Medical Records and Information

(1) For non-expedited reviews, the carrier or utilization review organization shall forward the insured’s medical and treatment records relevant to the review and created by or in the possession or control of the carrier and a copy of the carrier’s evidence of coverage applicable to the insured, to the identified external review agency within three business days of receipt of the notification provided pursuant to 958 CMR 3.408. It is the responsibility of the carrier to assemble a reasonably complete medical record or file, which shall include, but not be limited to, any medical records and medical opinions regarding medical necessity by the insured’s treating provider who requested or provided the disputed service. The carrier shall make good faith efforts to obtain records relevant to the review and not in the possession of the carrier from providers, whether the providers are in the carrier’s network or outside of the carrier’s network. Failure to make such good faith efforts shall be subject to the penalties listed at 958 CMR 3.412(2)(b). (2) For expedited reviews, the carrier or utilization review organization shall furnish to the identified external review agency the insured’s medical and treatment records relevant to the review and created by or in the possession or control of the carrier, and a copy of the carrier’s evidence of coverage applicable to the insured, within 24 hours of receipt of notification provided pursuant to 958 CMR 3.408. It is the responsibility of the carrier to assemble a reasonably complete medical record or file, which shall include, but not be limited to, any medical records and medical opinions regarding medical necessity by the insured’s treating provider who requested or provided the disputed service. The carrier shall make good faith efforts to obtain records relevant to the review and not in the possession of the carrier from providers, whether the providers are in the carrier’s network or outside of the carrier’s network. Failure to make such good faith efforts shall be subject to the penalties listed at 958 CMR 3.412(2)(b). (3) The carrier or utilization review organization or the insured or his or her authorized representative shall have access to all information filed by any party with the external review agency including any information filed pursuant to 958 CMR 3.412. (4) For the purposes of 958 CMR 3.409(1) and (2), "good faith efforts" shall be defined as no fewer than three reasonable documented attempts by the carrier to obtain the information from an in-network or out-of-network provider or the provider's designee.