Bill > S724

This bill aims to administer national standards to Medicaid medical necessity reviews. It defines "adverse determination" as a denial, reduction, modification, or termination of an admission, continued inpatient stay, or the availability of other healthcare services due to a failure to meet the requirements for coverage based on medical necessity, appropriateness of healthcare setting, and level of care or effectiveness. The bill also requires the division to provide a written notification of adverse determinations that includes a clinical justification, the specific information used, the recipient's condition and treatment, any alternative options, and the applicable clinical practice guidelines and review criteria. Furthermore, the bill gives providers an opportunity to seek reconsideration of adverse determinations within one working day, which must be conducted between the provider and a clinical peer reviewer.

Health and Social Services

https://malegislature.gov/Bills/193/S724