Bill > H1006

This bill aims to standardize how medical necessity reviews are conducted for Medicaid recipients by requiring that any adverse determination, which is a decision to deny, reduce, or terminate healthcare services based on not meeting medical necessity requirements, must be justified using national evidence-based medical standards and criteria. Specifically, when a healthcare provider's request for services is denied, the state's division responsible for Medicaid must provide a written explanation that includes the specific information used for the denial, the recipient's condition and why it doesn't meet national standards, any alternative treatments offered, and the clinical guidelines used. The bill also mandates a quick reconsideration process, occurring within one working day, between the treating provider and a clinical peer reviewer, who is a qualified healthcare professional practicing in a similar specialty, to address adverse determinations before a provider needs to go through the full appeal process.