HOUSE DOCKET, NO. 3953        FILED ON: 1/17/2025

HOUSE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No.         

The Commonwealth of Massachusetts

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PRESENTED BY:

Margaret R. Scarsdale

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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 relative to reducing the administrative burden for preauthorization.

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PETITION OF:

HOUSE DOCKET, NO. 3953        FILED ON: 1/17/2025

HOUSE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No.         

The Commonwealth of Massachusetts

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In the One Hundred and Ninety-Fourth General Court
(2025-2026)

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An Act relative to reducing the administrative burden for preauthorization.

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

Chapter 176O of the General Laws is hereby amended by inserting after section 12B the following section:- 12C.

SECTION 1. (a) A carrier that uses a preauthorization process for health care services shall not require a physician or provider to obtain preauthorization for a particular health care service if, in the most recent six-month evaluation period, as described by subsection (b), the carrier has approved or would have approved not less than 90 percent of the preauthorization requests submitted by the physician or provider for the particular health care service.

       (b)  Except as provided by subsection (c), a carrier shall evaluate whether a physician or provider qualifies for an exemption from preauthorization requirements under Subsection (a) once every six months.

       (c)  A carrier may continue an exemption under subsection (a) without evaluating whether the physician or provider qualifies for the exemption under subsection (a) for a particular evaluation period.

       (d)  A physician or provider is not required to request an exemption under Subsection (a) to qualify for the exemption.

       (e) A carrier that determines a provider or physician qualifies for the exemption must inform the provider or physician within 48 hours of determination.

SECTION 2. (a) A physician's or provider's exemption from preauthorization requirement remains in effect for six months from the date of notification by the carrier or until:

             (1)  the 30th day after the date the carrier notifies the physician or provider of the carrier's determination to rescind the exemption if the physician or provider does not appeal the carrier’s determination; or

             (2)  if the physician or provider appeals the determination, the fifth day after the date the appeal concludes and the rescission is confirmed.

SECTION 3. (a) Sections 1 and 2 shall take effect on July 1, 2026.