Section 22-B6005. EXHAUSTION OF INTERNAL REVIEW PROCESS

 

6005.1Except as provided in § 6005.2, a member or member representative shall exhaust the insurer's internal grievance process prior to filing a request for an external review with the Director under this chapter. Medicaid recipients need not exhaust the internal grievance process and may appeal immediately to the Office of Fair Hearing.

 

6005.2A member or a member representative may file a grievance without first exhausting the insurer's internal review process in the case of an emergency or urgent medical condition, if the grievance demonstrates to the satisfaction of the Director a compelling reason to do so, including a showing that the potential delay in receipt of a health care service until after the member or member representative exhausts the internal grievance process could result in loss of life, serious impairment to a bodily function, serious dysfunction of a bodily organ, or the member remaining seriously mentally ill with symptoms that cause the member to be a danger to self and others, or the review is from an emergency grievance which the insurer has not resolved within twenty-four (24) hours, or when the insurer fails to meet timelines specified by the Act.

 

source

Final Rulemaking published at 47 DCR 229 (January 14, 2000).