(1) Insurers and self‑insurers are required to undertake utilization review for health services rendered to injured employees, either by performing utilization review themselves or by contracting with a Commonwealth approved agent who will conduct utilization review services on their behalf. If an insurer or self‑insurer chooses to perform utilization review on its own, it must have its program approved through the OHP. Said utilization review program must remain separate and distinct from case management and all other claim functions. Utilization review organizations conducting Massachusetts reviews at multiple sites must seek separate approval for each site.
For the conditions to which the treatment guidelines endorsed by the Health Care Services Board and adopted by the Commissioner pursuant to M.G.L. c. 152, §§ 13 and 30 apply, the programs shall integrate said treatment guidelines.
(2) Application for Approval. An applicant requesting approval to conduct utilization review in the Commonwealth shall:
(a) submit a completed application to the OHP for each site where Massachusetts utilization review will be conducted, along with an initial application fee payable to the DIA. The application fee shall be $1,000.00 if the company is located in Massachusetts, excluding the Commonwealth and the various counties, cities, towns and districts; and $3,000.00 if the company is located outside of Massachusetts;
(b) submit a new application to the OHP every two years, along with a renewal fee. The renewal fee shall be $500.00 if the company is located in Massachusetts; and $1,500.00 if the company is located outside of Massachusetts; and
(c) make arrangements with the OHP for a site visit for all new applicants.
(3) Information Required with Application. To conduct utilization review in the Commonwealth, a utilization review agent must seek approval of its utilization review program from the Commissioner in writing and the application shall include, but not be limited to the following:
(a) corporate and site demographics: name, address, and telephone number of the program's corporate, public, and Massachusetts contacts; and the identification of each site where Massachusetts utilization review will be conducted along with the name and number of the contact person for each site;
(b) a list of all treatment guidelines which will be used by the licensed medical reviewer in rendering a determination, including DIA's Health Care Services Board Treatment Guidelines, secondary sources, and internally derived treatment guidelines. The utilization review agent shall also provide information pertaining to the procedures for implementing internal guidelines including the frequency of revisions;
(c) copies of all current professional licenses issued by the appropriate state licensing agency for all practitioners rendering utilization review determinations, including the medical director;
(d) a detailed description of the appeal procedures for utilization review determinations, including copies of all materials designed to inform injured employees of the requirements of the utilization review program and their responsibilities and rights under the program;
(e) the identity of each insurer/self‑insurer for which the utilization review agent performs Massachusetts reviews;
(f) an attestation in writing that the utilization review agent shall comply with all applicable laws, rules, regulations, orders, and requirements of the Commonwealth; and
(g) disclosure of any economic incentives for reviewers in the utilization review program.
Any material changes in the information filed in accordance with 452 CMR 6.04 shall be filed with the OHP within 30 days of said change.
(4) The OHP will publish the name and address of each approved UR agent on the DIA web site.
(5) All utilization review agents shall comply with the following procedures:
(a) All determination letters must identify the treatment guideline and set forth the clinical rationale. An adverse determination letter shall include instructions for the procedure to initiate an appeal of the adverse determination, and set forth the relevant section of the treatment guideline. A copy of the relevant section of the guideline must be provided upon request. The start and end dates for all scheduled health care services shall be clearly documented in the utilization review case note summary and on the determination notice. The date of request and the date of receipt of medical information must be documented by the utilization review agent in the utilization review case record.
(b) Notification of all utilization review determinations issued by the utilization review agent shall be communicated to the injured employee/representative and the ordering provider in writing. For prospective reviews, written notice of the determination shall be given within two business days from receipt of the request for approval of treatment and the receipt of all medical information necessary to conduct the review. For concurrent reviews, written notice of the determination shall be given at least one day prior to implementation, i.e., the start date for the ongoing health care service under review, and the receipt of all medical information necessary to conduct the review. For retrospective reviews, written notice of the determination shall be given within 20 business days from receipt of the request for approval of treatment and the receipt of all medical information necessary to conduct the review.
(c) Any adverse determination of a health care service issued by a utilization review agent shall be issued by a practitioner of the same school as the ordering provider.
(d) Utilization review agents shall maintain and make available a written description of the appeal procedure by which the ordering provider or the injured employee may seek review of an adverse determination by the utilization review agent. The appeal procedure, at a minimum, shall provide the following:
1. When an adverse determination is rendered during prospective or concurrent review, and the injured employee and/or the ordering provider believes that the determination warrants immediate appeal, the injured employee or the ordering provider may initiate the appeal via telephone to the utilization review agent with the right to communicate orally with a practitioner of the same school as the ordering provider on an expedited basis. The ordering provider or injured employee should be instructed to follow‑up with a written request for the appeal. If the injured employee or ordering provider fails to comply, the utilization review agent should send a written confirmation of the appeal request. Said notice of appeal to occur no later than 30 days from the date of receipt of notice of adverse determination. Utilization review agents shall complete the adjudication on an expedited basis and render the determination no later than two business days from the date the appeal is initiated, unless the ordering provider agrees to a different time period.
2. Appeal of retrospective reviews shall be made in writing to the utilization review agent and occur no later than 30 days from the date of receipt of notice of adverse determination. Utilization review agents shall complete the adjudication of a retrospective review/standard appeal no later than 20 days from the date the appeal is filed.
(e) Utilization review agents shall make staff available by toll‑free telephone system at least 40 hours per week between the hours of 9:00 A.M. to 5:00 P.M., EST each business day.
(f) Utilization review agents shall have a confidential telephone system capable of accepting and recording incoming telephone calls during other than normal business hours, and the agent shall respond to these calls on the following business day.
(g) Utilization review agents shall comply with all applicable laws to protect the confidentiality of medical records and when necessary, obtain a medical release.
(h) Practitioners rendering school to school utilization review determinations and medical directors must provide, and attest in writing to providing, patient care for at least eight hours per week.
(i) Once an insurer has commenced payment for a work related injury under M.G.L. c. 152, it must issue the employee a card listing the employee name, an identification number assigned to the employee, the name and telephone number of the utilization review agent, and the name of the insurer. The employee must seek approval from the insurer/utilization review agent before receiving medical services. In the case of an emergency, utilization review agents shall allow a minimum of 24 hours after an emergency admission, service, or procedure for an injured employee or injured employee's representative to notify the utilization review agent and request approval for treatment.
(j) Initial level reviews must be conducted at the location of the approved utilization review site.
(6) After exhaustion of the process set forth in 452 CMR 6.04(5)(d), a party may file a claim or complaint in accordance with 452 CMR 1.07 under the provisions of M.G.L. c. 152, § 10.
(7) Injured employees may be liable for care subsequent to the adverse determination after they have been notified of that adverse determination.
(8) Ancillary Services. 452 CMR 6.00 et seq. concerns the requirements for the performance of utilization review. Should an insurer or self‑insurer provide ancillary services such as managed care, case management, independent medical exams, or rehabilitation services from vendors who are also approved as utilization review agents, said ancillary services are not to be considered utilization review requirements or expenses. Ancillary services must remain separate and distinct from the utilization review services. Moreover, these ancillary services should not be construed as approved by the OHP by virtue of the OHP's approval of the same vendor to perform utilization review.
(9) Each insurer/self‑insurer is required to inform the OHP of the name of the approved utilization review agent currently responsible for conducting the reviews.