HOUSE DOCKET, NO. 450        FILED ON: 1/11/2013

HOUSE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No. 936

 

The Commonwealth of Massachusetts

_________________

PRESENTED BY:

Kay Khan

_________________

To the Honorable Senate and House of Representatives of the Commonwealth of Massachusetts in General
Court assembled:

The undersigned legislators and/or citizens respectfully petition for the adoption of the accompanying bill:

An Act to further define adverse determinations by insurers.

_______________

PETITION OF:

 

Name:

District/Address:

Date Added:

Kay Khan

11th Middlesex

 

Marcos A. Devers

16th Essex

1/28/2013

Ann-Margaret Ferrante

5th Essex

1/30/2013

Brian A. Joyce

Norfolk, Bristol and Plymouth

2/1/2013


HOUSE DOCKET, NO. 450        FILED ON: 1/11/2013

HOUSE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No. 936

By Ms. Khan of Newton, a petition (accompanied by bill, House, No. 936) of Kay Khan and others for legislation to further define adverse determinations by insurers.  Financial Services.

 

The Commonwealth of Massachusetts

 

_______________

In the Year Two Thousand Thirteen

_______________

 

An Act to further define adverse determinations by insurers.

 

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

Section 12(a) of Chapter 176O is amended by adding at the end thereof after the word "provider" the following new sentence:

Provided however, that in making said adverse determination, the carrier or its designated utilization review organization shall defer to the judgment of the treating clinician unless there is a preponderance of evidence that the requested admission, continued stay or other health care service does not meet the requirements for coverage based on medical necessity, appropriateness of health care setting and level of care, or effectiveness.