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452 CMR 6.00: Utilization Review and Quality Assessment

Date: 01/27/2017
Organization: Department of Industrial Accidents
Regulatory Authority: MGL c. 152
Official Version: Published by the Massachusetts Register

This is an unofficial version of Commonwealth regulations and is posted here for the convenience of the public. It is not an official statement of the regulations.

452 CMR 6.01: Scope and Authority

452 CMR 6.00 - Utilization Review And Quality Assessment is promulgated pursuant to MGL c. 152, § 5, § 13, and § 30. 452 CMR 6.00 shall apply to all claims for health care services:

(a) requires workers' compensation insurers to undertake utilization review for all medical services to be provided to the injured employee after 12 weeks from the date of injury. The insurer may choose to undertake utilization review at any time during the 12 week period immediately following the date of injury. However, the insurer is mandated to undertake utilization review before denying any request for medical services during this initial 12 week period. Treatment guidelines are in effect during this 12 week period.

(b) references the guidelines and review criteria that the Department of Industrial Accidents (DIA) requires providers to consider when treating certain medical conditions, and sets forth the mechanism for the development, endorsement, dissemination, and implementation of future guidelines;

(c) sets forth the nature of utilization data that must be reported to the DIA;

(d) sets forth the methods for quality assessment that will be used by the DIA;

(e) sets forth the nature of the mechanisms that DIA will use to ensure compliance with 452 CMR 6.00; and

(f) concerns the appropriateness of the health care service, i.e., whether the service is reasonable, necessary, and effective; and the quality of care provided to workers' compensation recipients, including consideration of the proper costs of services.

452 CMR 6.02: Definitions

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.

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 - Utilization Review And Quality Assessment, 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/Director 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 .

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 MGL c. 152.

Health Care Services Board means the Board created by MGL c. 152, § 13(3).

Injury means personal injury as defined in MGL c. 152, § 1(7A).

Insurer means an entity defined in MGL c. 152, § 1(7) and any self insured group as defined in  MGL c. 152,  25E through MGL c. 152,  25U.

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.

OHP means Office of Health Policy which is a division of the DIA.

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 MGL c. 176I, 211 CMR 51.00 - PREFERRED PROVIDER HEALTH PLANS AND WORKERS’ COMPENSATION PREFERRED PROVIDER ARRANGEMENTS  and MGL c. 152, to provide all or a specified portion of health care services resulting from workers' compensation claims against such organizations by covered persons.

Prospective Review means utilization review conducted prior to the delivery of the requested medical services.

Provider means a practitioner, facility, or other organization providing health care services.

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.

452 CMR 6.03: Preferred Providers Arrangements Under Workers' Compensation

(1) If an insurer receives approval of a preferred provider arrangement (PPA), an injured employee shall, if the arrangement is consented to by the employer and includes a provider in the specialty sought by the employee, be required to see a member of the preferred provider arrangement on the initial scheduled visit. Employees subject to any arrangement shall be provided information regarding their rights and obligations under MGL c. 152, § 30 and MGL c. 176I upon initial approval of the preferred provider arrangement and annually thereafter. Such information shall also be posted in a prominent place in all worksites.

(2) The list of names of the providers in the preferred provider arrangement within an employee's geographic region or of all health care providers within the arrangement organized geographically shall be distributed to each covered employee immediately following an alleged workplace injury. The names on such lists shall be arranged in order of medical specialty or provider type. A current list shall also be posted at a convenient and prominent place for covered persons to examine at worksites, and shall be given to any covered person upon request.

(3) Any insurer approved as a preferred provider arrangement for workers' compensation must send to the Department of Industrial Accidents a duplicate copy of all information filed with the Division of Insurance together with a copy of its approval letter.

(4) The Department of Industrial Accidents may require the approved PPA applicant to survey affected employees with a form of the Department's design to assess the employee's understanding of their rights with regard to participation in PPA's.

452 6.04: Utilization Review by Insurers

(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 by the OHP. Said utilization review program must remain separate and distinct from case management and all other claim functions. Utilization review organization 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 MGL c. 152, §§ 13 and 30 apply, the programs shall integrate said treatment guidelines.

(2) Application for Approval. An application requesting approval to conduct utilization review in the Commonwealth shall:

       (a) submit a completed application to the OHP 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 $1,000.00 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 limited to the following:

        (a) corporate and site demographics: name, address, and telephone number of the program;s corporate and Massachusetts contacts; and the identification of each site where Massachusetts utilization review will be conducted;
        (b) a list of all treatment guidelines which will be used by the licensed medical reviewer in rendering a determination, including DIA Treatment Guidelines, approved 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 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 website. 

(5) All utilization review agents shall comply with the following procedures:

(a) All determination letters must set forth the relevant section of the treatment guideline referenced and provide a clinical rationale. An adverse determination letter shall include instructions for the procedure to initiate an appeal of the adverse determination. 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. For concurrent reviews, if the ordering practitioner contacts the UR agent at least three business days prior to the start date for the ongoing treatment, written notice of the determination shall be given at least one day prior to the start/implementation date. If the ordering practitioner fails to request approval of ongoing treatment at least three business days prior to the start date, or fails to provide a start date, the UR agent shall issue the determination within five business days from the receipt of the request. For retrospective reviews, written notice of the determination shall be given within 20 business days from receipt of the request for approval of treatment.

If additional medical information is necessary in order to complete the review, the utilization review agent shall inform the requesting health care provider of the specific medical information needed, and the time period in which the information must be provided. Prospective and Concurrent Reviews: information must be provided within seven business days from the date of request. Retrospective Reviews: information must be provided within 30 business days from the date of request.

(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) Adverse determination letters must provide a description of the appeal procedure and 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 business 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 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 MGL 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: Claims And Complaints under the provisions of MGL 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 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.

452 CMR 6.05: Utilization Reporting

(1) Providers must use, and insurers must accept, standard forms prescribed by the DIA, based on the most recent Center for Medicare and Medicaid Services forms. 

(2) The Department may require utilization review agents to provide a sample of up to 100% of all billing records, both inpatient and outpatient, which sample shall be transmitted to the Department of Industrial Accidents so that the Department can implement appropriate utilization oversight. In addition to the standard billing file, for every outpatient service the Department may request information about the insurer, any procedures, and the employer's and provider's identification numbers. For inpatient services, the Department must receive all relevant diagnostic and procedure International Classification of Disease (ICD) codes, Current Procedural Terminology (CPT) and other codes, the length of stay and the cost of any ancillary services. The Department may require both counts of services as well as the amount reimbursed.

452 CMR 6.06: Treatment Guideline Development

(1) In promulgating 452 CMR 6.00, the Commissioner hereby utilizes the treatment guidelines developed and endorsed by the Health Care Services Board, recognizing that medical treatment cannot be reduced to regulation and that health care providers must be free to exercise their best judgements about the treatment of their patients. 

(2) The Health Care Services Board will review and update treatment guidelines at least annually. Providers shall consider the treatment guidelines endorsed by the Health Care Services Board and adopted by the Commissioner when caring for injured employees or risk nonpayment. The guidelines should not be construed as including all proper methods of care reasonably directed to obtaining the same results. The ultimate judgement regarding any specific procedure or treatment must be made by the provider in light of all circumstances presented by the injured employee and the needs and resources particular to the locality or facility. The adopted guidelines shall be used by utilization review programs administered by insurers in a form required by the Department, taking into account that appropriate care may vary on a case by case basis.

452 CMR 6.07: Quality Assessment and Enforcement

(1) General Rules for Compliance Enforcement. Pursuant to 452 CMR 6.00 - Utilization Review And Quality Assessment , the Office of Health Policy of the DIA monitors utilization review agents and their programs to ensure full compliance with Massachusetts General Laws and 452 CMR 6.00. Specific enforcement mechanisms include, but are not limited to, the following:

(a) The Commissioner may revoke or refuse to renew a license of a self‑insurer for the failure of any self‑insurer to comply with all applicable laws, rules, regulations, orders, and requirements of the Commonwealth.

(b) The Commissioner may revoke or refuse to renew the approval of the utilization review agent for failure to comply with all applicable laws, rules, regulations, orders, and requirements of the Commonwealth.

(2) The Department of Industrial Accidents will gather data on compliance with the treatment guidelines through reports from insurers and utilization review agents.

(3) If the Department finds that the care provided to injured employees through an insurer is more frequently deficient than that provided to other employees in receipt of workers' compensation, the Department will address this issue with the insurer by referring matters to the Division of Insurance.

(4) The Department shall monitor the utilization review techniques used, and determinations made, by utilization review agents. If the Commissioner receives a complaint from a practitioner, employer, or employee, or has reason to believe that a utilization review agent has been or is engaged in conduct that violates 452 CMR 6.00, the Commissioner shall notify the utilization review agent in writing of the alleged violation. The utilization review agent shall have 14 days from the date the notice is received to respond to the alleged violation. On or after the 14th day, the Commissioner shall render a finding after reviewing all documents submitted by the parties. The Commissioner may also schedule a hearing. If the Commissioner determines that the utilization review agent has violated or is in violation of any law, rule, regulation, order, or requirement, the Commissioner may issue an order requiring the insurer and/or utilization review agent to cease and desist from engaging in the violation(s). The Commissioner may also suspend or revoke the agent's approval to conduct utilization review and may assess a fine.

If the utilization review agent requests a hearing regarding the findings of the Commissioner, the request must be made in writing within 14 days from receipt of the findings. Upon receipt of the request, the Director shall schedule a hearing to be conducted pursuant to MGL c. 152, § 30A.

If the Commissioner renders a finding that the utilization agent has violated any law, rule, regulation, order, or requirement, the utilization review agent must inform the adjuster handling the injured employee's claim.

(5) A Cease and Desist order may include:

(a) a summary of the violation(s);

(b) a summary of the facts giving rise to the violation(s);

(c) the penalty that the Commissioner intends to apply; and

(d) information pertaining to the rights and obligations of the utilization review agent; as well as the procedure for the agent to file a written response or request a hearing.

(6) Non‑compliance Categories include but are not limited to:

(a) Failure of an insurer/self‑insurer to conduct a proper utilization review in accordance with 452 CMR 6.00.

(b) Failure of the utilization review agent to render a written determination to both the injured employee and the ordering provider within the proper time constraints.

(c) Failure of the utilization review agent to ensure an appeal level review is conducted by a same-school practitioner.

(d) Failure of the utilization review agent to issue a written introductory letter within the required time period.

(e) Failure of the utilization review agent to use the diagnosis and/or ICD code selected by the ordering provider when determining medical necessity and appropriateness of care.

(f) Failure of the utilization review agent to cite the correct, research based treatment guideline when rendering a determination.

(g) Failure of the utilization review agent to document clinical rationale to support the determination.

(h) Failure of the utilization review agent to utilize only licensed personnel to determine medical necessity and appropriateness for all health care services under review.

(i) Failure of the utilization review agent to maintain all required records in the form and manner prescribed by the OHP.

(j) Failure to inform the OHP of any material change to the approved utilization review application within 30 days of said change.

(k) Failure to adhere to the quality assurance and quality control measures set forth in the utilization review application.

(l) Failure to maintain hours of operation between 9:00 A.M. and 5:00 P.M. on each business day, and return after hour calls within one business day.

(m) Failure to inform the OHP of each site where utilization review is being conducted for Massachusetts claims.

(n) Failure of the utilization review agent to comply with audits.

(o) Failure of the medical director and school to school reviewers to maintain an active clinical practice of at least eight hours per week.

(p) Failure to conduct initial reviews at the approved utilization review site.

(7) Quality Assessment Audit Review Procedures.

(a) The OHP monitoring of the quality of care rendered to injured employees shall include, but not be limited to: onsite audits; desk audits; and review of patient satisfaction surveys, complaints, and statistical data provided by utilization review agents, insurers, and self‑insurers. Desk audits shall consist of review of case records selected by the OHP. The OHP may also monitor the performance of providers reimbursed by insurers.

(b) Approved utilization review agents shall comply with all requests for onsite and desk audits for continued utilization review approval.

(c) Utilization review agents are required to pay all reasonable travel expenses for each onsite audit of the OHP representatives.

(d) The OHP will determine the type of audit to be conducted (onsite or desk). The utilization review agent will be notified prior to the scheduled audit date. The agent shall submit a list of all utilization reviews conducted for the period specified by OHP. The OHP will notify the agent which files must be made available for the audit. The agent will make each sample record available, in hard copy, for review on the audit date.

(e) OHP audits are conducted yearly. However, if at any time the OHP has reason to believe that the agent is not in full compliance with the laws, rules, regulations, orders, and requirements, by way of complaint or any other means, the agent's approval status may be reviewed and an immediate audit may conducted.

(f) The Office of Health Policy, at the direction of the Commissioner, may implement internal OHP policies and procedures at any time to ensure and improve the quality of the utilization review program.

(8) Fines.

(a) Failure to comply with all applicable rules, regulations, orders and requirements of the OHP may result in a fine of up to $300.00 per violation.

(b) Should the utilization review agent violate a cease and desist order within one year from the issuance date, additional fines may be assessed based on the violation. Penalties shall be additional fines of up to $300.00 per occurrence, or may result in the Commissioner revoking the utilization review agent's continued approval.

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