Form of Written Resolution of the Internal Grievance

(1) Each written resolution of an internal grievance shall include a clear summary explanation of the basis for the decision and identification of the specific information considered. (2) In the case of an internal grievance that involves an adverse determination, the written resolution shall include a substantive clinical justification for the final adverse determination 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; (c) discuss the insured's presenting symptoms or condition, diagnosis and treatment interventions; (d) explain in a reasonable level of detail the specific reasons the reviewer found that the medical evidence does not support a finding of medical necessity; (e) reference and include a copy of any applicable clinical review criteria or other clinical basis for the adverse determination; (f) if the carrier or utilization review organization specifies alternative treatment options which are covered benefits, include identification of providers who are currently accepting new patients; (g) provide a summary of the reviewer's professional qualifications, and a signed statement certifying that the reviewer meets the qualifications specified at 958 CMR 3.306(1) and, if applicable, 958 CMR 3.306(2); and (h) notify the insured or the insured's authorized representative of any available procedure for reconsideration of the decision by the carrier, pursuant to 958 CMR 3.308, and the procedures for requesting external review, including the procedures to request an expedited external review. (3) The carrier or utilization review organization must include with every written final adverse determination the following: (a) A paper copy of the form prescribed by the Office of Patient Protection for the request for external review, as well as instructions for locating the form on the Office of Patient Protection's website; (b) The toll-free number and other contact information for the Massachusetts consumer assistance program, and the consumer assistance toll-free number and other contact information maintained by the Office of Patient Protection, as applicable; and (c) A clear written list of additional documents and information available to the insured from the carrier, including the insured's entire claim file, and other documents and information which may be provided to the insured by the carrier pursuant to state or federal law. The carrier shall include instructions for obtaining these documents, including instructions explaining that the insured may request these documents by calling the carrier's toll-free telephone number for assisting insureds in resolving grievances. (4) A carrier or utilization review organization shall send each written resolution of an internal grievance to the insured or the insured’s authorized representative, if any, by certified or registered mail, or other express carrier with proof of delivery.