Current through Register 1531, September 27, 2024
(1) Insurers and
self-insurers are required to undertake utilization review for health services
rendered to injured employees, either by performing utilization review
themselves or by contracting with a Commonwealth approved agent who will
conduct utilization review services on their behalf. If an insurer or
self-insurer chooses to perform utilization review on its own, it must have its
program approved through the OHP. Said utilization review program must remain
separate and distinct from case management and all other claim functions.
Utilization review organizations conducting Massachusetts reviews at multiple
sites must seek separate approval for each site.
For the conditions to which the treatment guidelines endorsed
by the Health Care Services Board and adopted by the Commissioner pursuant to
M.G.L. c. 152, §§ 13 and 30 apply, the programs shall integrate said
treatment guidelines.
(2)
Application for Approval . An applicant requesting
approval to conduct utilization review in the Commonwealth shall:
(a) submit a completed application to the OHP
along with an initial application fee payable to the DIA. The application fee
shall be $1,000.00 if the company is located in Massachusetts, excluding the
Commonwealth and the various counties, cities, towns and districts; and
$3,000.00 if the company is located outside of Massachusetts;
(b) submit a new application to the OHP every
two years, along with a renewal fee. The renewal fee shall be $500.00 if the
company is located in Massachusetts; and $1,500.00 if the company is located
outside of Massachusetts; and
(c)
make arrangements with the OHP for a site visit for all new
applicants.
(3)
Information Required with Application . To conduct
utilization review in the Commonwealth, a utilization review agent must seek
approval of its utilization review program from the Commissioner in writing and
the application shall include, but not be limited to the following:
(a) corporate and site demographics: name,
address, and telephone number of the program's corporate and Massachusetts
contacts; and the identification of each site where Massachusetts utilization
review will be conducted;
(b) a
list of all treatment guidelines which will be used by the licensed medical
reviewer in rendering a determination, including DIA Treatment Guidelines,
approved secondary sources, and internally derived treatment guidelines. The
utilization review agent shall also provide information pertaining to the
procedures for implementing internal guidelines including the frequency of
revisions;
(c) copies of all
current professional licenses issued by the appropriate state licensing agency
for all practitioners rendering utilization review determinations, including
the medical director;
(d) a
detailed description of the appeal procedures for utilization review
determinations, including copies of all materials designed to inform injured
employees of the requirements of the utilization review program and their
responsibilities and rights under the program;
(e) the identity of each insurer/self-insurer
for which the utilization review agent performs Massachusetts
reviews;
(f) an attestation in
writing that the utilization review agent shall comply with all applicable
laws, rules, regulations, orders, and requirements of the Commonwealth;
and
(g) disclosure of any economic
incentives for reviewers in the utilization review program. Any material
changes in the information filed in accordance with 452 CMR 6.04 shall be filed
with the OHP within 30 days of said change.
(4) The OHP will publish the name and address
of each approved UR agent on the DIA web site.
(5) All utilization review agents shall
comply with the following procedures:
(a) All
determination letters must set forth the relevant section of the treatment
guideline referenced and provide a clinical rationale. An adverse determination
letter shall include instructions for the procedure to initiate an appeal of
the adverse determination. A copy of the relevant section of the guideline must
be provided upon request. The start and end dates for all scheduled health care
services shall be clearly documented in the utilization review case note
summary and on the determination notice. The date of request and the date of
receipt of medical information must be documented by the utilization review
agent in the utilization review case record.
(b) Notification of all utilization review
determinations issued by the utilization review agent shall be communicated to
the injured employee/representative and the ordering provider in writing. For
prospective reviews, written notice of the determination shall be given within
two business days from receipt of the request for approval of treatment. For
concurrent reviews, if the ordering practitioner contacts the UR agent at least
three business days prior to the start date for the ongoing treatment, written
notice of the determination shall be given at least one day prior to the
start/implementation date. If the ordering practitioner fails to request
approval of ongoing treatment at least three business days prior to the start
date, or fails to provide a start date, the UR agent shall issue the
determination within five business days from receipt of the request. For
retrospective reviews, written notice of the determination shall be given
within 20 business days from receipt of the request for approval of treatment.
If additional medical information is necessary in order to
complete the review, the utilization review agent shall inform the requesting
health care provider of the specific medical information needed, and the time
period in which the information must be provided. Prospective and Concurrent
Reviews: information must be provided within seven business days from the date
of request. Retrospective Reviews: information must be provided within 30
business days from the date of request.
(c) Any adverse determination of a health
care service issued by a utilization review agent shall be issued by a
practitioner of the same school as the ordering provider.
(d) Adverse determination letters must
provide a description of the appeal procedure and at a minimum, shall provide
the following:
1. When an adverse
determination is rendered during prospective or concurrent review, and the
injured employee and/or the ordering provider believes that the determination
warrants immediate appeal, the injured employee or the ordering provider may
initiate the appeal via telephone to the utilization review
agent with the right to communicate orally with a practitioner of the same
school as the ordering provider on an expedited basis. The ordering provider or
injured employee should be instructed to follow-up with a written request for
the appeal. If the injured employee or ordering provider fails to comply, the
utilization review agent should send a written confirmation of the appeal
request. Said notice of appeal to occur no later than 30 days from the date of
receipt of notice of adverse determination. Utilization review agents shall
complete the adjudication on an expedited basis and render the determination no
later than two business days from the date the appeal is initiated, unless the
ordering provider agrees to a different time period.
2. Appeal of retrospective reviews shall be
made in writing to the utilization review agent and occur no later than 30 days
from the date of receipt of notice of adverse determination. Utilization review
agents shall complete the adjudication of a retrospective review/standard
appeal no later than 20 business days from the date the appeal is
filed.
(e) Utilization
review agents shall make staff available by toll-free telephone system at least
40 hours per week between the hours of 9:00 A.M. to 5:00 P.M. each business
day.
(f) Utilization review agents
shall have a confidential telephone system capable of accepting and recording
incoming telephone calls during other than normal business hours, and the agent
shall respond to these calls on the following business day.
(g) Utilization review agents shall comply
with all applicable laws to protect the confidentiality of medical records and
when necessary, obtain a medical release.
(h) Practitioners rendering school to school
utilization review determinations and medical directors must provide, and
attest in writing to providing, patient care for at least eight hours per
week.
(i) Once an insurer has
commenced payment for a work related injury under M.G.L. c. 152, it must issue
the employee a card listing the employee name, an identification number
assigned to the employee, the name and telephone number of the utilization
review agent, and the name of the insurer. The employee must seek approval from
the insurer/utilization review agent before receiving medical services. In the
case of an emergency, utilization review agents shall allow a minimum of 24
hours after an emergency admission, service, or procedure for an injured
employee or injured employee's representative to notify the utilization review
agent and request approval for treatment.
(j) Initial level reviews must be conducted
at the location of the approved utilization review site.
(6) After exhaustion of the process set forth
in 452 CMR 6.04(5)(d), a party may file a claim or complaint in accordance with
452 CMR
1.07: Claims and Complaints
under the provisions of M.G.L. c. 152, § 10.
(7) Injured employees may be liable for care
subsequent to the adverse determination after they have been notified of that
adverse determination.
(8)
Ancillary Services.
452 CMR 6.00 concerns the
requirements for the performance of utilization review. Should an insurer or
self-insurer provide ancillary services such as managed care, case management,
independent medical exams, or rehabilitation services from vendors who are also
approved as utilization review agents, said ancillary services are not to be
considered utilization review requirements or expenses. Ancillary services must
remain separate and distinct from the utilization review services. Moreover,
these ancillary services should not be construed as approved by the OHP by
virtue of the OHP's approval of the same vendor to perform utilization
review.
(9) Each
insurer/self-insurer is required to inform the OHP of the name of the approved
utilization review agent currently responsible for conducting the
reviews.
