Amendment #10 to S2142

Transparency in Peer Review

Mr. Nangle of Lowell moves to amend the bill be amended by adding at the end thereof the following new section:-

SECTION XX: Section 16 of Chapter 176O of the General Laws is hereby amended by inserting after clause (c) the following new paragraph:-

“(d) If a carrier determines that the service ordered by a treating physician is not medically necessary pursuant to the carrier’s guidelines for medical necessity and the carrier has offered an alternative treatment that would meet the guidelines for medical necessity, the carrier shall communicate the alternative treatment to the treating physician in written or electronic form. Conversations regarding approved treatments shall only occur between the treating physician who has the authority to make a final decision regarding a member’s treatment and the licensed physician at the carrier. The treating physician shall document that the approved alternative treatment was presented to the member at the point of service by the treating physician, the member’s preferred course of treatment, and whether the member or facility has determined to file an internal grievance with the carrier. Either the member, the member’s authorized representative or the treating physician may file an internal grievance with the carrier, which may be requested on an expedited basis.”