6.01: Scope and Authority
452 CMR 6.00 - Utilization Review And Quality Assessment is promulgated pursuant to MGL c. 152, 5, 13, and 30. 452 CMR 6.00 shall apply to all claims for health care services
(a) requires workers' compensation insurers to undertake utilization review for all medical services to be provided to the injured employee after 12 weeks from the date of injury. The insurer may choose to undertake utilization review at any time during the 12 week period immediately following the date of injury. However, the insurer is mandated to undertake utilization review before denying any request for medical services during this initial 12 week period. Treatment guidelines are in effect during this 12 week period.
(b) references the guidelines and review criteria that the Department of Industrial Accidents (DIA) requires providers to consider when treating certain medical conditions, and sets forth the mechanism for the development, endorsement, dissemination, and implementation of future guidelines;
(c) sets forth the nature of utilization data that must be reported to the DIA;
(d) sets forth the methods for quality assessment that will be used by the DIA;
(e) sets forth the nature of the mechanisms that DIA will use to ensure compliance with 452 CMR 6.00; and
(f) concerns the appropriateness of the health care service, i.e., whether the service is reasonable, necessary, and effective; and the quality of care provided to workers' compensation recipients, including consideration of the proper costs of services.