Maryland External Review (MIA)

What is external review?

External review in Maryland means asking the Maryland Insurance Administration (MIA)—the Insurance Commissioner—to review a carrier's adverse or grievance decision after internal appeal. For medical necessity disputes, the Commissioner may obtain advice from an independent review organization (IRO) or medical expert (§ 15-10A-05).

The process is in Insurance Article Subtitle 10A, especially § 15-10A-03. The carrier bears the burden of persuasion that its denial was correct.

General overview: Appeals roadmap. Complete Maryland internal appeals first unless an exception applies.

Who can use Maryland review?

External review through MIA generally applies when:

• You have a Maryland-regulated health carrier (insurer, HMO, or nonprofit health service plan)
• The dispute involves medical necessity, experimental/investigational treatment, or similar clinical judgments described in MIA materials
• You exhausted internal grievance—or qualify to skip it (late carrier, urgent case, compelling reason)

Usually does not apply to:

• Self-funded ERISA employer plans
• Medicaid / HealthChoice (MCO appeal and state fair hearing)
• Medicare
• Pure billing or eligibility disputes with no medical-necessity component

Deadlines & exhaustion

Four-month filing window

File a written complaint with the Commissioner within 4 months after you receive an adverse decision or grievance decision (§ 15-10A-03(a)(1)). Coverage appeals under § 15-10D-02 also reference a 4-monthwindow after the carrier's appeal decision.

Exhaust internal grievance first

Normally complete the carrier's internal grievance process (§ 15-10A-02(c)), unless:

• No grievance decision by the 30th working day
• Carrier failed grievance requirements or waived exhaustion
• Urgent medical condition before care is rendered—you may file with MIA without waiting (§ 15-10A-03(b), § 15-10D-02(d))

How to file

1. Complete internal grievance (unless an exception applies) and keep the final denial letter.
2. Gather medical records, the adverse decision, grievance correspondence, and a signed medical records consent if requested.
3. File a written appeals and grievance complaint with MIA:
   • MIA consumer complaint portal
   • MIA — Appeals and grievances
4. Consider contacting HEAU for help preparing the complaint.

Questions: MIA 800-492-6116 or 410-468-2000.

How long it takes

• MIA notifies the carrier within 5 working days of receiving your complaint
• Standard: Commissioner's final decision often within 45 days for pending services or retrospective denials (§ 15-10A-03(c))
• Emergency: expedited procedure for a decision within 24 hours after filing (§ 15-10A-03(b))
• Commissioner may extend up to 30 additional working days if needed records are outstanding

Is the decision binding?

The Commissioner issues a written final decisionon complaints within MIA jurisdiction. You may have a right to request a further hearing under state administrative law to contest the Commissioner's decision (§ 15-10A-03, § 15-10D-02(i)). The carrier must comply with the Commissioner's order for regulated plans.

For ongoing insurer conduct issues, see Regulator complaints.

Medicaid & Medicare

HealthChoice

Medicaid managed care uses MCO appeals and Office of Administrative Hearings fair hearings—not MIA subtitle 10A review (MDH — Medicaid appeal).

Medicare

Use Medicare appeal levels—see Medicare appeals.