Expedited Internal Review of Adverse Determinations

(1) A carrier or utilization review organization shall provide for expedited internal review of an adverse determination concerning a carrier's coverage or provision of immediate and urgently needed service(s), that meets the minimum requirements of 958 CMR 3.309. (a) For purposes of 958 CMR 3.309, immediate and urgently needed service(s) means, in the opinion of the health care professional responsible for the treatment or proposed treatment: 1. the service is medically necessary; 2. a denial of coverage for such service(s) would create a substantial risk of serious harm to the insured; and 3. such risk of serious harm is so immediate that the provision of such service(s) should not await the outcome of the normal internal grievance process. (b) A carrier or utilization review organization shall provide a written resolution of an expedited internal review in compliance with 958 CMR 3.307 as soon as possible and no later than 72 hours after receipt of the request for expedited review, or as otherwise specified in 958 CMR 3.309. A carrier or utilization review organization shall also provide a copy of the written resolution by any electronic means consented to by the insured. (c) If the expedited internal review process results in a final adverse determination, the written resolution must inform the insured or the insured’s authorized representative of: 1. the opportunity to request an expedited external review pursuant to 958 CMR 3.401; and 2. if the review involves the termination of ongoing services, the opportunity to request continuation of services pursuant to 958 CMR 3.414; and 3. a description of the insured’s right to request a conference pursuant to 958 CMR 3.310. (d) An insured or insured's authorized representative may file a request for an expedited external review at the same time as the insured or insured's authorized representative files a request for expedited internal review of the grievance pursuant to 958 CMR 3.401(4). (2) If the insured or the insured's authorized representative submits a request for expedited internal review while the insured is an inpatient in a hospital, a carrier or utilization review organization shall provide a written resolution of the expedited internal review before the insured's discharge from the hospital. For the purposes of 958 CMR 3.309(2) only, and only while the insured is an inpatient, a health care professional or a representative of the hospital may be the insured's authorized representative without a written authorization by the insured. (3) When a grievance is submitted by an insured with a terminal illness, or by the insured’s authorized representative on behalf of the insured with a terminal illness, a resolution shall be provided to the insured or insured’s authorized representative within five business days from the receipt of such grievance, except that grievances regarding urgently needed services for such insureds shall be resolved within 72 hours. (4) A carrier or utilization review organization shall provide for automatic reversal of decisions denying coverage for service(s) or durable medical equipment within 48 hours, or earlier, pending written resolution of the expedited internal review process, as follows: (a) A carrier or utilization review organization shall provide for automatic reversal of the decision within 48 hours of receipt of certification by the physician responsible for the treatment or proposed treatment that is the subject of the grievance that, in the physician's opinion: 1. the service(s) or durable medical equipment is medically necessary; 2. a denial of coverage for such service(s) or durable medical equipment would create a substantial risk of serious harm to the patient; and 3. such risk of serious harm is so immediate that the provision of such service(s) or durable medical equipment should not await the outcome of the normal grievance process. (b) For durable medical equipment, in the event the certifying physician exercises the option of automatic reversal earlier than 48 hours, the physician must further certify as to the specific, immediate and severe harm that will result to the patient absent action within the 48-hour time period.