Bill > H614

This bill aims to establish national standards for Medicaid medical necessity reviews. It defines key terms such as "adverse determination" (a decision to deny, reduce, modify, or terminate medical services based on lack of medical necessity or appropriateness) and "clinical peer reviewer" (a licensed healthcare professional who is board-certified in the relevant specialty and whose compensation is not tied to the services approved or denied). The bill requires the state Medicaid agency to provide a detailed written justification for any adverse determinations, including the specific evidence and criteria used, and to allow providers to seek a same-day reconsideration of such decisions by a clinical peer reviewer. This is intended to ensure consistency and transparency in Medicaid medical necessity reviews.

Health and Social Services

https://malegislature.gov/Bills/190/H614