By Mr. Spellane of Worcester, petition (accompanied by bill, House, No. 870) of Robert P. Spellane and Joyce A. Spiliotis relative to administrative simplification under the health consumer protection law.  Environment, Natural Resources and Agriculture.

The Commonwealth of Massachusetts

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PETITION OF:

Robert P. Spellane

Joyce A. Spiliotis

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In the Year Two Thousand and Seven.

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An Act relative to administrative simplification.

    Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority of the same, as follows:

SECTION 1. Section 12 of chapter 176O of the General Laws, as appearing in the 2002 Official Edition, is hereby amended by striking out subsections (b) and (c) and inserting in place thereof the following subsections:—

            (b) A carrier or utilization review organization shall make a determination regarding the medical necessity of a proposed admission, procedure or service that requires a determination within two working days of obtaining all necessary information. For purposes of this section, “necessary information” shall include the results of any face-to-face clinical evaluation or second opinion that may be required.
            In the case of a determination to approve an admission, procedure or service, the carrier or utilization review organization shall notify the provider rendering or requesting the service within 24 hours. In the case of an adverse determination, the carrier or utilization review organization shall notify the provider rendering or requesting the service within 24 hours, and shall provide written or electronic confirmation of the notification to the insured and the provider within one working day thereafter.
            (c) A carrier or utilization review organization shall make a concurrent review determination within one working day of obtaining all necessary information.
            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 or requesting the service within one working day.
            In the case of an adverse determination, the carrier or utilization review organization shall notify the provider rendering or requesting the service within 24 hours and shall provide written or electronic notification to the insured and the provider within one working day thereafter. The service shall be continued without liability to the insured until the insured has been notified of the determination.

            SECTION 2. Subsection (a) of section 6 of Chapter 176O of the General Laws, as so appearing in the 2002 Official Edition, is hereby amended by striking out clause (2) thereof.