Whom to contact:

Maryland Insurance Administration (MIA)

Who can appeal:

You, your provider (with consent), or your health plan

What you can appeal:

Denials of coverage for services the health plan determines are not medically necessary or are experimental or investigational. There is also a separate appeals process for coverage decisions.

When you can appeal:

After denial for medical necessity has been appealed through the health plan’s internal process, you must file within 30 working days from receipt of the final adverse determination. If there is a compelling reason as determined by the MIA, you may go directly to the MIA.

After denial of a coverage decision has been appealed through the health plan’s internal process, you must file within 60 working days from receipt of the final appeal decision, except for an urgent medical condition.

What to send:

A written appeals and grievances complaint, including copies of all relevant documentation, such as the denial letter from the health plan and pertinent medical records.

What you must pay:

No charge

What will happen:

For a medical necessity appeal:

• The MIA will notify your health plan within 5 working days after receiving your request.
• Your health plan will provide all pertinent information within 7 working days of notification.
• The MIA may seek advice from an independent review organization.
• The MIA will investigate your case and return a final decision.

When you will get a decision:

For medical necessity: Within 30 working days of filing a complaint with the MIA if the service has not been provided; within 45 working days if the service has already been provided. The deadline may be extended up to an additional 30 working days if the pertinent information has not been received or it is necessary.

For coverage decisions: The time requirement for investigation may vary.

In urgent situations:

For expedited reviews you will receive a response within 24 hours. If your appeal "involves compelling circumstances" you may skip the health plan’s internal process and file directly with the MIA.