SENATE DOCKET, NO. 255        FILED ON: 1/15/2013

SENATE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No. 571

The Commonwealth of Massachusetts

_________________

PRESENTED BY:

James E. Timilty

_________________

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 ensuring clinically appropriate peer review.

_______________

PETITION OF:

SENATE DOCKET, NO. 255        FILED ON: 1/15/2013

SENATE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No. 571

The Commonwealth of Massachusetts

_______________

In the Year Two Thousand Thirteen

_______________

An Act ensuring clinically appropriate peer review.

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 1760 of the General Laws, as most recently amended by section 200 of Chapter 224 of the Acts of 2012, is hereby amended by striking subsection (f) and inserting in place thereof the following:

(f) A carrier or utilization review organization that issues a retroactive adverse determination for services that have already been provided shall give the provider an opportunity to seek reconsideration from a clinical peer reviewer.  The request for review must be submitted within 45 days of the provider’s receipt of the denial. Upon receipt of the request for reconsideration, the carrier or utilization review organization shall have 30 business days to notify the provider in writing of the determination.  The written notification of an adverse determination shall include a substantive clinical justification from a clinical peer reviewer that is consistent with generally accepted principles of professional medical practice, and shall, at a minimum: (1) identify the specific information upon which the adverse determination was based; (2) discuss the insured's presenting symptoms or condition, diagnosis and treatment interventions and the specific reasons such medical evidence fails to meet the relevant medical review criteria; (3) reference and include applicable clinical practice guidelines and review criteria.

SECTION 2. The Commissioner of Insurance shall promulgate regulations to enforce the provisions of this Act no later than 90 days after the effective date of the Act, which shall be effective for provider contracts which are entered into, renewed, or amended on or after the regulations effective date.