Code of Massachusetts Regulations
958 CMR - HEALTH POLICY COMMISSION
Title 958 CMR 3.000 - Health Insurance Consumer Protection
Section 3.415 - Decisions and Notice

Universal Citation: 958 MA Code of Regs 958.3

Current through Register 1518, March 29, 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.

(3) The external review agency shall provide a copy of the final decision to the insured, the insured's authorized representative and the carrier. Where the insured is a minor or a person with a legal guardian, the external review agency shall provide the insured's copy of the final decision to the insured's parent or legal guardian.

(4) For non-expedited reviews, an external review agency shall issue its final disposition within 45 calendar days from its receipt of the referral from the Office of Patient Protection.

(5) For expedited reviews, the external review agency shall issue its final disposition within 72 hours of its receipt of the referral from the Office of Patient Protection.

(6) Each external review agency shall retain records of all external review requests, decisions and notices for three years from the date of the final disposition, and shall make these records available to the Office of Patient Protection upon request.

(7) The decision of the external review agency shall be binding on the carrier and the insured, except to the extent other remedies are available under state or federal law, and except that the requirement that the decision is binding shall not preclude the carrier from making payment on the claim or otherwise providing benefits at any time, including after a final external review decision that denies the claim or otherwise fails to require such payment or benefits. Nothing in 958 CMR 3.415 shall prohibit the parties from voluntarily proceeding with any informal efforts to resolve the matter under review prior to the issuance of a final decision.

(8) Upon written request by the insured, the insured's authorized representative or the carrier, and at the sole discretion of the Director of the Office of Patient Protection, an external review agency may be directed to retract and revise a decision only upon a finding of clear procedural or factual error which is evident on the face of the decision. Any such written request must be received by the Office of Patient Protection within seven days of the date of the external review agency's final decision, in order to be considered. For the purposes of 958 CMR 3.415(8), "clear procedural or factual error" is defined as including at least one of the following:

(a) the decision by the external review agency fails to acknowledge or consider medical records which were submitted to the external review agency within the time limits specified at 958 CMR 3.412;

(b) the decision by the external review agency identifies the incorrect insured, provider, carrier, diagnosis or medical treatment in its decision; or

(c) the decision by the external review agency fails to cite the correct Massachusetts medical necessity standard as defined at 958 CMR 3.020.

(9) If the external review agency overturns a carrier's decision in whole or in part, the carrier shall issue a written notice to the insured within five business days of receipt of the written decision from the review agency. Such notice shall:

(a) acknowledge the decision of the review agency;

(b) advise the insured of any additional procedures for obtaining the requested coverage or services;

(c) advise the insured of the date by which the payment will be made or the authorization for services will be issued by the carrier or utilization review organization; and

(d) advise the insured of the name and phone number of the person at the carrier who will assist the insured with final resolution of the grievance.

(10) The carrier shall comply with the external review agency's decision and shall make payment, authorize services, or otherwise comply without delay. A carrier's failure to promptly comply with an external review agency's decision shall be an unfair and deceptive practice in violation of M.G.L. c. 93 A.

Disclaimer: These regulations may not be the most recent version. Massachusetts may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.