reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.100 - Clinical Decisions

Current through Register 1525, July 5, 2024
The health care professional treating any insured shall make all clinical decisions regarding the medical treatment to be provided to the insured, including the provision of durable medical equipment and hospital lengths of stay:
(1) Clinical decisions shall be made in accordance with generally accepted principles of professional medical practice and in consultation with the insured.
(2) Nothing contained in 958 CMR 3.100 shall be construed as altering, affecting or modifying either the obligations of any third party payor or the terms and conditions of any agreement or contract between either the treating health care professional or the insured and any third party.
(3) Carriers shall pay for health care services ordered by a treating health care professional if the services are a covered benefit under the insured's health benefit plan, and the services are medically necessary.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.101 - Carrier's Medical Necessity Guidelines

Current through Register 1525, July 5, 2024
(1) A carrier may
			 develop guidelines to be used by the carrier in determining if services are
			 medically necessary. Any such guidelines used by a carrier in determining if
			 covered services are medically necessary shall be, at a minimum:
(a) developed with input from practicing
			 physicians and participating providers in the carrier's or utilization review
			 organization's service area;
(b)
			 developed in accordance with standards adopted by national accreditation
			 organizations;
(c) updated at least
			 biennially or more often as new treatments, applications and technologies are
			 adopted as generally accepted professional medical practice;
(d) evidence based, if practicable;
(e) applied in a manner that considers the
			 individual health care needs of the insured;
(f) prior to implementation of any new or
			 amended guidelines to be effective on or after April 28,2023, assessed by the
			 carrier or utilization review organization to show compliance with state and
			 federal parity requirements as required by the Division of Insurance under
			 M.G.L. c. 26, § 8K; and
(g)
			 otherwise compliant with applicable state and federal law.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.200 - Internal Inquiry Process

Current through Register 1525, July 5, 2024
(1) A carrier or
			 utilization review organization may maintain an internal inquiry process, in
			 addition to the internal grievance process in
			 958
			 CMR 3.300 through
			 3.314.
(2) The inquiry process is a process prior to
			 the grievance process during which a carrier or utilization review organization
			 may attempt to answer questions and/or resolve concerns communicated on behalf
			 of an insured to the insured's satisfaction within three business days.
(a) This process shall not be used for review
			 of an adverse determination, which must be reviewed through the internal
			 grievance process set forth in
			 958
			 CMR 3.300 through
			 3.314.
(b) When this inquiry process fails to answer
			 the insured's questions or resolve the insured's concerns to his or her
			 satisfaction within three business days, the inquiry will, at the option of the
			 insured, be subject to the internal grievance process.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.300 - Right to an Internal Grievance Process

Current through Register 1525, July 5, 2024
(1) A carrier or
			 utilization review organization shall maintain an internal grievance process
			 that provides for adequate consideration and timely resolution of
			 grievances.
(2) There shall be only
			 one level of review for an internal grievance, regardless of whether the
			 carrier contracts with a utilization review organization or other entity that
			 as part of its contractual responsibilities provides utilization review
			 services or otherwise reviews internal grievances and issues determinations
			 regarding these grievances.
(3) A
			 carrier may waive the internal grievance process, and allow the insured to seek
			 immediate external review of an adverse determination, at the carrier's
			 discretion and upon receiving a written request from the insured or the
			 insured's authorized representative which clearly seeks a waiver of the
			 internal grievance process and includes a request to proceed directly to
			 external review. Any such request by the insured or insured's authorized
			 representative must be provided to the carrier in writing within 48 hours of
			 the insured's or insured's authorized representative's receipt of the notice of
			 adverse determination. If the carrier waives the internal grievance process,
			 the carrier shall notify the insured and the insured's authorized
			 representative in writing within 48 hours of receiving the written request, and
			 the insured or insured's authorized representative shall provide a copy of this
			 written waiver to the Office of Patient Protection along with the timely
			 request for external review.
(4)
			 The carrier or utilization review organization shall establish a clear process
			 to allow the insured to request the appointment of an authorized representative
			 to act on the insured's behalf.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.301 - Information on Internal Grievance Process

Current through Register 1525, July 5, 2024
(1) The carrier
			 or utilization review organization shall provide insureds with:
(a) A clear, concise and complete written
			 description of the carrier's internal grievance process.
(b) A toll-free telephone number for
			 assisting insureds in resolving such grievances and the consumer assistance
			 toll-free number maintained by the Office of Patient Protection, and if
			 applicable, the designated state consumer assistance program.
(c) Notification about the availability of
			 these resources.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.302 - Form and Manner of Request

Current through Register 1525, July 5, 2024
(1) Each carrier or
			 utilization review organization shall adopt a process to accept grievances by
			 telephone, in person, by mail, or by electronic means, provided that an oral
			 grievance made by the insured or the authorized representative shall be reduced
			 to writing by the carrier and a copy thereof forwarded to the insured by the
			 carrier or utilization review organization within 48 hours of receipt, except
			 where this time limit is waived or extended by mutual written agreement of the
			 insured or the insured's authorized representative and the carrier.
(2) Each grievance filed pursuant to
			 958
			 CMR 3.300 through
			 3.314 that requires the
			 review of medical records shall include the signature of the insured or the
			 insured's authorized representative on a form provided within 48 hours of
			 receipt of the grievance by the carrier authorizing the release of medical and
			 treatment information relevant to the grievance to the carrier or utilization
			 review organization, consistent with state and federal law. The carrier shall
			 request this authorization from the insured when necessary for requests reduced
			 to writing by the carrier and for any written requests lacking an
			 authorization. The carrier or utilization review organization shall establish a
			 process to deliver and accept the medical release form to the insured or the
			 insured's authorized representative by electronic means, which shall include,
			 but not be limited to, delivery to a designated email address or in an online
			 consumer portal. The insured and the authorized representative shall have
			 access to any medical information and records relevant to the grievance
			 relating to the insured which is in the possession of the carrier and under its
			 control.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.303 - Carrier and Utilization Review Organization Records of Grievances

Current through Register 1525, July 5, 2024
The carrier or utilization review organization shall establish
				a system for maintaining records of each grievance filed by an insured or on
				his behalf, and responses thereto, for a period of seven years, which records
				shall be subject to inspection by the Commissioner of Insurance and the Office
				of Patient Protection.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.304 - Carrier and Utilization Review Organization Acknowledgment of Internal Grievances

Current through Register 1525, July 5, 2024
(1) A written
			 acknowledgment of the receipt of a grievance shall be sent by the carrier or
			 utilization review organization to the insured or the insured's authorized
			 representative, if any, within 15 days of receipt, except where an oral
			 grievance has been reduced to writing by the carrier or utilization review
			 organization pursuant to
			 958
			 CMR 3.302(1)  or this time
			 period is waived or extended by mutual written agreement of the insured or the
			 insured's authorized representative and the carrier.
(2) In its written acknowledgement, the
			 carrier or utilization review organization shall describe the carrier's process
			 for considering the grievance and the date by which the insured will receive a
			 decision.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.305 - Time Limits for Resolution of Non-expedited Internal Grievances

Current through Register 1525, July 5, 2024
(1) A carrier or utilization review
			 organization shall provide the insured or the insured's authorized
			 representative, if any, with a written resolution of a grievance within 30 days
			 of receipt of the oral or written grievance.
(2) When a grievance requires the review of
			 medical records, the 30-day period will not begin to run until the insured or
			 the insured's authorized representative submits a signed authorization for
			 release of medical records and treatment information as required in
			 958
			 CMR 3.302(2). In the event
			 that the signed authorization is not provided by the insured or the insured's
			 authorized representative, if any, within 30 days of the receipt of the
			 grievance, the carrier or utilization review organization may, in its
			 discretion, issue a resolution of the grievance without review of some or all
			 of the medical records.
(3) The
			 time limits in
			 958
			 CMR 3.305 may be waived or extended by mutual
			 written agreement of the insured or the insured's authorized representative and
			 the carrier. Any such agreement shall state the additional time limits, which
			 shall not exceed 30 days from the date of the agreement.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.306 - Review of Internal Grievances

Current through Register 1525, July 5, 2024
(1) Each reviewer
			 assigned by a carrier or utilization review organization to perform review of
			 an internal grievance must meet the following qualifications:
(a) Each reviewer shall not have participated
			 in any of the carrier's prior decisions regarding the treatment or service at
			 issue in the grievance, and shall not be subordinate to or under the
			 supervision of the reviewer who issued the adverse determination.
(b) Each reviewer shall have no conflict of
			 interest, such that decisions by the carrier or utilization review organization
			 regarding the hiring, compensation, termination, promotion, or other similar
			 matters with respect to the reviewer must not be based upon the likelihood that
			 the reviewer will support the denial of benefits.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.307 - Form of Written Resolution of the Internal Grievance

Current through Register 1525, July 5, 2024
(1) Each written resolution of an internal
			 grievance shall include a clear summary explanation of the basis for the
			 decision and identification of the specific information considered.
(2) In the case of an internal grievance that
			 involves an adverse determination, the written resolution shall include a
			 substantive clinical justification for the final adverse determination that is
			 consistent with generally accepted principles of professional medical practice,
			 and shall at a minimum:
(a) include
			 information about the claim including, if applicable, the date(s) of service,
			 the health care provider(s), the claim amount, and any diagnosis, treatment,
			 and denial code(s) and their corresponding meaning(s);
(b) identify the specific information upon
			 which the adverse determination was based;
(c) discuss the insured's presenting symptoms
			 or condition, diagnosis and treatment interventions;
(d) explain in a reasonable level of detail
			 the specific reasons the reviewer found that the medical evidence does not
			 support a finding of medical necessity;
(e) reference and include a copy of any
			 applicable clinical review criteria or other clinical basis for the adverse
			 determination;
(f) if the carrier
			 or utilization review organization specifies alternative treatment options
			 which are covered benefits, include identification of providers who are
			 currently accepting new patients;
(g) provide a summary of the reviewer's
			 professional qualifications, and a signed statement certifying that the
			 reviewer meets the qualifications specified at
			 958
			 CMR 3.306(1)  and, if
			 applicable,
			 958
			 CMR 3.306(2); and
(h) notify the insured or the insured's
			 authorized representative of any available procedure for reconsideration of the
			 decision by the carrier, pursuant to
			 958
			 CMR 3.308, and the procedures for requesting
			 external review, including the procedures to request an expedited external
			 review.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.308 - Reconsideration of Carrier Decisions on Internal Grievances

Current through Register 1525, July 5, 2024
(1) The carrier or
			 utilization review organization may offer to the insured or the insured's
			 authorized representative, if any, the opportunity for reconsideration of a
			 carrier's final adverse determination where:
(a) relevant medical information was received
			 too late to review within the 30-day time limit;
(b) relevant medical information was not
			 received but is expected to become available within a reasonable time period
			 following the written resolution; or
(c) for other good cause offered by the
			 insured or insured's authorized representative.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.309 - Expedited Internal Review of Adverse Determinations

Current through Register 1525, July 5, 2024
(1) A carrier or utilization review
			 organization shall provide for expedited internal review of an adverse
			 determination concerning a carrier's coverage or provision of immediate and
			 urgently needed service(s), that meets the minimum requirements of
			 958
			 CMR 3.309.
(a) For purposes of
			 958
			 CMR 3.309, immediate and urgently needed
			 service(s) means, in the opinion of the health care professional responsible
			 for the treatment or proposed treatment:
1.
			 the service is medically necessary;
2. a denial of coverage for such service(s)
			 would create a substantial risk of serious harm to the insured; and
3. such risk of serious harm is so immediate
			 that the provision of such service(s) should not await the outcome of the
			 normal internal grievance process.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.310 - Right to Request a Conference

Current through Register 1525, July 5, 2024
If the expedited review process affirms the denial of coverage
				or treatment, the carrier or utilization review organization shall allow the
				insured or the insured's authorized representative, if any, to request a
				conference.
(a) The conference shall be
			 scheduled within ten days of receiving a request from an insured; provided
			 however that the conference shall be held within five business days of the
			 request if the treating physician determines, after consultation with the
			 carrier's medical director or his designee, and based on standard medical
			 practice, that the effectiveness of either the proposed treatment, services or
			 supplies or any alternative treatment, services or supplies covered by the
			 carrier, would be materially reduced if not provided at the earliest possible
			 date.
(b) At the conference, the
			 carrier shall permit attendance of the insured, the authorized representatives
			 of the insured, if any, or both.
(c) At the request of the insured or the
			 insured's authorized representative, the carrier may permit attendance at the
			 conference of the insured's treating health care professional or other
			 providers.
(d) At the conference,
			 the insured and/or the insured's authorized representative, if any, and a
			 representative of the carrier who has authority to determine the disposition of
			 the grievance shall review the information provided to the insured under
			 958
			 CMR 3.09(l)(b) and
			 (c).
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.311 - Failure of Carrier to Meet Time Limits

Current through Register 1525, July 5, 2024
A grievance not properly acted on by the carrier within the
				time limits required by
				958
				CMR 3.300 through
				3.310 shall be deemed
				resolved in favor of the insured. Time limits include any extensions made by
				mutual written agreement of the insured or the insured's authorized
				representative, if any, and the carrier.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.312 - Coverage or Treatment Pending Resolution of Internal Grievance

Current through Register 1525, July 5, 2024
(1) If a grievance is filed concerning the
			 termination of ongoing coverage or treatment, the disputed coverage or
			 treatment shall remain in effect at the carrier's expense through completion of
			 the internal grievance process regardless of the final internal grievance
			 decision, provided that the grievance is filed on a timely basis, based on the
			 course of treatment. For the purposes of
			 958
			 CMR 3.312, ongoing coverage or treatment
			 includes only that medical care that, at the time it was initiated, was
			 authorized by the carrier or utilization review organization and does not
			 include medical care that was terminated pursuant to a specific time or
			 episode-related exclusion from the insured's contract for benefits.
(2) The carrier's internal grievance process
			 shall include provision for automatic reversal of the carrier's or utilization
			 review organization's adverse determinations denying coverage for services,
			 pending the outcome of the internal grievance process, within 48 hours of
			 receipt by the carrier or utilization review organization of certification by
			 the physician responsible for the insured's treatment or proposed treatment,
			 which states the physician's opinion that the following factors are present:
(a) the service at issue in the grievance is
			 medically necessary;
(b) denial of
			 coverage for these services would create a substantial risk of serious harm to
			 the patient; and
(c) the risk of
			 that harm is so immediate that the provision of such services should not await
			 the outcome of the normal grievance process.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.313 - Confidentiality

Current through Register 1525, July 5, 2024
No carrier or utilization review agency shall, except as
				specifically authorized by an appropriate release signed by an insured or
				authorized representative, release medical and treatment information or other
				information obtained as part of the internal inquiry or grievance process
				unless otherwise required or authorized by law.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.314 - Internal Review Conference

Current through Register 1525, July 5, 2024
Nothing in
				958 CMR
				3.000 shall be construed to prohibit an insured or
				insured's authorized representative from voluntarily participating in a
				conference or informal meeting with the carrier or utilization review
				organization to attempt to resolve the subject matter of the grievance.
(1) Any insured or authorized representative
			 of an insured who is aggrieved by a final adverse determination issued by a
			 carrier or utilization review organization may request an external review by
			 filing a request in writing with the Office of Patient Protection within four
			 months of the insured's receipt of written notice of the final adverse
			 determination, except that no final adverse determination is required when the
			 insured simultaneously requests an expedited internal review and expedited
			 external review pursuant to
			 958
			 CMR 3.401(4), or where a
			 carrier has waived internal review pursuant to
			 958
			 CMR 3.300(3).
(2) An insured or insured's authorized
			 representative may file a request for external review for services of any
			 monetary value. There is no minimum financial threshold for filing a request
			 for external review.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.400 - External Review

Current through Register 1525, July 5, 2024
(1) Any insured or authorized representative of an insured who is aggrieved by a final adverse determination issued by a carrier or utilization review organization may request an external review by filing a request in writing with the Office of Patient Protection within four months of the insured's receipt of written notice of the final adverse determination, except that no final adverse determination is required when the insured simultaneously requests an expedited internal review and expedited external review pursuant to 958 CMR 3.401(4), or where a carrier has waived internal review pursuant to 958 CMR 3.300(3).
(2) An insured or insured's authorized representative may file a request for external review for services of any monetary value. There is no minimum financial threshold for filing a request for external review.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.401 - Expedited External Review

Current through Register 1525, July 5, 2024
(1) An insured or
			 the insured's authorized representative may request to have the request for
			 review processed as an expedited external review.
(2) Each request for an expedited external
			 review shall contain a certification, in writing, from a health care
			 professional responsible for the treatment or proposed treatment that delay in
			 the provision or continuation of health care services that are the subject of a
			 final adverse determination, would pose a serious and immediate threat to the
			 health of the insured.
(3) Upon
			 receiving a properly executed certification that a serious and immediate threat
			 to the insured exists, the Office of Patient Protection shall qualify such
			 request as eligible for an expedited external review.
(4) The insured or insured's authorized
			 representative may file a request for expedited external review concurrently
			 with a request for expedited internal review.
(5) The external review agency shall issue a
			 decision within 72 hours of receiving the request for expedited external
			 review.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.402 - Fees

Current through Register 1525, July 5, 2024
(1) An insured seeking an external review
			 shall pay a fee of $25.00, which shall accompany the request for a review, to
			 the Office of Patient Protection.
(a) No
			 insured shall be required to pay more than $75 in fees for external review
			 requests per plan year, regardless of the number of external review requests
			 submitted.
(b) If the $25 fee has
			 been paid, the Office of Patient Protection shall refund the $25 fee to the
			 insured if the adverse determination is reversed or overturned in its entirety
			 by the external review agency.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.403 - Consent to Release of Medical Information

Current through Register 1525, July 5, 2024
(1) Any request
			 for an external review pursuant to
			 958
			 CMR 3.400 shall include the signature of the
			 insured, or the insured's authorized representative authorizing the release and
			 forwarding of medical information and records relevant to the subject matter of
			 the external review, in a manner consistent with state and federal law, to any
			 external review agency assigned to conduct external reviews pursuant to
			 958
			 CMR 3.407.
(2) In connection with any request for an
			 external review, the carrier shall assure that the insured, and where
			 applicable the insured's authorized representative, has access to any medical
			 information and records relating to the insured, in the possession of the
			 carrier or under its control.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.404 - Form and Manner of Request for External Review

Current through Register 1525, July 5, 2024
Requests for external review submitted by the insured or the
				insured's authorized representative shall:
(1) be on a form prescribed by the Office of
			 Patient Protection;
(2) include the
			 signature of the insured or the insured's authorized representative consenting
			 to the release of medical information;
(3) include a copy of the written final
			 adverse determination issued by the carrier; and,
(4) include the $25.00 fee required by
			 958
			 CMR 3.402 unless not required pursuant to
			 958
			 CMR 3.402(l)(a)  or waived
			 pursuant to
			 958
			 CMR 3.402(2).
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.405 - Screening of Requests for External Review

Current through Register 1525, July 5, 2024
(1) The Office of
			 Patient Protection shall screen all requests for external reviews to determine
			 ifthey:
(a) comply with the requirements of
			 958
			 CMR 3.404;
(b) do not involve a service or benefit that
			 has been explicitly excluded from coverage by the carrier in its evidence of
			 coverage; and
(c) result from a
			 carrier's issuance of a notice of final adverse determination; provided,
			 however, that no final adverse determination is necessary where the carrier has
			 failed to comply with timelines for the internal grievance process, the carrier
			 has waived the internal grievance process in writing pursuant to
			 958
			 CMR 3.300(3), or if the
			 insured or his or her authorized representative is requesting an expedited
			 external review at the same time that the insured is requesting an expedited
			 internal review pursuant to
			 958
			 CMR 3.401(4).
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.406 - Requests Ineligible for External Review - Notification

Current through Register 1525, July 5, 2024
(1) Notification of the rejection of a
			 request for external review for failure to meet the requirements of
			 958
			 CMR 3.400 shall be issued by the Office of
			 Patient Protection to the insured, the insured's authorized representative and
			 the carrier within 72 hours of a receipt of a request for an expedited review
			 and within ten business days of receipt of all other requests. The notification
			 shall set forth the specific reason why the request has been determined
			 ineligible for an external review and any submitted fee shall be
			 returned.
(2) The Office of Patient
			 Protection shall determine that a request for external review is ineligible for
			 review based on the following:
(a) Insured or
			 insured's authorized representative filed the request for external review after
			 the time limit provided at
			 958
			 CMR 3.400;
(b) Insured seeks external review of a
			 decision by a self-funded plan not eligible for review under M.G.L. c.
			 1760;
(c) Insured seeks external
			 review of a decision by a health benefit plan licensed in a state other than
			 Massachusetts, which is not eligible for review under M.G.L. c. 1760;
(d) Insured seeks external review of a
			 decision by a plan issued by Medicaid, Medicare, or other health benefit plan
			 not subject to M.G.L. c. 1760;
(e)
			 Insured's treatment was found to be medically necessary by the carrier, and the
			 insured is attempting to seek external review of an issue related to the amount
			 of copayment, deductible, coinsurance or other out-of-pocket expense;
			 or
(f) Insured seeks external
			 review of a decision by a carrier which was not a final adverse determination,
			 except that an adverse determination will be sufficient where the insured seeks
			 an expedited external review and has simultaneously filed a request for
			 expedited internal review.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.407 - Assignment of External Reviews

Current through Register 1525, July 5, 2024
Upon the determination by the Office of Patient Protection that
				a request for review is eligible for an external review, the external review
				request shall be assigned promptly to an external review agency by the Office
				of Patient Protection on a random basis. The Office of Patient Protection shall
				forward a copy of the insured's request for an external review together with
				any related documentation filed with the Office by the insured or the carrier
				to the external review agency.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.408 - Notification of Assignment and Request for Information

Current through Register 1525, July 5, 2024
Upon the referral of a request to an external review agency,
				the Office of Patient Protection shall notify the insured, the insured's
				authorized representative if applicable and the carrier, that the request has
				been referred and shall identify the selected external review agency, and where
				applicable, identify that the review is being considered on an expedited basis.
				A copy of the insured's written authorization for the release of medical
				records and information shall be included with notification sent to the
				carrier.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.409 - Medical Records and Information

Current through Register 1525, July 5, 2024
(1) For
			 non-expedited reviews, the carrier or utilization review organization shall
			 forward the insured's medical and treatment records relevant to the review and
			 created by or in the possession or control of the carrier and a copy of the
			 carrier's evidence of coverage applicable to the insured, to the identified
			 external review agency within three business days of receipt of the
			 notification provided pursuant to
			 958
			 CMR 3.408. It is the responsibility of the
			 carrier to assemble a reasonably complete medical record or file, which shall
			 include, but not be limited to, any medical records and medical opinions
			 regarding medical necessity by the insured's treating provider who requested or
			 provided the disputed service. The carrier shall make good faith efforts to
			 obtain records relevant to the review and not in the possession of the carrier
			 from providers, whether the providers are in the carrier's network or outside
			 of the carrier's network. Failure to make such good faith efforts shall be
			 subject to the penalties listed at
			 958
			 CMR 3.412(2)(b).
(2) For expedited reviews, the carrier or
			 utilization review organization shall furnish to the identified external review
			 agency the insured's medical and treatment records relevant to the review and
			 created by or in the possession or control of the carrier, and a copy of the
			 carrier's evidence of coverage applicable to the insured, within 24 hours of
			 receipt of notification provided pursuant to
			 958
			 CMR 3.408. It is the responsibility of the
			 carrier to assemble a reasonably complete medical record or file, which shall
			 include, but not be limited to, any medical records and medical opinions
			 regarding medical necessity by the insured's treating provider who requested or
			 provided the disputed service. The carrier shall make good faith efforts to
			 obtain records relevant to the review and not in the possession of the carrier
			 from providers, whether the providers are in the carrier's network or outside
			 of the carrier's network. Failure to make such good faith efforts shall be
			 subject to the penalties listed at
			 958
			 CMR 3.412(2)(b).
(3) The carrier or utilization review
			 organization or the insured or his or her authorized representative shall have
			 access to all information filed by any party with the external review agency
			 including any information filed pursuant to
			 958
			 CMR 3.412.
(4) For the purposes of
			 958
			 CMR 3.409(1) and (2), "good
			 faith efforts" shall be defined as no fewer than three reasonable documented
			 attempts by the carrier to obtain the information from an in-network or
			 out-of-network provider or the provider's designee.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.410 - Review Panel

Current through Register 1525, July 5, 2024
(1) Upon receipt of
			 an external review referral the external review agency shall assign the review
			 to a panel that is comprised of one or more clinical reviewers who did not
			 participate in any of the carrier's prior decisions on the claim or internal
			 grievance. These reviewers shall be actively practicing health care
			 professionals in the same or similar specialty who typically treat the medical
			 condition, perform the procedure or provide the treatment that is the subject
			 of the external review.
(2) Upon
			 receipt of an external review referral involving services or treatment
			 considered by the carrier or utilization review organization to be experimental
			 or investigational, or other services or treatment as determined by the Office
			 of Patient Protection, the external review agency shall assign the review to a
			 panel that is comprised of three clinical reviewers who did not participate in
			 any of the carrier's prior decisions on the claim or internal grievance. These
			 reviewers shall be actively practicing health care professionals in the same or
			 similar specialty who typically treat the medical condition, perform the
			 procedure or provide the treatment that is the subject of the external
			 review.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.411 - Conflict of Interest

Current through Register 1525, July 5, 2024
(1) External review
			 agencies shall ensure that the external review agency and the clinical
			 reviewers assigned to any external review:
(a)
			 shall have no material professional, familial or financial affiliation with any
			 party that is the subject of the review;
(b) shall have no material professional,
			 family or financial affiliation with any party that participated in the
			 delivery of health care to the insured who is the subject of the review:
1. shall not have participated as a clinical
			 reviewer in connection with any medical necessity determination with respect to
			 the insured who is the subject of the review; and
2. shall have no material professional,
			 familial or financial conflict of interest with any officer, director, or
			 management employee of the carrier or utilization review organization; the plan
			 administrator, plan fiduciaries, or plan employees; the health care provider,
			 the health care provider's group, or practice association recommending the
			 treatment that is subject to the external review; the facility at which the
			 recommended treatment would be provided; or the developer or manufacturer of
			 the principal drug, device, procedure, or other therapy being
			 recommended.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.412 - Additional Medical or Other Information

Current through Register 1525, July 5, 2024
(1) The insured or
			 the insured's authorized representative may submit additional medical evidence
			 or other relevant information to the external review agency.
(a) The Office of Patient Protection will
			 notify the insured or insured's authorized representative of the right to
			 submit additional medical evidence or other relevant information in its letter
			 to the insured or insured's authorized representative acknowledging the receipt
			 and assignment of the request for external review. The Office of Patient
			 Protection will include in its letter instructions for submitting any
			 additional medical evidence or other relevant information to the external
			 review agency.
(b) In a
			 non-expedited review, any such additional medical evidence or other relevant
			 information shall be reviewed by the external review agency if received within
			 ten days from the date of the notice from the Office of Patient Protection. Any
			 such additional medical evidence or other relevant information may be reviewed
			 by the external review agency if received more than ten days from the date of
			 the notice from the Office of Patient Protection but before the decision is
			 rendered.
(c) In an expedited
			 review, any such additional medical evidence or other relevant information
			 shall be reviewed by the external review agency if received within 24 hours of
			 the insured's or insured's authorized representative's filing of the request
			 for expedited external review. Any such additional medical evidence or other
			 relevant information may be reviewed by the external review agency if received
			 more than 24 hours after the insured's or insured's authorized representative's
			 filing of the request for expedited external review but before the decision is
			 rendered.
(d) The external review
			 agency shall forward a copy of any additional medical evidence or other
			 relevant information submitted by the insured or the insured's authorized
			 representative to the carrier within one business day of receipt.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.414 - Continuation of Services

Current through Register 1525, July 5, 2024
(1) If the subject
			 matter of the expedited or non-expedited external review involves the
			 termination of ongoing services, the insured or insured's authorized
			 representative may apply to the external review agency to seek the continuation
			 of coverage for the terminated service during the period the review is pending.
			 The insured or the insured's representative should include, when applying, any
			 evidence of a pattern of denials that have been overturned by prior internal or
			 external review. Any such request to the external review agency must be made
			 before the end of the second business day following receipt of the final
			 adverse determination, or when the internal and external reviews are filed
			 simultaneously, the second business day following receipt of the adverse
			 determination.
The external review agency shall order the continuation of
				coverage or treatment where it determines that substantial harm to the
				insured's health may result absent such continuation or for such other good
				cause as the external review agency shall determine, which shall include, but
				not be limited to, a pattern of denials that have been overturned by prior
				internal or external reviews. Continuation of coverage shall be at the
				carrier's expense regardless of the final external review
				determination.
(2) A request
			 for continuation of coverage by an insured or insured's authorized
			 representative shall be included in the external review request, on the
			 external review request form issued by the Office of Patient
			 Protection.
(3) If continuation of
			 coverage was provided during the internal review process, then any continuation
			 of coverage ordered during the external review shall follow immediately upon
			 the prior coverage so that there is no gap in coverage between the internal
			 review process and external review process.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.415 - Decisions and Notice

Current through Register 1525, July 5, 2024
(1) The external
			 review agency shall determine whether the service that is the subject of the
			 review is medically necessary and is a covered benefit as defined in
			 958
			 CMR 3.020.
(2) The final decision of the external review
			 agency shall be in writing and shall contain the following information:
(a) the specific medical and scientific
			 reasons for the decision;
(b) an
			 analysis of the medical evidence and how the evidence supports the finding of
			 the reviewer;
(c) the Massachusetts
			 medical necessity standard as defined at
			 958
			 CMR 3.020, and an explanation of why the
			 requested treatment or service was found or was not found to be medically
			 necessary;
(d) a list of any
			 medical literature or references relied upon in making the decision;
(e) a statement that the decision is final
			 and binding, but the insured may have other legal rights under state or federal
			 law; and
(f) a statement prepared
			 by the Office of Patient Protection, which notifies the insured of the
			 availability of translation and interpretation assistance from the
			 carrier.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.416 - Confidentiality - External Review

Current through Register 1525, July 5, 2024
No external review agency or reviewer shall, except as
				specifically authorized by an appropriate release signed by an insured or
				representative authorized by law, release medical and treatment information or
				other information obtained as part of an external review, except to the Office
				of Patient Protection and as otherwise authorized or required by
				law.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.417 - External Review Conference

Current through Register 1525, July 5, 2024
Nothing in
				958 CMR
				3.000 shall be construed to prohibit an insured or
				insured's authorized representative from voluntarily participating in a
				conference or informal meeting with the external review agency regarding the
				external review request, or with the carrier or utilization review organization
				to resolve the matter which is the subject of the external review
				request.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.500 - Disenrollment of Primary Care Provider

Current through Register 1525, July 5, 2024
Where a carrier allows or requires the designation of a primary
				care provider, the carrier shall in the event of disenrollment of a primary
				care provider for reasons other than those related to quality or fraud:
(1) provide to any insured written notice of
			 the disenrollment of the insured's primary care provider at least 30 days prior
			 to any such disenrollment;
(2)
			 include in said notice a description of the procedure for choosing an alternate
			 primary care provider; and
(3)
			 permit the insured to be covered for health services, consistent with the terms
			 of the carrier's evidence of coverage, provided by such primary care provider
			 for at least 30 days after the provider is disenrolled.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.501 - Disenrollment of Providers of Care to Pregnant Women

Current through Register 1525, July 5, 2024
Carriers shall allow any female insured who is in her second or
				third trimester of pregnancy and whose provider in connection with said
				pregnancy is involuntarily disenrolled for reasons other than those related to
				quality or fraud, to continue treatment with her provider, consistent with the
				carrier's evidence of coverage, for a period up to and including the insured's
				first postpartum visit.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.502 - Disenrollment of Providers of Care to the Terminally 111

Current through Register 1525, July 5, 2024
Carriers shall allow any insured who is terminally ill, and
				whose provider in connection with the treatment of the insured's terminal
				illness is involuntarily disenrolled for reasons other than those related to
				quality or fraud, to continue treatment with the provider, consistent with the
				terms of the carrier's evidence of coverage, until the insured's
				death.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.503 - Coverage for the Newly Insured

Current through Register 1525, July 5, 2024
(1) A carrier shall
			 provide coverage for health services to a newly insured provided by a provider
			 who is not a participating provider in the carrier's network for up to 30 days
			 from the effective date of coverage if:
(a)
			 the insured's employer only offers the insured a choice of carriers in which
			 said provider is not a participating provider; and
(b) said provider is providing the insured
			 with an ongoing course of treatment or is the insured's primary care
			 provider.