Budget Amendment ID: FY2015-S4-764-R1

Redraft EHS 764

Medical Necessity Utilization Review Criteria

Mr. Welch moved that the proposed new text be amended moved that the bill be amended by inserting after section 9 the following section:-

“SECTION 9A.  Section 16 of chapter 6D of the General Laws, as appearing in the 2012 Official Edition, is hereby amended by striking out, in lines 9 to 12, inclusive, the words “Utilization review criteria, medical necessity criteria and protocols must be made available to the public at no charge regardless of proprietary claims” and inserting in place thereof the following words:- Utilization review criteria, medical necessity criteria and protocols shall be provided: (i) with a notice of adverse determination, (ii) upon request, to an insured who has not received a notice of adverse determination, to the insured’s provider or to the insured’s representative, the criteria and protocols that relate to a specific diagnosis or treatment, (iii) upon request to the office of patient protection and the division of insurance; provided, that such criteria and protocols shall not be public records and shall be exempt from disclosure under clause Twenty-sixth of section 7 of chapter 4 and section 10 of chapter 66 and (iv) upon request, to members of the public at no charge; provided, that this clause shall not apply to criteria and protocols that are determined to be proprietary by the commission.”; and

by inserting after section 81 the following 2 sections:-

“SECTION 81A. The second paragraph of section 12 of chapter 176O of the General Laws, as appearing in section 199 of chapter 224 of the acts of 2012, is hereby amended by striking out the third sentence and inserting place thereof the following sentence:- Utilization review criteria shall be applied consistently by a carrier or a utilization review organization and made easily accessible and up-to-date on a carrier or utilization review organization’s website to subscribers, health care providers and the general public in accordance with section 16 of chapter 6D.

SECTION 81B. Section 16 of said chapter 176O, as appearing in the 2012 Official Edition, is hereby amended by inserting after the word “public”, in line 27, the following words:- in accordance with section 16 of chapter 6D.”; and

by inserting after section 131 the following section:-

“SECTION 131A. Section 81A shall take effect on October 1, 2015.”.