Bill > S587

This bill amends existing Massachusetts law, specifically Chapter 176O, Section 12, concerning how health insurance carriers and utilization review organizations (companies that review the appropriateness of medical care) handle requests for medical services. It shortens the timeframe for these organizations to determine the medical necessity of a proposed admission, procedure, or service to two working days after receiving all necessary information, which includes any required in-person evaluations or second opinions. If a request is approved, the provider must be notified within 24 hours. In cases where a request is denied (an adverse determination), the provider must be notified within 24 hours, and both the insured individual and the provider must receive written or electronic confirmation of this denial within one working day. The bill also clarifies that for concurrent reviews, which involve reviewing ongoing care like extended hospital stays, a determination must be made within one working day of receiving necessary information. If an extension is approved, the provider gets notified within one working day. If an extension is denied, the provider is notified within 24 hours, and written or electronic confirmation goes to both the insured and provider within one working day, with the service continuing without cost to the insured until they are officially notified of the denial.