Bill > H1157

This bill aims to establish national standards and requirements for Medicaid medical necessity reviews. It defines "adverse determination" as a decision by a clinical peer reviewer to deny, reduce, modify, or terminate a medical service due to a lack of medical necessity, appropriateness of setting, or effectiveness. The bill also specifies that the Division of Medical Assistance must provide a written notification of any adverse determination, including a clinical justification based on national evidence-based standards and the ability for providers to seek reconsideration of such determinations within one working day. This process is intended to promote more transparent and consistent Medicaid medical necessity reviews across the state.