Maryland's Insurance Commissioner can order your insurer to pay

A preauthorization cannot be undone after the fact

Maryland closes a door most states leave open. Where a course of treatment has been preauthorized or approved, a private review agent may not retrospectively render an adverse decision on it — and may not revise or modify the criteria or standards used for utilization review in order to reach an adverse decision about services already delivered.

The panel is specified too: an adverse decision requires at least one physician board certified or eligible in the same specialty as the treatment under review, and a grievance decision requires such a physician who is also knowledgeable about the service through actual clinical experience.

• Initial determination on a non-emergency course of treatment: two working days after the agent has the information it needs.
• Preauthorized treatment: no retrospective adverse decision.
• The criteria may not be rewritten after the service was delivered.

Two offices, and what each one does

Maryland splits the work between a regulator and an advocate, which is unusual and useful. The Maryland Insurance Administration takes the complaint, routes the medical question to an independent review organization, and can act on the result. The Health Education and Advocacy Unit sits inside the Office of the Attorney General and works on the consumer's side of the same dispute, for free.

• Maryland Insurance Administration — receives the appeal and grievance complaint and obtains the independent medical review.
• Health Education and Advocacy Unit (Office of the Attorney General) — assists with filing the appeal at no charge, on 1-877-261-8807.
• The independent review organization supplies the medical judgement; the Commissioner acts on it.

The order the Commissioner can issue

This is what separates Maryland from a state where an independent decision simply lands on the carrier. Where the independent medical expert finds that the service the treating provider recommended is medically necessary, the Insurance Commissioner — after considering all the facts of the case — may order the health insurer or HMO to pay for that service in accordance with the policy. The remedy comes from the regulator, with the regulator's authority behind it.

Four months from the grievance decision

Once the plan's internal grievance process is exhausted and the result is still unsatisfactory, the enrollee or an authorised representative may seek the Maryland Insurance Administration's assistance within four months of the plan's grievance decision. The window keys to that decision, so file the internal grievance promptly — the external clock does not start until it ends.

Filing it

1. 1

   Put it in writing

   Maryland asks for the appeals and grievance complaint in writing, with copies of everything relevant — the plan's denial letter and the medical records that support the case.

2. 2

   Send it to the Life and Health unit

   Maryland Insurance Administration, Consumer Complaint Investigation, Life and Health / Appeals and Grievance, 200 St. Paul Place, Suite 2700, Baltimore, MD 21202. Telephone 410-468-2000 or 1-800-492-6116; fax 410-468-2270.

3. 3

   Use the free advocate

   The Attorney General's Health Education and Advocacy Unit assists with the appeal at no cost, toll free on 1-877-261-8807.

4. 4

   Ask for speed where the facts justify it

   Where delay would harm life, health or function — or another compelling reason applies — request expedited handling explicitly rather than leaving it to be inferred.

The internal clocks that run first

Because the external window opens on the grievance decision, the internal timeframes are part of your calendar. On a medical-necessity question, the insurer has 30 working days to decide when the care has not yet been provided, and 45 working days when it has. Knowing which of those applies tells you roughly when the external door opens.

If the reviewer sides with the carrier, there is still a rung left

In most states an adverse external decision ends the administrative road. Maryland keeps one more open: where the independent review organization recommends upholding the carrier's denial, the complainant is notified by mail and told of the right to request a hearing. It is a genuine second look, and it is easy to miss because it arrives inside a letter delivering bad news.

• A carrier must render its final written grievance decision within 30 working days of the grievance being filed.
• In an emergency case that decision must come within 24 hours.
• An adverse recommendation from the independent reviewer carries notice of the right to request a hearing.

What Maryland now requires of prior authorization

Maryland rewrote its utilization-review rules in 2024 (House Bill 932 and Senate Bill 791), and the operative deadlines took effect in January 2026:

• A standard, non-urgent prior-authorization request must be decided within 7 calendar days.
• An urgent request must be decided within 72 hours.
• Carriers must state the reasons for a denial rather than issuing it bare.
• Electronic prior authorization is required by July 1, 2026.
• A 2024 amendment defines step therapy as any protocol requiring a sequence of prescription drugs before coverage — whatever the carrier calls it internally.

What counts as a compelling reason to expedite

Maryland names the circumstances rather than leaving urgency to argument. Expedited review can be requested where a delay could result in death, serious impairment to a bodily function, serious dysfunction of a bodily organ, the patient becoming a threat to themselves or others, or the patient continuing to experience severe withdrawal symptoms. Where one of those fits, say so in those terms.