211 CMR 52.07 - Utilization Review

Current through Register 1466, April 1, 2022

(1) Standards. A Carrier's application will be reviewed for compliance with the applicable NCQA Standards for utilization management. In addition, Carriers shall meet the requirements identified in 211 CMR 52.07(2) through (10). In cases where the standards in 211 CMR 52.07(2) through (10) differ from those in the NCQA Standards, the standards in 211 CMR 52.07(2) through (10) shall apply.

(2) Written Plan. Utilization Review conducted by a Carrier or a Utilization Review Organization shall be conducted pursuant to a written plan, under the supervision of a physician and staffed by appropriately trained and qualified personnel, and shall include a documented process to:

(a) review and evaluate its effectiveness;

(b) ensure the consistent application of Utilization Review criteria; and

(c) ensure the timeliness of Utilization Review determinations.

(3) Criteria. A Carrier or Utilization Review Organization shall adopt Utilization Review criteria and conduct all Utilization Review activities pursuant to said criteria.

(a) The criteria shall be, to the maximum extent feasible, scientifically derived and evidence-based, and developed with the input of Participating Providers, consistent with the development of Medical Necessity criteria consistent with 958 CMR 3.101: Carrier's Medical Necessity Guidelines.

(b) Utilization Review criteria shall be up to date and applied consistently by a Carrier or the Utilization Review Organization and made easily accessible to subscribers, Health Care Providers and the general public on a Carrier's website; or, in the alternative, on the Carrier's Utilization Review Organization's website so long as the Carrier provides a link on its website to the Utilization Review Organization's website; provided, however, that a Carrier shall not be required to disclose licensed, proprietary criteria purchased by a Carrier or Utilization Review Organization on its website, but must disclose such criteria to a Provider or subscriber upon request.

(c) Any new or amended preauthorization requirement or restriction shall not be implemented unless the Carrier's and/or Utilization Review Organization's respective website has been updated to clearly reflect the new or amended requirement or restriction.

(d) Adverse Determinations rendered by a program of Utilization Review, or other denials of requests for Health Services, shall be made by a person licensed in the appropriate specialty related to such Health Services and, where applicable, by a Provider in the same licensure category as the ordering Provider.

(4) Initial Determination Regarding a Proposed Admission, Procedure or Service.

(a) When requiring prior authorization for a Health Care Service or Benefit, a Carrier shall use and accept, or a Carrier shall require and ensure that its Utilization Review Organization use and accept, only the prior authorization forms designated by the Commissioner for the specific types of Health Care Services and Benefits identified in the designated forms.

(b) If the Carrier fails to use or accept the designated prior authorization form, or fails to respond within two business days after receiving a completed prior authorization request from a Provider, pursuant to the submission of the prior authorization form under 211 CMR 52.07(4)(a), the prior authorization request shall be deemed to have been granted.

(c) In addition to any other requirements under applicable law, a Carrier shall make, or a Carrier shall require and ensure that its Utilization Review Organization makes, an initial determination regarding a proposed admission, procedure or service that requires such a determination within two working days of obtaining all necessary information. For purposes of 211 CMR 52.07, "necessary information" shall include the results of any face-to-face clinical evaluation or Second Opinion that may be required.

(d) In the case of a determination to approve an admission, procedure or service, the Carrier or Utilization Review Organization shall notify the Provider rendering the service by telephone within 24 hours, and shall send written or electronic confirmation of the telephone notification to the Insured and the Provider within two working days thereafter.

(e) In the case of an Adverse Determination, the Carrier or the Utilization Review Organization shall notify the Provider rendering the service by telephone within 24 hours, and shall send written or electronic confirmation of the telephone notification to the Insured and the Provider within one working day thereafter.

(f) Any new or amended Prospective Review requirement or restriction shall not be effective unless and until the Carrier's or Utilization Review Organization's website has been updated to reflect the new or amended requirement or restriction.

(g) Subject to 211 CMR 52.07(4)(a) through (f), nothing in 211 CMR 52.07(4) shall:

1. require a treating Health Care Provider to obtain information regarding whether a proposed admission, procedure or service is Medically Necessary on behalf of an Insured;

2. restrict the ability of a Carrier or Utilization Review Organization to deny a claim for an admission, procedure or service if the admission, procedure or service was not Medically Necessary, based on information provided at the time of claim; or

3. shall restrict the ability of a Carrier or Utilization Review Organization to deny a claim for an admission, procedure or service if other terms and conditions of coverage are not met at the time of service or time of claim.

(5) Concurrent Review. A Carrier or the Utilization Review Organization shall make a Concurrent Review determination within one working day of obtaining all necessary information.

(a) 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 the service by telephone within one working day, and shall send written or electronic confirmation to the Insured and the Provider within one working day thereafter. A written or electronic notification shall include the number of extended Days or the next review date, the new total number of Days or services approved, and the date of admission or initiation of services.

(b) In the case of an Adverse Determination, the Carrier or Utilization Review Organization shall notify the Provider rendering the service by telephone within 24 hours, and shall send written or electronic notification to the Insured and the Provider within one working Day thereafter.

(c) The service shall be continued without liability to the Insured until the Insured has been notified of the determination.

(6) Written Notice. The written notification of an Adverse Determination shall include a substantive clinical justification that is consistent with generally accepted principles of professional medical practice, and shall, at a minimum:

(a) include information about the claim including, if applicable, the date(s) of service, the Health Care Provider(s), the claim amount, and any diagnosis, treatment, and denial code(s) and their corresponding meaning(s);

(b) identify the specific information upon which the Adverse Determination was based shall explain the reason for any denial, including the specific Utilization Review criteria or Benefits provisions used in the determination, and;

(c) discuss the Insured's presenting symptoms or condition, diagnosis and treatment interventions;

(d) explain in a reasonable level of detail the specific reasons such medical evidence fails to meet the relevant medical review criteria;

(e) reference and include, or provide a website link(s) to the specifically applicable, clinical practice guidelines, medical review criteria, or other clinical basis for the Adverse Determination;

(f) a description of any additional material or information necessary for the Insured to perfect the claim and an explanation of why such material or information is necessary;

(g) if the carrier specifies alternative treatment options which are Covered Benefits, include identification of providers who are currently accepting new patients;

(h) prominently explain all appeal rights applicable to the denial, including a clear, concise and complete description of the Carrier's formal internal Grievance process and the procedures for obtaining external review pursuant to 958 CMR 3.000: Health Insurance Consumer Protection, and a clear, prominent description of the process for seeking expedited internal review and concurrent expedited internal and external reviews, including applicable timelines, pursuant to 958 CMR 3.000; and a clear and prominent notice of a patient's right to file a grievance with the with the Office of Patient Protection; and information on how to file a grievance with the Office of Patient Protection.

(i) prominently notify the Insured of the availability of, and contact information for, the consumer assistance toll-free number maintained by the Office of Patient Protection, and if applicable, the Massachusetts consumer assistance program; and

(j) include a statement, prominently displayed in at least the languages identified by the Centers for Medicare & Medicaid Services as the top non-English languages in Massachusetts, that clearly indicates how the Insured can request oral interpretation and written translation services from the Carrier consistent with 958 CMR 3.000: Health Insurance Consumer Protection.

(7) Reconsideration of an Adverse Determination. A Carrier or Utilization Review Organization shall give a Provider treating an Insured an opportunity to seek reconsideration of an Adverse Determination from a Clinical Peer Reviewer in any case involving an initial determination or a Concurrent Review determination.

(a) The reconsideration process shall occur within one working day of the receipt of the request and shall be conducted between the Provider rendering the service and the Clinical Peer Reviewer or a clinical peer designated by the Clinical Peer Reviewer if the reviewer cannot be available within one working day.

(b) If the Adverse Determination is not reversed by the reconsideration process, the Insured, or the Provider on behalf of the Insured, may pursue the Grievance process established pursuant to 958 CMR 3.000: Health Insurance Consumer Protection.

(c) The reconsideration process allowed pursuant to 211 CMR 52.07(7) shall not be a prerequisite to the internal Grievance process or an expedited appeal required by 958 CMR 3.000: Health Insurance Consumer Protection.

(8) Continuity of Care. A Carrier must provide evidence that its policies regarding continuity of care comply with all provisions of 958 CMR 3.000: Health Insurance Consumer Protection.

(9) Workers' Compensation Preferred Provider Arrangement. A Carrier that provides specified services through a workers' compensation preferred provider arrangement shall be deemed to have met the requirements of 211 CMR 52.07, except 211 CMR 52.07(10), if it has met the requirements of 452 CMR 6.00: Utilization Review and Quality Assessment.

(10) Annual Survey. A Carrier or Utilization Review Organization shall conduct an annual survey of Insureds to assess satisfaction with access to primary care services, specialist services, ancillary services, hospitalization services, durable medical equipment and other covered services.

(a) The survey shall compare the actual satisfaction of Insureds with projected measures of their satisfaction.

(b) Carriers that utilize Incentive Plans shall establish mechanisms for monitoring the satisfaction, quality of care and actual utilization compared with projected utilization of Health Care Services of Insureds.

(11) Religious Non-medical Treatment and Providers. Nothing in 211 CMR 52.07 shall be construed to require Health Benefit Plans to use medical professionals or criteria to decide insured access to Religious Non-medical Providers, utilize medical professionals or criteria in making decisions in internal appeals from decisions denying or limiting coverage or care by Religious Non-medical Providers, compel an Insured to undergo a medical examination or test as a condition of receiving coverage for treatment by a Religious Non-medical Provider, or require Health Benefit Plans to exclude Religious Non-medical Providers because they do not provide medical or other data otherwise required, if such data is inconsistent with the religious non-medical treatment or nursing care provided by the Provider.

Notes

211 CMR 52.07

Amended by Mass Register Issue 1345, eff. 8/11/2017.