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HOUSE DOCKET, NO. 2235         FILED ON: 1/20/2011

HOUSE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No. 2061

 

The Commonwealth of Massachusetts

_________________

PRESENTED BY:

Bradley H. Jones, Jr.

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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 administrative simplification.

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PETITION OF:

 

Name:

District/Address:

Bradley H. Jones, Jr.

20th Middlesex

Donald F. Humason, Jr.

4th Hampden

Elizabeth A. Poirier

14th Bristol

F. Jay Barrows

1st Bristol

Shaunna O'Connell

3rd Bristol

Donald H. Wong

9th Essex

Todd M. Smola

1st Hampden

Sheila C. Harrington

1st Middlesex

Steven L. Levy

4th Middlesex

Paul K. Frost

7th Worcester


HOUSE DOCKET, NO. 2235        FILED ON: 1/20/2011

HOUSE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No. 2061

By Mr. Jones of North Reading, a petition (accompanied by bill, House, No. 2061) of Bradley H. Jones, Jr. and others relative to determinations of medical necessity by insurance carriers or utilization review organizations.  Financial Services. 


The Commonwealth of Massachusetts
 

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In the Year Two Thousand Eleven

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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 2008 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 2008 Official Edition, is hereby amended by striking out clause (2) thereof.

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