Maryland Health Insurance Appeals and Grievances

What is an internal appeal?

An internal appeal—called a grievance under Maryland law—asks the insurance company to reconsider its adverse decision about coverage, payment, or prior authorization.

This is different from external review, where you file a complaint with the Maryland Insurance Administration (MIA) after internal grievance is complete (with exceptions).

General walkthrough: Appeals roadmap. Maryland specifics below.

Maryland appeal timelines

Insurance § 15-10A-02 requires each carrier to maintain an internal grievance process (read statute):

• Standard grievance: final written decision within 30 working days of filing
• Retrospective denial: within 45 working days; grievance may be filed for at least 180 days after the adverse decision
• Emergency grievance: expedited decision often within 24 hours of filing
• Written adverse decision notice within 5 working days, with factual bases, criteria used, and MIA/HEAU contact information
• A health care provider or authorized representative may file on the member's behalf

Missed deadlines = deemed exhaustion

If you do not receive a grievance decision by the 30th working day (subject to agreed extensions), you may file a complaint with the Commissioner (§ 15-10A-02(d)(2)).

Skip internal grievance in limited cases

You may file directly with MIA without a final grievance decision if the carrier waives exhaustion, fails to follow grievance rules, or a compelling reason exists—and in some urgent cases before care is rendered (§ 15-10A-02(d)(1), § 15-10A-03).

How to file

1. Read the adverse decision letter for deadlines, fax, portal, and required forms.
2. Submit the grievance to the carrier in writing when possible.
3. Request expedited review for emergency cases.
4. Contact HEAU for free help mediating or drafting grievances.
5. Keep proof of the filing date.

Carrier links: Maryland prior auth & internal appeals links.

Evidence that helps

• Treating provider letter on medical necessity
• Clinical records and plan medical policy or criteria
• Peer-reviewed literature for experimental/investigational disputes

See Building a strong appeal packet.

HealthChoice appeals

HealthChoice members must usually appeal with their MCO first within 60 days of the notice (MDH — Medicaid appeal). MCO appeals often resolve within 30 days (COMAR 10.67.09.05). If the MCO upholds denial, you may request a state fair hearing—often within 120 days of the MCO resolution notice.

HealthChoice Help Line: 800-284-4510.

After internal appeal

If the carrier upholds denial, keep the final grievance decision letter. It should explain your right to file a complaint with MIA within 4 months.

Next step: Maryland external review (MIA).