Adverse Determination means a determination by the utilization review agent that a health care service has been reviewed, and based on the information provided, does not meet the clinical requirements for medical necessity and reasonableness of said service in accordance with medical guidelines.
Approved Utilization Review Agent means any person or entity, insurer or self‑insurer, including the Commonwealth of Massachusetts, which has been authorized by the DIA to perform utilization review.
Authorization means a determination by the utilization review agent that a health care service has been reviewed, and based on the information provided, meets the clinical requirements for medical necessity and reasonableness of said service in accordance with medical guidelines.
Case Record means the complete record that is maintained by the utilization review agent and pertains to the injured employee's industrial injury. The case record shall include all of the following information and documents: date of injury; date of utilization review request; name of claim adjuster; name, address, telephone number, and school of ordering practitioner; International Classification of Disease (ICD) code and diagnosis; name, title, and credentials of utilization review staff; health care service requested; treatment guideline used to determine medical necessity; type and category of review; and supporting medical documentation.
Cease and Desist Order means a written notice of a violation issued by the Commissioner pursuant to 452 CMR 6.00 et seq., when the Commissioner determines that a utilization review agent, insurer, or self‑insurer has failed to comply with all applicable laws, rules, regulations, orders, and requirements of the Commonwealth.
Clinical Reviewer means a licensed health care professional who holds a non‑restricted license in any state.
Commissioner means the Commissioner of the Department of Industrial Accidents (DIA).
Concurrent Review means utilization review conducted during the patient's course of treatment.
Department/DIA means Department of Industrial Accidents .
Detailed Description of Services Rendered means pursuant to M.G.L. c. 152, § 13 a report demonstrating the diagnosis, medical appropriateness of the service, pertinent physical findings, diagnostic and therapeutic procedures, prognosis, concurrent problems, and follow‑up care; the injured employee's functional limitations, the ability to perform either regular duties, limited duties, full or part time hours and whether the medical condition is at a point of maximum medical improvement.
Emergency Treatment means care of an employee for a work‑related medical condition requiring immediate attention.
Guidelines mean optimal strategies for patient management around which practice patterns should converge.
Health Care Services means treatment services rendered to an injured employee by a provider pursuant to M.G.L. c. 152.
Health Care Services Board means the Board created by M.G.L. c. 152, § 13(3).
Injury means personal injury as defined in M.G.L. c. 152, § 1(7A).
Insurer means an entity defined in M.G.L. c. 152, § 1(7) and any self insured group as defined in M.G.L. c. 152, § 25(E) through (U).
Medical Condition means the physical or mental health status of an injured employee as determined by the provider administering health care services.
Medical Director means a board certified physician duly licensed to practice in at least one state in the United States, and in active practice at least eight hours per week. The OHP may waive the active practice requirement for otherwise qualified, licensed physicians with administrative experience in utilization review oversight or quality assessment. Each utilization review organization shall have available a licensed medical director to provide for clinical oversight of the utilization review program.
Medical Report means a report of the Initial Industrial Accident office visit as defined in 114.3 CMR 40.03 pursuant to 452 CMR 1.13(1).
OHP means Office of Health Policy which is a division of the DIA.
Patient Satisfaction Measurement means use of a standard patient questionnaire form, including, but not limited to, the American College of Physicians questionnaire to determine a particular individual's satisfaction with his or her care.
Practitioner means any person who is licensed to practice under the laws of the jurisdiction within which such health care services are rendered including physicians, dentists, chiropodists, chiropractors, optometrists, osteopaths, physical therapists, podiatrists, psychologists, and other licensed medical personnel.
Preferred Provider Arrangement (PPA) means a contract between or on behalf of an organization and health care provider(s), as defined by M.G.L. c. 176I, 211 CMR 112.00 and M.G.L. c. 152, to provide all or a specified portion of health care services resulting from workers' compensation claims against such organizations by covered persons.
Probationary Approval means a temporary six‑month approval status after the utilization review agent fails a quality assessment audit. During this six‑month period, the utilization review agent may continue to conduct utilization review pending the results of interim follow up audits.
Prospective Review means utilization review conducted prior to the delivery of the requested medical service.
Provider means a practitioner, facility, or other organization providing health care services.
Quality Assessment Tool is a guide used to evaluate the utilization review agent's quality assessment compliance rate.
Retrospective Review means utilization review conducted after services have been rendered.
School means a grouping of practitioners as defined by their professional degree. Schools include, but are not limited to, medical, physical and occupational therapy, chiropractic, osteopathic, allopathic, nursing and dentistry.
Utilization Review concerns the quality of care provided to injured employees, including whether the service is appropriate and effective, the proper costs of services, and the quality of treatment. Appropriate service is health care service that is medically necessary and reasonable, and based on objective, clinical findings.
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