State Law

MA. General Laws-Part I-Title XXII-Chapter 176O. Health Insurance Consumer Protections

08/08/2023 Massachusetts Section 1


Medical Necessity-Definition, U.R. Criteria

See bold sections below:

As used in this chapter, the following words shall have the following meanings:—

“Adverse 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.

“Ambulatory review”, utilization review of health care services performed or provided in an outpatient setting, including, but not limited to, outpatient or ambulatory surgical, diagnostic and therapeutic services provided at any medical, surgical, obstetrical, psychiatric and chemical dependency facility, as well as other locations such as laboratories, radiology facilities, provider offices and patient homes.

“Behavioral health manager”, a company, organized under the law of the commonwealth or organized under the laws of another state and qualified to do business in the commonwealth, that has entered into a contractual arrangement with a carrier to provide or arrange for the provision of behavioral, substance use disorder and mental health services to voluntarily enrolled member of the carrier.

“Capitation”, a set payment per patient per unit of time made by a carrier to a licensed health care professional, health care provider group or organization that employs or utilizes services of health care professionals to cover a specified set of services and administrative costs without regard to the actual number of services provided.

“Carrier”, an insurer licensed or otherwise authorized to transact accident or health insurance under chapter 175; a nonprofit hospital service corporation organized under chapter 176A; a nonprofit medical service corporation organized under chapter 176B; a health maintenance organization organized under chapter 176G; and an organization entering into a preferred provider arrangement under chapter 176I, but not including an employer purchasing coverage or acting on behalf of its employees or the employees of one or more subsidiaries or affiliated corporations of the employer. Unless otherwise noted, the term “carrier” shall not include any entity to the extent it offers a policy, certificate or contract that is not a health benefit plan, as defined in section 1 of chapter 176J.

“Case management”, a coordinated set of activities conducted for individual patient management of serious, complicated, protracted or other health conditions.

“Clinical peer reviewer”, a physician or other health care professional, other than the physician or other health care professional who made the initial decision, who holds a non–restricted license from the appropriate professional licensing board in the commonwealth, current board certification from a specialty board approved by the American Board of Medical Specialties or of the Advisory Board of Osteopathic Specialists from the major areas of clinical services or, for non–physician health care professionals, the recognized professional board for their specialty, who actively practices in the same or similar specialty as typically manages the medical condition, procedure or treatment under review, and whose compensation does not directly or indirectly depend upon the quantity, type or cost of the services that such person approves or denies.

“Clinical review criteria”, 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.

“Commissioner”, the commissioner of insurance.

“Concurrent review”, utilization review conducted during an insured’s inpatient hospital stay or course of treatment.

“Covered benefits” or “benefits”, health care services to which an insured is entitled under the terms of the health benefit plan.

“Dental carrier”, an entity that offers a policy, certificate or contract that provides coverage solely for dental care services.

“Discharge planning”, the formal process for determining, prior to discharge from a facility, the coordination and management of the care that an insured receives following discharge from a facility.

“Division”, the division of insurance.

“Downside risk”, the risk taken on by a provider organization as part of an alternate payment contract with a carrier or other payer where the provider organization is responsible for either the full or partial costs of treating a group of patients that exceeds a contract’s budgeted payment arrangements.

“Emergency medical condition”, a medical condition, whether physical, behavioral, related to substance use disorder, or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in placing the health of the insured or another person in serious jeopardy, serious impairment to body function or serious dysfunction of any body organ or part or, with respect to a pregnant woman, as further defined in section 1867(e)(1)(B) of the Social Security Act, 42 U.S.C. section 1395dd(e)(1)(B).

“Facility”, a licensed institution providing health care services or a health care setting, including, but not limited to, hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings.

“Grievance”, any oral or written complaint submitted to the carrier which has been initiated by an insured, or on behalf of an insured with the consent of the insured, 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, under the requirements of this chapter.

“Health benefit plan”, a policy, contract, certificate or agreement entered into, offered or issued by a carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.

“Health care professional”, a physician or other health care practitioner licensed, accredited or certified to perform specified health services consistent with law.

“Health care provider” or “provider”, a health care professional or a facility.

“Health care services”, services for the diagnosis, prevention, treatment, cure or relief of a physical, behavioral, substance use disorder or mental health condition, illness, injury or disease.

“Incentive plan”, any compensation arrangement between a carrier and licensed health care professional or licensed health care provider group or organization that employs or utilizes services of one or more licensed health care professionals that may directly or indirectly have the effect of reducing or limiting services furnished to insureds of the organization.

“Insured”, an enrollee, covered person, insured, member, policyholder or subscriber of a carrier, including an individual whose eligibility as an insured of a carrier is in dispute or under review, or any other individual whose care may be subject to review by a utilization review program or entity as described under other provisions of this chapter.

“Licensed health care provider group”, a partnership, association, corporation, individual practice association, or other group that distributes income from the practice among members. An individual practice association is a licensed health care provider group only if it is composed of individual health care professionals and has no subcontracts with licensed health care provider groups.

“Medical necessity” or “medically necessary”, health care services that are consistent with generally accepted principles of professional medical practice.

“National accreditation organization”, the American accreditation health care commission/URAC, the National Committee for Quality Assurance, or any other national accreditation entity approved by the division that accredits carriers subject to the provisions of this chapter.

“Network”, a grouping of health care providers who contract with a carrier to provide services to insureds covered by any or all of the carrier’s plans, policies, contracts or other arrangements.

“Office of patient protection”, the office in the health policy commission established by section 16 of chapter 6D, responsible for the administration and enforcement of sections 13, 14, 15 and 16.

“Participating provider”, a provider who, under a contract with the carrier or with its contractor or subcontractor, has agreed to provide health care services to insureds with an expectation of receiving payment, other than coinsurance, copayments or deductibles, directly or indirectly from the carrier.

“Person”, an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity or combination of the foregoing.

“Primary care provider”, a health care professional qualified to provide general medical care for common health care problems who: (i) supervises, coordinates, prescribes, or otherwise provides or proposes health care services; (ii) initiates referrals for specialist care; and (iii) maintains continuity of care within the scope of practice.

“Prospective review”, utilization review conducted prior to an admission or a course of treatment and shall include any pre–authorization and pre–certification requirements of a carrier or utilization review organization.

“Religious non–medical provider”, a provider who provides no medical care but who provides only religious non–medical treatment or religious non–medical nursing care.

“Retrospective review”, utilization review of medical necessity that is conducted after services have been provided to a patient, but does not include the review of a claim that is limited to an evaluation of reimbursement levels, veracity of documentation, accuracy of coding or adjudication for payment.

“Risk-Bearing Provider Organization,” a provider organization that manages the treatment of a group of patients and bears the downside risk according to the terms of an alternate payment contract.

“Second opinion”, an opportunity or requirement to obtain a clinical evaluation by a health care professional other than the health care professional who made the original recommendation for a proposed health service, to assess the clinical necessity and appropriateness of the initial proposed health service.

“Terminally ill”, an illness which is likely, within a reasonable degree of medical certainty, to cause one’s death within six months, or as otherwise defined in section 1861(dd)(3)(A) of the Social Security Act, 42 U.S.C. section 1395x(dd)(3)(A).

“Utilization review”, 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.

“Utilization review organization”, an entity that conducts utilization review, other than a carrier performing utilization review for its own health benefit plans.

“Vision carrier”, an entity that offers a policy, certificate or contract that provides coverage solely for vision care services.