Carrier's Medical Necessity Guidelines

(1) A carrier may develop guidelines to be used by the carrier in determining if services are medically necessary. Any such guidelines used by a carrier in determining if covered services are medically necessary shall be, at a minimum: (a) developed with input from practicing physicians and participating providers in the carrier's or utilization review organization's service area; (b) developed in accordance with standards adopted by national accreditation organizations; (c) updated at least biennially or more often as new treatments, applications and technologies are adopted as generally accepted professional medical practice; (d) evidence based, if practicable; (e) applied in a manner that considers the individual health care needs of the insured; (f) prior to implementation of any new or amended guidelines to be effective on or after April 28, 2023, assessed by the carrier or utilization review organization to show compliance with state and federal parity requirements as required by the Division of Insurance under M.G.L. c. 26, § 8K; and (g) otherwise compliant with applicable state and federal law. (2) In instances where the insured is enrolled in a health benefit plan where the carrier or utilization review organization provides only administrative services, the obligations of the carrier or utilization review organization related to payment as provided by M.G.L. c. 176O, § 16 and 958 CMR 3.100 are limited to recommending to the third party payer that coverage should be authorized. (3) Carriers or utilization review organizations shall provide utilization review criteria and clinical review criteria, including medical necessity criteria and protocols, in the following manner: (a) with a notice of adverse determination, as required at 211 CMR 52.00: Managed Care Consumer Protections and Accreditation of Carriers; (b) upon request to the Office of Patient Protection, provided, however, that licensed, proprietary criteria and protocols purchased by a carrier shall not be public records and shall be exempt from disclosure pursuant to M.G.L. c. 4, § 7, clause twenty-sixth and M.G.L. c. 66, § 10; (c) upon oral or written request to the general public, for criteria or protocols that are not licensed or proprietary; (d) upon oral or written request to insureds, prospective insureds and health care providers where criteria or protocols are licensed or proprietary and have been purchased by a carrier or utilization review organization, provided that the insured, prospective insured or health care provider identifies particular treatments or services for which applicable criteria or protocols are requested; or (e) as otherwise required by 958 CMR 3.000. (4) The carrier or utilization review organization shall publish criteria and protocols which are not licensed or proprietary on its publicly accessible website. Such criteria and protocols shall be up to date and easily accessible to the general public. The carrier or utilization review organization shall not implement any new or amended criteria or protocols until the carrier's or utilization review organization's website has been updated to reflect the new or amended criteria or protocols. (5) The carrier or utilization review organization shall provide a copy of the requested criteria or protocols in hard copy or electronic format as requested, and shall comply with all requests for criteria or protocols as promptly as possible and in accordance with applicable grievance and appeal time limits as required by 958 CMR 3.000, or within 21 days of receipt of a request.