SENATE DOCKET, NO. 860        FILED ON: 1/15/2015

SENATE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No. 518

The Commonwealth of Massachusetts

_________________

PRESENTED BY:

Thomas P. Kennedy

_________________

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:

SENATE DOCKET, NO. 860        FILED ON: 1/15/2015

SENATE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No. 518

[SIMILAR MATTER FILED IN PREVIOUS SESSION
SEE SENATE, NO. 453 OF 2013-2014.]

The Commonwealth of Massachusetts

_______________

In the One Hundred and Eighty-Ninth General Court
(2015-2016)

_______________

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.