing claims and appeals in any applicable non-English language;

(2) The insurer provides, upon request, a notice in any applicable non-English language; and

(3) The insurer includes in the English version of all notices a statement prominently displayed in any applicable non-English language, clearly indicating how to access the language services provided by the insurer.

J. With respect to an address in any United States county to which a notice is sent, a non-English language is an applicable non-English language if 10 percent or more of the population residing in the county is literate only in the same non-English language, as determined in guidance published by the U.S. Secretary of Labor.

Md. Code Regs. 31.10.30.05

Regulation .05 amended effective 51:7 Md. R. 321-354, eff. 4/15/2024.