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State guide

Maryland

Pick the kind of plan you have to see who to call first. Maryland can only help with plans it regulates.

On this page 8

Which plan do you have? Who to call first, by coverage

The short version for Maryland

Maryland's outside review is a complaint to the Maryland Insurance Administration, which consults an independent review organization or medical expert, and the insurer carries the burden of proving its denial was right. The Attorney General's Health Education and Advocacy Unit helps for free. In fiscal year 2026 the Insurance Administration changed or reversed the insurer's decision (or the insurer reversed itself) in 68% of the cases it investigated.

At a glance: independent review for plans Maryland regulates

This box is for insurance you buy, or an employer plan bought from an insurer. It is not for Medicaid, Medicare or a plan your employer funds itself.

Main regulator
Maryland Insurance Administration (MIA) · 410-468-2000 or 1-800-492-6116
Independent review
A state process (Complaint to the Maryland Insurance Administration under the Appeals and Grievances Law)
Deadline to request it
4 months after you receive the health plan's grievance (internal appeal) decision
Cost
No fee is mentioned on the official pages or in the statute section reviewed
Decision time
45 days after the complaint is filed (can be extended up to 30 working days if requested information is still missing); fast track: 24 hours in emergency cases

Your own notice states the deadline and process for your plan, and controls if it differs. Plans your state does not regulate (for example job-based plans the employer funds itself) follow federal rules; see who regulates your plan.

Who regulates health plans

The Maryland Insurance Administration does not regulate employer self-funded plans (the employer pays the medical costs even if an insurance company runs the plan); those complaints go to the United States Department of Labor. Policies issued in another state are usually governed by that state. If your Medicaid card has the letters MDH on it, file with the Maryland Department of Health instead.

Independent (external) review

Process
A state process. Run by Maryland Insurance Administration, which seeks advice from an independent review organization or medical expert on medical necessity cases.
Where you file
regulator
How
File a complaint with the Maryland Insurance Administration through its secure online portal, by email to agcomplaints.mia@maryland.gov, or by mailing or faxing (410-468-2270) the complaint form with your denial letters and a signed medical records release.
Which denials qualify
Decisions that a service is not medically necessary, including cosmetic, dental, experimental or investigational, pre-authorization and prescription denials. Coverage (contract) decisions can also be the subject of a complaint.
Appeal to the plan first?
Generally yes. You can go straight to the Insurance Administration if care has not yet been provided and you have a compelling reason, meaning delay could cause loss of life, serious impairment of a bodily function, serious dysfunction of an organ, the member remaining seriously mentally ill or using intoxicating substances with symptoms that make them a danger to self or others, or continued severe withdrawal symptoms.
Published results
Fiscal year 2026: the Maryland Insurance Administration modified or reversed the carrier's grievance decision, or the carrier reversed itself during the review, in 68% of cases (549 complaints investigated). When consumers challenged denials inside the plan, carriers overturned or modified 52%. Source

Official page Request form

General rules and what to send: how external review works, how to request it.

Free help in Maryland

Medicare and Medicaid in Maryland

Medicare counseling
Maryland State Health Insurance Assistance Program (SHIP) · 1-800-243-3425 . Free help with Medicare appeals.
Medicaid agency
Maryland Department of Health (Maryland Medicaid; the managed care program is called HealthChoice). Hearings are held by the Office of Administrative Hearings.
Fair hearing deadline
120 days from the managed care plan's written appeal decision; 90 days from the notice if the service was denied by the fee-for-service program. Your notice states the deadline that applies to you.
Good to know
If you are in a HealthChoice plan you must appeal to the plan first, within 60 days of the date on its denial notice. To keep services that are being cut, ask within 10 days of the plan's appeal decision. The HealthChoice Help Line (1-800-284-4510) explains how to ask for a State fair hearing and can ask the Department to review the plan's decision.

Medicaid appeals page How Medicaid appeals work

State laws that can help

  • Denial notice. A denial letter must explain in clear language the specific facts and criteria behind the decision (not just 'not medically necessary'), name who made it, and tell you how to appeal, how to complain to the Insurance Administration within 4 months, and how to reach the Health Education and Advocacy Unit.

    Maryland Insurance Article, section 15-10A-02

  • External review. When you complain to the Insurance Commissioner, the insurer has the burden of persuasion that its denial was correct, and the Commissioner must decide within 45 days (24 hours in emergencies).

    Maryland Insurance Article, section 15-10A-03

  • Step therapy. Insurers cannot require step therapy in listed situations (for example a drug that worked for you in the past 180 days) and must grant an exception when the required drug is contraindicated, expected not to work, already tried and failed, or you are stable on your current drug; denials can be appealed.

    Maryland Insurance Article, section 15-142

  • AI in utilization review. Insurers that use artificial intelligence or algorithms in coverage reviews must base decisions on your own clinical record rather than only group data, and the tool cannot replace the health care provider who must make the decision.

    Maryland Insurance Article, section 15-10B-05.1 (House Bill 820 of 2025)

State laws usually reach only plans your state regulates. They often do not reach job-based plans the employer funds itself.

Sources and what we could not confirm

Read from official pages on . Phone numbers and deadlines change; check the official page before you rely on one.

  1. Appeals and Grievances (Maryland Insurance Administration)
  2. File A Complaint (Maryland Insurance Administration)
  3. MIA Jurisdiction (Maryland Insurance Administration)
  4. Health Education and Advocacy Unit (Attorney General of Maryland)
  5. Health Billing & Insurance Complaints (Attorney General of Maryland)
  6. Health Education and Advocacy Unit Annual Report, Fiscal Year 2026
  7. COMAR 10.01.04.04 Request for Fair Hearing
  8. COMAR 10.67.09.05 MCO Appeal Process for Enrollees
  9. State Health Insurance Assistance Program (Maryland Department of Aging)
  10. CMS: State External Appeals Review Processes
Not confirmed (5)
  • The cost of independent review. no fee is mentioned on the Insurance Administration pages or in section 15-10A-03, but no page states outright that the complaint is free
  • Who runs the independent review. the consumer page says the Administration's medical experts review the case, while the statute says it must seek advice from an independent review organization or medical expert
  • The Medicare counseling program's phone number. statewide number taken from the federal SHIP directory (shiphelp.org); the state page lists county office numbers
  • The Medicaid fair hearing page. page found in search results with matching content but not fully loaded; deadlines come from Maryland regulations (COMAR 10.01.04.04 and 10.67.09.05) and the state's model appeal notice
  • Free consumer help programs. the unit's own page stresses mediation; help with filing grievances is stated in the Insurance Administration page and in the required denial-notice wording (COMAR 31.10.18.04)

Sources last checked . Found a mistake? Report it.