Current through Register 1531, September 27, 2024
(1)
Standards. A Carrier's application will be reviewed
for compliance with the applicable NCQA Standards for utilization management.
In addition, Carriers shall meet the requirements identified in
211
CMR 52.07(2) through (10).
In cases where the standards in
211
CMR 52.07(2) through (10)
differ from those in the NCQA Standards, the standards in
211
CMR 52.07(2) through (10)
shall apply.
(2)
Written Plan. Utilization Review conducted by a
Carrier or a Utilization Review Organization shall be conducted pursuant to a
written plan, under the supervision of a physician and staffed by appropriately
trained and qualified personnel, and shall include a documented process to:
(a) review and evaluate its
effectiveness;
(b) ensure the
consistent application of Utilization Review criteria; and
(c) ensure the timeliness of Utilization
Review determinations.
(3)
Criteria. A
Carrier or Utilization Review Organization shall adopt Utilization Review
criteria and conduct all Utilization Review activities pursuant to said
criteria.
(a) The criteria shall be, to the
maximum extent feasible, scientifically derived and evidence-based, and
developed with the input of Participating Providers, consistent with the
development of Medical Necessity criteria consistent with
958
CMR 3.101: Carrier's Medical
Necessity Guidelines.
(b)
Utilization Review criteria shall be up to date and applied consistently by a
Carrier or the Utilization Review Organization and made easily accessible to
subscribers, Health Care Providers and the general public on a Carrier's
website; or, in the alternative, on the Carrier's Utilization Review
Organization's website so long as the Carrier provides a link on its website to
the Utilization Review Organization's website; provided, however, that a
Carrier shall not be required to disclose licensed, proprietary criteria
purchased by a Carrier or Utilization Review Organization on its website, but
must disclose such criteria to a Provider or subscriber upon request.
(c) Any new or amended preauthorization
requirement or restriction shall not be implemented unless the Carrier's and/or
Utilization Review Organization's respective website has been updated to
clearly reflect the new or amended requirement or restriction.
(d) Adverse Determinations rendered by a
program of Utilization Review, or other denials of requests for Health
Services, shall be made by a person licensed in the appropriate Specialty
related to such Health Services and, where applicable, by a Provider in the
same licensure category as the ordering Provider.
(4)
Initial Determination
Regarding a Proposed Admission, Procedure or Service.
(a) When requiring prior authorization for a
Health Care Service or Benefit, a Carrier shall use and accept, or a Carrier
shall require and ensure that its Utilization Review Organization use and
accept, only the prior authorization forms designated by the Commissioner for
the specific types of Health Care Services and Benefits identified in the
designated forms.
(b) If the
Carrier fails to use or accept the designated prior authorization form, or
fails to respond within two business days after receiving a completed prior
authorization request from a Provider, pursuant to the submission of the prior
authorization form under
211
CMR 52.07(4)(a), the prior
authorization request shall be deemed to have been granted.
(c) In addition to any other requirements
under applicable law, a Carrier shall make, or a Carrier shall require and
ensure that its Utilization Review Organization makes, an initial determination
regarding a proposed admission, procedure or service that requires such a
determination within two working days of obtaining all necessary information.
For purposes of
211
CMR 52.07, "necessary information" shall
include the results of any face-to-face clinical evaluation or Second Opinion
that may be required.
(d) In the
case of a determination to approve an admission, procedure or service, the
Carrier or Utilization Review Organization shall notify the Provider rendering
the service by telephone within 24 hours, and shall send written or electronic
confirmation of the telephone notification to the Insured and the Provider
within two working days thereafter.
(e) In the case of an Adverse Determination,
the Carrier or the Utilization Review Organization shall notify the Provider
rendering the service by telephone within 24 hours, and shall send written or
electronic confirmation of the telephone notification to the Insured and the
Provider within one working day thereafter.
(f) Any new or amended Prospective Review
requirement or restriction shall not be effective, unless and until the
Carrier's or Utilization Review Organization's website has been updated to
reflect the new or amended requirement or restriction.
(g) Subject to
211
CMR 52.07(4)(a) through (f),
nothing in
211
CMR 52.07(4) shall:
1. require a treating Health Care Provider to
obtain information regarding whether a proposed admission, procedure or service
is Medically Necessary on behalf of an Insured;
2. restrict the ability of a Carrier or
Utilization Review Organization to deny a claim for an admission, procedure or
service if the admission, procedure or service was not Medically Necessary,
based on information provided at the time of claim; or
3. shall restrict the ability of a Carrier or
Utilization Review Organization to deny a claim for an admission, procedure or
service if other terms and conditions of coverage are not met at the time of
service or time of claim.
(5)
Concurrent
Review. A Carrier or the Utilization Review Organization shall
make a Concurrent Review determination within one working day of obtaining all
necessary information.
(a) In the case of a
determination to approve an extended stay or additional services, the Carrier
or Utilization Review Organization shall notify the Provider rendering the
service by telephone within one working day, and shall send written or
electronic confirmation to the Insured and the Provider within one working day
thereafter. A written or electronic notification shall include the number of
extended Days or the next review date, the new total number of Days or services
approved, and the date of admission or initiation of services.
(b) In the case of an Adverse Determination,
the Carrier or Utilization Review Organization shall notify the Provider
rendering the service by telephone within 24 hours, and shall send written or
electronic notification to the Insured and the Provider within one working Day
there after.
(c) The service shall
be continued without liability to the Insured until the Insured has been
notified of the determination.
(6)
Written Notice.
The written notification of an Adverse Determination shall include a
substantive clinical justification 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 shall explain the reason for any denial, including the specific
Utilization Review criteria or Benefits provisions used in the determination,
and;
(c) discuss the Insured's
presenting symptoms or condition, diagnosis and treatment
interventions;
(d) explain in a
reasonable level of detail the specific reasons such medical evidence fails to
meet the relevant medical review criteria;
(e) reference and include, or provide a
website link(s) to the specifically applicable, clinical practice guidelines,
medical review criteria, or other clinical basis for the Adverse
Determination;
(f) a description of
any additional material or information necessary for the Insured to perfect the
claim and an explanation of why such material or information is
necessary;
(g) if the Carrier
specifies alternative treatment options which are Covered Benefits, include
identification of Providers who are currently accepting new patients;
(h) prominently explain all appeal rights
applicable to the denial, including a clear, concise and complete description
of the Carrier's formal internal Grievance process and the procedures for
obtaining external review pursuant to
958 CMR
3.000: Health Insurance Consumer
Protection, and a clear, prominent description of the process for
seeking expedited internal review and concurrent expedited internal and
external reviews, including applicable timelines, pursuant to
958 CMR
3.000; and a clear and prominent notice of a patient's
right to file a Grievance with the with the Office of Patient Protection; and
information on how to file a Grievance with the Office of Patient
Protection.
(i) prominently notify
the Insured of the availability of, and contact information for, the consumer
assistance toll-free number maintained by the Office of Patient Protection, and
if applicable, the Massachusetts consumer assistance program; and
(j) include a statement, prominently
displayed on all product/plan materials in at least the languages identified by
the Centers for Medicare & Medicaid Services as the top non-English
languages in Massachusetts, that clearly indicates how the Insured can request
oral interpretation and written translation services from the Carrier
consistent with
958 CMR
3.000: Health Insurance Consumer
Protection.
(7)
Reconsideration of an Adverse Determination. A Carrier
or Utilization Review Organization shall give a Provider treating an Insured an
opportunity to seek reconsideration of an Adverse Determination from a Clinical
Peer Reviewer in any case involving an initial determination or a Concurrent
Review determination.
(a) The reconsideration
process shall occur within one working day of the receipt of the request and
shall be conducted between the Provider rendering the service and the Clinical
Peer Reviewer or a clinical peer designated by the Clinical Peer Reviewer if
the reviewer cannot be available within one working day.
(b) If the Adverse Determination is not
reversed by the reconsideration process, the Insured, or the Provider on behalf
of the Insured, may pursue the Grievance process established pursuant to
958 CMR
3.000: Health Insurance Consumer
Protection.
(c) The
reconsideration process allowed pursuant to
211
CMR 52.07(7) shall not be a
prerequisite to the internal Grievance process or an expedited appeal required
by 958 CMR
3.000: Health Insurance Consumer
Protection.
(8)
Continuity of Care. A Carrier must provide evidence
that its policies regarding continuity of care comply with all provisions of
958 CMR
3.000: Health Insurance Consumer
Protection.
(9)
Step Therapy. A Carrier must provide evidence that its
protocols regarding step therapy comply with all provisions of section 12A of
chapter 176O.
(10)
Workers' Compensation Preferred Provider Arrangement.
A Carrier that provides specified services through a workers' compensation
preferred Provider arrangement shall be deemed to have met the requirements of
211
CMR 52.07, except
211
CMR 52.07(10), if it has met
the requirements of
452 CMR
6.00: Utilization Review and Quality
Assessment.
(11)
Annual Survey. A Carrier or Utilization Review
Organization shall conduct an annual survey of Insureds to assess satisfaction
with access to Primary Care Services, Specialty Care services, ancillary
services, hospitalization services, durable medical equipment and other covered
services.
(a) The survey shall compare the
actual satisfaction of Insureds with projected measures of their
satisfaction.
(b) Carriers that
utilize Incentive Plans shall establish mechanisms for monitoring the
satisfaction, quality of care and actual utilization compared with projected
utilization of Health Care Services of Insureds.
(12)
Religious Non-medical
Treatment and Providers. Nothing in
211
CMR 52.07 shall be construed to require
Health Benefit Plans to use medical professionals or criteria to decide insured
access to Religious Non-medical Providers, utilize medical professionals or
criteria in making decisions in internal appeals from decisions denying or
limiting coverage or care by Religious Non-medical Providers, compel an Insured
to undergo a medical examination or test as a condition of receiving coverage
for treatment by a Religious Non-medical Provider, or require Health Benefit
Plans to exclude Religious Non-medical Providers because they do not provide
medical or other data otherwise required, if such data is inconsistent with the
religious non-medical treatment or nursing care provided by the
Provider.
