Definitions; Clinical Decisions; Carrier’s Medical Necessity Guidelines; Time Limits for Resolution of Non-expedited Internal Grievances; Review of Internal Grievances; Expedited Internal Review of Adverse Determinations; Additional Requirements for Expedited Internal Review; Failure of Carrier to Meet Time Limits
See the bold text below:
Section 958 CMR 3.020. Definitions. Note: To make the size of this entry easier to use, not all of the terms that are defined under 958 CMR 3.o20 are reproduced below. One can see all of the definitions by clicking on the link at the end of this entry. The definitions listed below are those that are the most relevant to the purposes of this database.
As used in 958 CMR 3.000 the following words shall have the following meanings:
“Actively Practicing” means that a health care professional regularly treats patients in a clinical setting.
“Adverse Determination” means a determination, based upon a review of information provided, by a carrier or its designated utilization review organization, to deny, reduce, modify, or terminate an admission, continued inpatient stay, or the availability of any other health care services, for failure to meet the requirements for coverage based on
medical necessity, appropriateness of health care setting and level of care, or effectiveness, including a determination that a requested or recommended health care service or treatment is experimental or investigational.
“Clinical Review Criteria” means the written screening procedures, decisions, abstracts, clinical protocols and practice guidelines used by a carrier to determine the medical necessity and appropriateness of health care services.
“Days” means calendar days, unless otherwise specified.
“Final Adverse Determination” means an adverse determination made after an insured has exhausted all remedies available through a carrier’s formal internal grievance process.
“Grievance” means any oral or written complaint submitted to the carrier that has been initiated by an insured, or the insured’s authorized representative, concerning any aspect or action of the carrier relative to the insured, including, but not limited to, review of adverse determinations regarding scope of coverage, denial of services, rescission of
coverage, quality of care and administrative operations, in accordance with the requirements of 958 CMR 3.000.
“Medical Necessity” or “Medically Necessary” means health care services that are consistent with generally accepted principles of professional medical practice as determined by whether the service:
(a) is the most appropriate available supply or level of service for the insured in question considering potential benefits and harms to the individual;
(b) is known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes; or
(c) for services and interventions not in widespread use, is based on scientific evidence.
“Same or Similar Specialty” means that the health care professional has similar credentials and licensure as those who typically provide the treatment in question and has experience treating the same condition that is the subject of the grievance. Such experience shall extend to the treatment of children in a grievance involving a child where the age of the patient is relevant to the determination of whether a requested service or supply is medically necessary.
“Service Area” means the geographical area as approved by the Commissioner of Insurance within which the carrier has developed a network of providers to afford adequate access to members for covered health services.
“Terminal Illness” means an illness that is likely, within a reasonable degree of medical certainty, to cause one’s death within six months, or as otherwise defined in § 1861(dd)(3)(A) of the Social Security Act (42 U.S.C. 1395x(dd)(3)(A)).
“Utilization Review” means a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures or settings. Such techniques may include, but are not limited to, ambulatory review, prospective review, second opinion, certification, concurrent review,
case management, discharge planning or retrospective review.
Section 958 CMR 3.100. Clinical Decisions.
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.
Section 958 CMR 3.101: Carrier’s Medical Necessity Guidelines
(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; and
(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 Section 8K of M.G.L. c. 26; and
(g) otherwise compliant with applicable state and federal law.
(2) In instances where the insured is enrolled in a health benefit plan where the carrier or utilization review organization provides only administrative services, the obligations of the carrier or utilization review organization related to payment as provided by M.G.L. c. 176O, §16 and 958 CMR 3.100 are limited to recommending to the third party payer that coverage should be authorized.
(3) Carriers or utilization review organizations shall provide utilization review criteria and clinical review criteria, including medical necessity criteria and protocols, in the following manner:
(a) with a notice of adverse determination, as required at 211 CMR 52.00: Managed Care Consumer Protections and Accreditation of Carriers;
(b) upon request to the Office of Patient Protection, provided, however, that licensed, proprietary criteria and protocols purchased by a carrier shall not be public records and shall be exempt from disclosure pursuant to M.G.L. c. 4, §7, clause Twenty-sixth and M.G.L. c. 66, §10;
(c) upon oral or written request to the general public, for criteria or protocols that are not licensed or proprietary;
(d) upon oral or written request to insureds, prospective insureds and health care providers where criteria or protocols are licensed or proprietary and have been purchased by a carrier or utilization review organization, provided that the insured, prospective insured or health care provider identifies particular treatments or services for which applicable criteria or protocols are requested; or
(e) as otherwise required by 958 CMR 3.000.
(4) The carrier or utilization review organization shall publish criteria and protocols which are not licensed or proprietary on its publicly accessible website. Such criteria and protocols shall be up to date and easily accessible to the general public. The carrier or utilization review organization shall not implement any new or amended criteria or protocols until the carrier’s or utilization review organization’s website has been updated to reflect the new or amended criteria or protocols.
(5) The carrier or utilization review organization shall provide a copy of the requested criteria or protocols in hard copy or electronic format as requested, and shall comply with all requests for criteria or protocols as promptly as possible and in accordance with applicable grievance and appeal time limits as required by 958 CMR 3.000, or within 21 days of receipt of a request.
Section 958 CMR 3.305. Time Limits for Resolution of Non- Expedited Internal Grievances
State Medical Necessity Appeals-Deadlines
(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.
Section 958 CMR 3.306. Review of Internal Grievances
(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.
(2) Where the grievance was the result of an adverse determination, each reviewer shall be an actively practicing health care professional in the same or similar specialty and shall typically treat the medical condition, perform the procedure or provide the treatment that is the subject of the grievance.
(3) The carrier shall assemble a medical record that is sufficiently complete such that the carrier or utilization review organization is able to conduct a full and fair review of the grievance.
Section 958 CMR 3.309. Expedited Internal Review of Adverse Determinations
(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.
State Medical Necessity Appeals-Deadlines
(b) A carrier or utilization review organization shall provide a written resolution of an expedited internal review in compliance with 958 CMR 3.307 as soon as possible and no later than 72 hours after receipt of the request for expedited review, or as otherwise specified in 958 CMR 3.309.
(c) If the expedited internal review process results in a final adverse determination, the written resolution must inform the insured or the insured’s authorized representative of the opportunity to request an expedited external review pursuant to 958 CMR 3.401 and, if the review involves the termination of ongoing services, the opportunity to request continuation of services pursuant to 958 CMR 3.414.
(d) An insured or insured’s authorized representative may file a request for an expedited external review at the same time as the insured or insured’s authorized representative files a request for expedited internal review of the grievance
pursuant to 958 CMR 3.401(4).
(2) If the insured or the insured’s authorized representative submits a request for expedited internal review while the insured is an inpatient in a hospital, a carrier or utilization review organization shall provide a written resolution of the expedited internal review before the insured’s discharge from the hospital. For the purposes of 958 CMR 3.309(2) only, and only while the insured is an inpatient, a health care professional or a representative of the hospital may be the insured’s authorized representative without a written authorization by the insured.
(3) When a grievance is submitted by an insured with a terminal illness, or by the insured’s authorized representative on behalf of the insured with a terminal illness, a resolution shall be provided to the insured or insured’s authorized representative within five business days from the receipt of such grievance, except that grievances regarding urgently needed services for such insureds shall be resolved within 72 hours.
(4) A carrier or utilization review organization shall provide for automatic reversal of decisions denying coverage for service(s) or durable medical equipment within 48 hours, or earlier, pending written resolution of the expedited internal review process, as follows:
(a) A carrier or utilization review organization shall provide for automatic reversal of the decision within 48 hours of receipt of certification by the physician responsible for the treatment or proposed treatment that is the subject of the grievance that, in the physician’s opinion:
1. the service(s) or durable medical equipment is medically necessary;
2. a denial of coverage for such service(s) or durable medical equipment would create a substantial risk of serious harm to the patient; and
3. such risk of serious harm is so immediate that the provision of such service(s) or durable medical equipment should not await the outcome of the normal grievance process.
(b) For durable medical equipment, in the event the certifying physician exercises the option of automatic reversal earlier than 48 hours, the physician must further certify as to the specific, immediate and severe harm that will result to the patient absent action within the 48 hour time period.
Section 958 CMR 3.310. Additional Requirements for Expedited Internal Review
State Medical Necessity Appeals-Deadlines
(1) If the expedited review process affirms the denial of coverage or treatment, the carrier shall provide the insured or the insured’s authorized representative, if any, within two business days of the decision:
(a) a statement setting forth the specific medical and scientific reasons for denying coverage or treatment and,;
(b) a description of alternative treatment, services or supplies covered or provided by the carrier, if any;
(c) a descriptions of the insured’s right to any further appeal; and
(d) a description of the insured’s right to request a conference.
State Medical Necessity Appeals-Deadlines
(2) 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 3.310(1).
(3) If the review process set forth in 958 CMR 3.310 results in a final adverse determination, the written resolution must inform the insured or the insured’s authorized representative of the opportunity to request an expedited external review pursuant to 958 CMR 3.401 and, if the review involves the termination of ongoing services, the opportunity to request continuation of services pursuant to 958 CMR 3.414.
Section 958 CMR 3.311. Failure of Carrier to Meet Time Limits
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.
This entry was updated in the database on July 26, 2023. One can view the revised regulation at https://www.mass.gov/regulations/958-CMR-300-health-insurance-consumer-protection