Health Claim Denials

The MIA website has a two-part video series (also available on Apple podcast) on how to handle Health Claim Denials:

1. Medical Necessity & Emergency Appeals Hotline:  Call 1-800-492-6116 for immediate help with insurance concerns involving physical care and mental health and substance use disorder care 24/7, 365 days a year.
2. Filing an appeal: The Maryland Attorney General’s Health Education and Advocacy Unit will assist free-of-charge with filing appeals. Call toll-free at 1-877-261-8807.

Take Action on Coverage Denials!

The 1998 “Appeals and Grievance Law” (Health General 19-705.2 and Commercial Law Articles 12-4A-04 and 13-4A-02) assists patients in appealing adverse decisions made by their insurance companies. The law empowers two different state agencies to assist patients when they feel they have been denied coverage for needed medical care.  Under the law, carriers must provide their members with a written copy of an adverse decision within five days of its being made. The decision must clearly state the exact factual basis for the carrier’s decision, including the specific criteria the company used in making its decision.  Click here for a complete summary of Maryland Grievance Law.

Patients and psychiatrists are encouraged to take advantage of the opportunity to file complaints if a carrier denies coverage and peer-to-peer fails, or if the peer-to-peer resolution is not satisfactory.  The Health Education and Advocacy Unit of the Maryland Attorney General’s Office (HEAU) can assist with filing an appeal through the carrier’s internal process, or with filing a complaint with the Maryland Insurance Administration (MIA) or other external reviewer.  If it is an emergency and care has not been provided yet, a complaint can be filed without first going through the carrier’s process.

• For the HEAU, please refer to the patient information sheet, review the provider filing information, and click here to choose an HEAU online complaint form. For assistance by phone, call toll free 877-261-8807 or email heau@oag.state.md.us.

• For the MIA, find out what to do if a carrier denies an emergency inpatient admission; review how the MIA assists with denials involving opioid use disorder; and read the MIA consumer guide to mental health and substance use coverage. The guide addresses steps to take in the appeals and grievance process.  For assistance by phone, call toll free 800-492-6116.

In November 2017, Maryland Attorney General Frosh announced that the Health Education Advocacy Unit, within the Consumer Protection Division, closed 2,487 cases in Fiscal Year 2017, assisting patients in saving or recovering nearly $3.7 million. This news comes from one of three sets of data included in the comprehensive Annual Report on the Health Insurance Carrier Appeals and Grievances Process that was submitted to the Governor and General Assembly.

Important note regarding MIA jurisdiction

The Maryland Insurance Administration (MIA) has authority to regulate (i.e. license, review rates and policies, review financial statements, investigate complaints, conduct examinations and issue orders/penalties) all insurance companies, producers, and HMOs licensed to conduct business in Maryland.  Maryland law generally does not apply to insurance contracts (or policies) issued in other states. For example, if a policy was issued in Virginia, then Virginia law applies to the coverage. In these instances, to contact the regulator in the applicable state for assistance – see map of states and jurisdictions.

In addition, self-funded employer plans fall outside MIA’s jurisdiction. Self-funded plans are those where the employer pays medical expenses, rather than contracting with a health plan to do so. The U.S. Department of Labor Employee Benefits Security Administration regulates self-funded plans and has the authority to investigate and resolve complaints.

Also, the MIA does not have jurisdiction over federal programs such as the Federal Employee Health Benefit Program (FEHBP), Medicare, Medicaid, Workers Compensation and Social Security.