New to helping someone in Maryland?
You do not need a law degree to help someone fight a health insurance denial. Start by gathering three basic documents:
- Insurance card — shows which company administers the plan. Use the name and phone number on the card when you call or file paperwork (it may differ from an employer or clinic name).
- Denial letter or explanation of benefits (EOB)— the notice that says a service was denied, not paid, or needs approval first. Look for appeal instructions and a deadline. On an EOB alone, search for words like "denied," "adverse determination," or "appeal."
- Summary of Benefits and Coverage (SBC) — a plain-language summary of what the plan covers. It helps you tell whether the fight is about medical necessity or whether the benefit exists at all.
Your first tasks: identify what type of plan this is (Marketplace, job-based, Medicaid, Medicare) and write down the appeal deadline from the letter. Missing a deadline is one of the most common reasons people lose appeals they could have won.
Maryland carriers often use terms like adverse decision or grievance decision. You usually appeal first with the insurance company (internal grievance). If that fails, you may file a complaint with the Maryland Insurance Administration (MIA) for independent review.
For steps that work in every state, read these general guides first, then return here for Maryland rules:
- Denial decoder — what the denial letter is actually saying
- Appeals roadmap — internal appeal, then external review
- Building a strong appeal packet — records and letters to gather
What is different in Maryland?
- Maryland Health Connection: Maryland runs its own Marketplace at MarylandHealthConnection.gov. The insurer on your ID card (CareFirst, Kaiser, UnitedHealthcare, Wellpoint, and others) handles PA and grievances.
- Prior authorization (Insurance § 15-10B): Many non-emergency PA decisions within 2 working days after complete information; emergency often 24 hours; mental health emergency inpatient admissions may require a decision within 2 hours.
- Internal grievances (§ 15-10A-02): Written decision often within 30 working days (45 for retrospective denials); emergency grievances often within 24 hours.
- MIA review (§ 15-10A-03): Complaint to the Commissioner within 4 months of an adverse or grievance decision; final decision often within 45 days (or 24 hours for defined emergencies); carrier has burden of proof; Commissioner may use an IRO.
- HealthChoice (Medicaid MCO): Appeal with your MCO first (often 60 days), then state fair hearing—separate from MIA commercial review.
Who is in charge of your plan?
The right agency depends on plan type. When in doubt, call member services and ask whether the plan is "fully insured in Maryland" or "self-funded ERISA."
- Maryland Insurance Administration (MIA): Fully insured health plans, appeals and grievances complaints — insurance.maryland.gov. Consumer line: 800-492-6116 (TTY 800-735-2258).
- Health Education and Advocacy Unit (HEAU): Free help mediating and filing appeals — Maryland Attorney General — HEAU.
- U.S. Department of Labor: Many self-funded employer plans.
- Maryland Department of Health / HealthChoice: Medicaid MCO appeals and fair hearings — MDH — Medicaid appeal, Help Line 800-284-4510.
- CMS: Medicare and Medicare Advantage.
After appeals are exhausted, see Regulator complaints.