Reporting Form For Adverse Decisions and Grievances


As required by Maryland law, insurance carriers licensed to sell health insurance in this state must provide an accounting of the adverse decisions issued by their company and the disposition of any ensuing grievance filed by the member appealing that decision. This accounting will be submitted quarterly to the Maryland Insurance Administration on the form entitled "Reporting Form for Maryland Insurance Code §15-10A-06." All carriers that conduct utilization review must be registered as a Private Review Agent or must delegate this responsibility to an entity that is registered as a Private Review Agent with the Maryland Insurance Administration.

The specific statutory requirements of the report are set forth in §15-10A-06 of the Insurance Article. Statutes can be found via the General Assembly's Web site,, using the link for Maryland Statutes.


Reports are to be submitted on a quarterly basis within 15 days of the end of the following reporting periods:

                            1stQ - First Quarter (1/1 - 3/31)
                            2ndQ - Second Quarter (4/1 - 6/30)
                            3rdQ - Third Quarter (7/1 - 9/30)
                            4thQ - Fourth Quarter (10/1 - 12/31)



DENTAL ONLY CARRIERS: If your company only provides coverage for dental services, and you are not reporting denials for any medical procedures, then you should use the CDT code published by the ADA instead of the ICD-9 or CPT codes.

Note: For people who may use a scroll wheel on their mouse, please make sure you are aware of what data field your cursor is in when scrolling. Certain fields with multiple selections can be changed by scrolling through the options while that field is selected. If you want to scroll through the whole page, make sure no data field is selected.

If you have any questions you are welcome to contact Louis Butler by email or call 410-468-2271. The attached Instructions Guide below provides helpful hints, definitions, etc. you will need to complete the filing.

Carrier Reporting Instructions Guide (PDF)

File On-Line:

All companies have the option of filing their required report electronically. All carriers that have filed reports in the past will be sent a user ID and password in the mail. If you have not received this information, please contact Louis Butler at 410-468-2271. Each user ID and password are unique. You may not file the user ID and password of one Company to file on behalf of another. You should print the report for your records as well as the confirmation sheet.

Login for On-Line Carrier Report Filing

File A Print Form:

Carriers may also report by mailing or faxing us a copy of your report. If you choose to either mail or fax your report, you may download this form below.

Mail responses should be forwarded to:

Louis Butler
Maryland Insurance Administration
200 St. Paul Place, Suite 2700, Baltimore, MD 21202.

Faxed responses should be sent to Louis Butler at 410-468-2270.

Carrier Report Form (PDF)​​​​

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