Md. Code Regs. 10.67.09.03

Current through Register Vol. 51, No. 25, December 13, 2024

Section 10.67.09.03 - MCO Provider Complaint Process

A. An MCO shall have a complaint procedure for providers that is:

(1) Documented in writing;

(2) Disseminated in writing to all of the MCO's providers at the time they join the MCO's provider panel, and furnished to a provider at any time, upon request; and

(3) Linked to the MCO's internal quality assurance program.

B. An MCO shall include in its provider complaint process at least the following elements:

(1) Procedures for registering and responding to provider grievances in a timely fashion, including standards for timeliness that recognize the need for expedited determinations in situations that are time-sensitive, that is, when an enrollee's treatment outcome may be significantly affected by the promptness of treatment, as set forth in Regulation .02C(1)(a) and (b) of this chapter apply;

(2) Notification to the provider of an MCO's determination that affects the provider or that provider's patient, which includes a description of how to file an internal appeal with the MCO;

(3) Documentation of the substance of complaints and steps taken;

(4) Procedures to ensure the timely resolution of the complaint and response by the MCO to the provider;

(5) Procedures for the termination or withdrawal of a provider from the MCO's provider panel, including:

(a) At least 90 days prior notice to the primary care providers in the MCO's provider panel of the MCO's termination of a specialty services provider when the reason for the termination is unrelated to fraud, patient abuse, incompetency, or loss of licensure status;

(b) If possible, at least 90 days prior notice to the primary care providers in the MCO's provider panel of a specialty services provider's withdrawal from the MCO's provider panel; and

(c) Notices to primary care providers informing them of the enrollee's right to change MCOs as described in COMAR 10.67.63.06A(1)(e).

(6) Mechanisms to aggregate and analyze appeal and grievance data and to use the data for quality improvement;

(7) An appeal process which:

(a) Is available when the provider's appeal or grievance is not resolved to the provider's satisfaction, or when the MCO acts to reduce, suspend, or terminate provider's privileges with the MCO;

(b) Acknowledges receipt of provider appeals within 5 business days of receipt by the MCO;

(c) Allows providers 90 business days from the date of a denial to file an initial appeal;

(d) Allows providers at least 15 business days from the date of denial to file each subsequent level of appeal;

(e) Resolves appeals, regardless of the number of appeal levels allowed by the MCO, within 90 business days of receipt of the initial appeal by the MCO;

(f) Pays claim within 30 days of the appeal decision when a claim denial is overturned;

(g) Provides at its final level an opportunity for the provider to be heard by the MCO's chief executive officer, or the chief executive officer's designee;

(h) Provides timely written notice to the provider of the results of the internal appeal; and

(i) Provides for written notice of the substance of the dispute and the result of the internal appeal to appropriate quality assurance committees and departments within the MCO; and

(8) A protocol for transmitting provider appeal and grievance reports and aggregate provider grievance and appeal data to the Department when requested.

C. An MCO may not take any punitive action against a provider for utilizing the MCO provider complaint process, for supporting an enrollee's appeal, or for requesting expedited resolution for an enrollee's appeal.

D. An MCO or its pharmacy benefits manager shall resolve pharmacy appeals concerning drug pricing within 21 days of the receipt of a request.

Md. Code Regs. 10.67.09.03

Regulations .03 recodified from 10.09.71.03 effective 46:22 Md. R. 976, eff. 11/1/2019; amended effective 47:10 Md. R. 515, eff. 5/18/2020