HOUSE DOCKET, NO. 2454        FILED ON: 1/14/2009

HOUSE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No. 1046

The Commonwealth of Massachusetts

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In the Year Two Thousand Nine

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An Act relative to administrative simplification..

Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority of the same, as follows:
 

SECTION 1. Section 12 of Chapter 176O of the General Laws, as  appearing in the 2006 Official Edition, is hereby amended by  striking out subsections (b) and (c) and inserting in place thereof the following subsections:—

(b) A carrier or utilization review organization shall make a determination regarding the medical necessity of a proposed admission, procedure or service that requires a determination within two working days of obtaining all necessary information. For purposes of this section, “necessary information” shall include the results of any face-to-face clinical evaluation or second opinion that may be  required. In the case of a determination to approve an admission, procedure or service, the carrier or utilization review organization shall notify 14 the provider rendering or requesting the service within 24 hours. In the case of an adverse determination, the carrier or utilization review 16 organization shall notify the provider rendering or requesting the service within 24 hours, and shall provide written or electronic confirmation of the notification to the insured and the provider within  one working day thereafter.

(c) A carrier or utilization review organization shall make a concurrent review determination within one working day of obtaining all necessary information. 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 or requesting the service within  one working day.

In the case of an adverse determination, the carrier or utilization review organization shall notify the provider rendering or requesting the service within 24 hours and shall provide written or electronic notification to the insured and the provider within one working day thereafter. The service shall be continued without liability to the insured until the insured has been notified of the determination.

SECTION 2. Subsection (a) of Section 6 of Chapter 176O of the General Laws, as so appearing in the 2006 Official Edition, is hereby amended by striking out clause (2) thereof.