Department of Budget and Management Health Benefits

Internal Appeals

If a healthcare claim you will be incurring or have incurred is denied, you may contact your insurance carrier using the contact information on your Explanation of Benefits (EOB) form or on the back of your insurance identification card for information on filing an internal appeal. This must be done within 180 days (six months) from the date the claim was denied. If your insurance carrier upholds the denial, you have the right to request an external review (external appeal) of the denial by the Maryland Insurance Administration.

External Appeals

For a claim denied because the service was considered not medically necessary, medically inappropriate or is considered cosmetic, experimental or investigational, you, your representative or a healthcare provider acting on your behalf, may be entitled to request an independent, external review within 120 days (four months) from the date the claim was denied. If you request an external review, the Employee Benefits Division may request the Maryland Insurance Administration (MIA) to review and provide a final, written determination. If MIA decides to overturn the insurance carrier's decision, we will instruct the insurance carrier to provide coverage or payment for your healthcare item or service.

For questions on your rights to external review, contact the Maryland Insurance Administration (MIA):

If a claim is denied because the service was not a covered service and is not eligible for an independent, external review, but you still disagree with the denial, you may contact the Employee Benefits Division for additional review:

Urgent Care Request

If your situation meets the definition of urgent care under the law, a review of your claim will be conducted as expeditiously as possible. An urgent care situation is one in which your health may be in serious jeopardy or, in the opinion of your physician, you may experience pain that cannot be adequately controlled while you wait for a decision on the external review of your claim. If you believe your situation is urgent, you may request an expedited review process by contacting your plan at the phone number listed on the back of your insurance identification card, or you may contact the Maryland Insurance Administration (see above).

Assistance Resources

For questions about your rights or for assistance in filing an appeal, you can contact the Office of Health Insurance Consumer Assistance:

OR

Employee Benefits Security Administration: 1-866-444-3272