Massachusetts Regulations 452.6.04

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§ 452.6.04 Utilization Review By Insurers

(1) Insurers must either contract with agents who provide utilization review services to develop utilization review programs or develop their own utilization review programs for both outpatient and inpatient health care services. These programs may include, but not be limited to: prospective, concurrent or retrospective review; second opinion programs; or mandatory ambulatory surgery programs.

For the conditions to which the treatment guidelines endorsed by the Health Care Services Board and adopted by the Commissioner pursuant to M.G.L. c. 152, Secs. 13 and 30 apply, the programs shall integrate said treatment guidelines. The only utilization review criteria which can be applied relative to medical conditions addressed by said treatment guidelines are those criteria published by the Department.

(2) To conduct utilization review in the Commonwealth, a utilization review agent must request approval of its utilization review program from the Commissioner in writing and shall file the following information:

(a) The name, address, telephone number, contact person, and normal business hours of the utilization review agent;

(b) Review criteria: source(s) of criteria, (name of utilization review agent or whether internally derived), type(s) of criteria (i.e., diagnostic, treatment), process for and frequency of revisions, protocols and/or decision rules for utilization review determinations, and public availability of criteria;

(c) Current professional licenses issued by the appropriate state licensing agency for all providers rendering utilization review determinations;

(d) A detailed description of the appeal procedures for utilization review determinations, a copy of the materials designed to inform employees of the requirements of the utilization review program and the responsibilities and rights of employees under the program; and

(e) Disclosure of any economic incentives for reviewers in the utilization review program.

Any material changes in the information filed in accordance with 452 CMR 6.04 shall be filed with the Commissioner within 30 days of said change. The utilization review agent shall comply with all applicable laws, rules, regulations, ordinances, orders or requirements of the Commonwealth.

(3) The Department will annually publish the list of approved utilization review agents, and the nature of their utilization review programs.

(4) All utilization review agents shall, at a minimum, meet the following standards:

(a) Any adverse determination by a utilization review agent as to an admission, service, or procedure following the health care providers' submission of a detailed description of the services rendered, as required by M.G.L. c. 152, Sec. 13, shall be reviewed by a practitioner as defined in 452 CMR 6.02 herein. When the service is one ordered by a practitioner, such review shall be conducted by a practitioner in the same school;

(b) Notification of all adverse determinations by the utilization review agent shall be communicated to the provider of record and the injured employee or other appropriate individual in writing. For prospective review, notice must occur within two business days of the receipt of the request for determination and the receipt of all information necessary to complete the review. For concurrent review, the notification should be within one day prior to implementation (i.e., discharge) and for retrospective review, the notification should be within ten days of the adverse determination;

(c) Any notification to the provider and the injured employee of an adverse determination must include the review criteria and all the reasons for the determination and the procedure to initiate an appeal of the determination.

Utilization review agents shall maintain and make available a written description of the appeal procedure by which the attending practitioner and/or the injured employee may seek review of a determination by the utilization review agent. The appeal procedure, at a minimum, shall provide for the following:

1. When an adverse determination not to approve a health care service is made prior to or during an ongoing service requiring review, and the injured employee and/or the provider believes that the determination warrants immediate appeal, the injured employee and/or the provider shall have an opportunity to appeal that determination over the telephone to the utilization review agent, with the right to speak to a practitioner of the same school on an expedited basis, said appeal to occur not later than 30 days from the date of receipt of notice of adverse determination. Utilization review agents shall complete the adjudication on an expedited basis, but at least within two business days of the date the appeal is made

2. Utilization review agents shall complete the adjudication of all other appeals of adverse determinations no later than 20 days from the date the appeal is filed;

(d) Utilization review agents shall make staff available by toll-free telephone at least 40 hours per week between the hours of 9:00 AM to 5:00 PM, EST;

(e) Utilization review agents shall have a telephone system capable of accepting or recording incoming telephone calls during other than normal business hours and shall respond to these calls within two business days of its receipt. If the utilization review agent maintains a pre-certification program, then telephone contact shall be available 24 hours a day.

Once an insurer has commenced payments for a work related injury under M.G.L. c. 152, it must issue the employee a card listing the employee name, an identification number assigned to the employee, the name and telephone number of the utilization review agent, and the name of the insurer. When the employee seeks further care, he or she must contact the utilization review agent for approval.

In the case of an emergency, utilization review agents shall allow a minimum of 24 hours after an emergency admission, service, or procedure for an injured employee or injured employee's representative to notify the utilization review agent and request approval for treatment;

(f) Utilization review agents shall comply with all applicable laws to protect the confidentiality of medical records and, where necessary, obtain a medical release; and

(g) Practitioners rendering utilization review determinations must provide patient care for at least eight hours per week.

(5) After exhaustion of the process set forth in 452 CMR 6.04(4)(c) appealing the determination of the utilization review agent, or if payment of an approved claim has not been issued within 45 days, a party may file a claim or complaint in accordance with 452 CMR 1.07 under the provisions of M.G.L. c. 152, Secs. ( 8)( 4) and/or 10.

(6) Injured employees may be liable for care subsequent to the adverse determination after they have been notified of that adverse determination.