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HOUSE DOCKET, NO. 2345         FILED ON: 1/17/2013

HOUSE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No. 924

 

The Commonwealth of Massachusetts

_________________

PRESENTED BY:

Bradley H. Jones, Jr.

_______________

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.

_______________

PETITION OF:

 

Name:

District/Address:

Bradley H. Jones, Jr.

20th Middlesex

George N. Peterson, Jr.

9th Worcester

Bradford Hill

4th Essex

Elizabeth A. Poirier

14th Bristol

Viriato Manuel deMacedo

1st Plymouth

Donald Humason

 

Sheila C. Harrington

1st Middlesex

Paul K. Frost

7th Worcester

Kimberly N. Ferguson

1st Worcester

Daniel B. Winslow

9th Norfolk

Keiko M. Orrall

12th Bristol


HOUSE DOCKET, NO. 2345        FILED ON: 1/17/2013

HOUSE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No. 924

By Mr. Jones of North Reading, a petition (accompanied by bill, House, No. 924) of Bradley H. Jones, Jr. and others relative to determinations of medical necessity by insurance carriers or utilization review organizations.  Financial Services. 

 

[SIMILAR MATTER FILED IN PREVIOUS SESSION
SEE HOUSE, NO. 2061 OF 2011-2012.]


The Commonwealth of Massachusetts
 

_______________

In the Year Two Thousand Thirteen

_______________

 

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 most recently amended by section 199 of chapter 224 of the acts of 2012, 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 the provider rendering or requesting the service within 24 hours. 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 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 most recently amended by section 192 of chapter 224 of the acts of 2012, is hereby amended by striking out clause (2) thereof.

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