6.04: Utilization Review by Insurers
(1) Insurers and self-insurers are required to undertake utilization review for health services rendered to injured employees, either by performing utilization review themselves or by contracting with a Commonwealth approved agent who will conduct utilization review services on their behalf. If an insurer or self-insurer chooses to perform utilization review on its own, it must have its program approved by the OHP. Said utilization review program must remain separate and distinct from case management and all other claim functions. Utilization review organization conducting Massachusetts reviews at multiple sites must seek separate approval for each site.
For the conditions to which the treatment guidelines endorsed by the Health Care Services Board and adopted by the Commissioner pursuant to MGL c. 152, 13 and 30 apply, the programs shall integrate said treatment guidelines.
(2) Application for Approval. An application requesting approval to conduct utilization review in the Commonwealth shall:
(a) submit a completed application to the OHP along with an initial application fee payable to the DIA. The application fee shall be $1.000.00 if the company is located in Massachusetts, excluding the Commonwealth and the various counties, cities, towns and districts; and $3,000.00 if the company is located outside of Massachusetts.
(b) submit a new application to the OHP every two years, along with a renewal fee. The renewal fee shall be $500.00 if the company is located in Massachusetts; and $1,500.00 if the company is located outside of Massachusetts; and
(c) make arrangements with the OHP for a site visit for all new applicants.
(3) Information Required with Application. To conduct utilization review in the Commonwealth, a utilization review agent must seek approval of its utilization review program from the Commissioner in writing and the application shall include, but not limited to the following:
(a) corporate and site demographics: name, address, and telephone number of the program;s corporate and Massachusetts contacts; and the identification of each site where Massachusetts utilization review will be conducted;
(b) a list of all treatment guidelines which will be used by the licensed medical reviewer in rendering a determination, including DIA Treatment Guidelines, approved secondary sources, and internally derived treatment guidelines. The utilization review agent shall also provide information pertaining to the procedures for implementing internal guidelines including the frequency of revisions;
(c) copies of all current professional licenses issued by the appropriate state licensing agency for all practitioners rendering utilization review determinations, including the medical director;
(d) a detailed description of the appeal procedures for utilization review determinations, including copies of all materials designed to inform injured employees of the requirements of the utilization review program and their responsibilities and rights under the program;
(e) the identity of each insurer/self-insurer for which utilization review agent performs Massachusetts reviews;
(f) an attestation in writing that the utilization review agent shall comply with all applicable laws, rules, regulations, orders, and requirements of the Commonwealth; and
(g) disclosure of any economic incentives for reviewers in the utilization review program.
Any material changes in the information filed in accordance with 452 CMR 6.04 shall be filed with the OHP within 30 days of said change.
(4) The OHP will publish the name and address of each approved UR agent on the DIA website.
(5) All utilization review agents shall comply with the following procedures:
(a) All determination letters must set forth the relevant section of the treatment guideline referenced and provide a clinical rationale. An adverse determination letter shall include instructions for the procedure to initiate an appeal of the adverse determination. A copy of the relevant section of the guideline must be provided upon request. The start and end dates for all scheduled health care services shall be clearly documented in the utilization review case note summary and on the determination notice. The date of request and the date of receipt of medical information must be documented by the utilization review agent in the utilization review case record.
(b) Notification of all utilization review determinations issued by the utilization review agent shall be communicated to the injured employee/representative and the ordering provider in writing. For prospective reviews, written notice of the determination shall be given within two business days from receipt of the request for approval of treatment. For concurrent reviews, if the ordering practitioner contacts the UR agent at least three business days prior to the start date for the ongoing treatment, written notice of the determination shall be given at least one day prior to the start/implementation date. If the ordering practitioner fails to request approval of ongoing treatment at least three business days prior to the start date, or fails to provide a start date, the UR agent shall issue the determination within five business days from the receipt of the request. For retrospective reviews, written notice of the determination shall be given within 20 business days from receipt of the request for approval of treatment.
If additional medical information is necessary in order to complete the review, the utilization review agent shall inform the requesting health care provider of the specific medical information needed, and the time period in which the information must be provided. Prospective and Concurrent Reviews: information must be provided within seven business days from the date of request. Retrospective Reviews: information must be provided within 30 business days from the date of request.
(c) Any adverse determination of a health care service issued by a utilization review agent shall be issued by a practitioner of the same school as the ordering provider.
(d) Adverse determination letters must provide a description of the appeal procedure and at a minimum, shall provide the following:
1. When an adverse determination is rendered during prospective or concurrent review, and the injured employee and/or the ordering provider believes that the determination warrants immediate appeal, the injured employee or the ordering provider may initiate the appeal via telephone to the utilization review agent with the right to communicate orally with a practitioner of the same school as the ordering provider on an expedited basis. The ordering provider or injured employee should be instructed to follow‑up with a written request for the appeal. If the injured employee or ordering provider fails to comply, the utilization review agent should send a written confirmation of the appeal request. Said notice of appeal to occur no later than 30 days from the date of receipt of notice of adverse determination. Utilization review agents shall complete the adjudication on an expedited basis and render the determination no later than two business days from the date the appeal is initiated, unless the ordering provider agrees to a different time period.
2. Appeal of retrospective reviews shall be made in writing to the utilization review agent and occur no later than 30 days from the date of receipt of notice of adverse determination. Utilization review agents shall complete the adjudication of a retrospective review/standard appeal no later than 20 business days from the date the appeal is filed.
(e) Utilization review agents shall make staff available by toll‑free telephone system at least 40 hours per week between the hours of 9:00 A.M. to 5:00 P.M each business day.
(f) Utilization review agents shall have a confidential telephone system capable of accepting and recording incoming telephone calls during other than normal business hours, and the agent shall respond to these calls on the following business day.
(g) Utilization review agents shall comply with all applicable laws to protect the confidentiality of medical records and when necessary, obtain a medical release.
(h) Practitioners rendering school to school utilization review determinations and medical directors must provide, and attest in writing to providing, patient care for at least eight hours per week.
(i) Once an insurer has commenced payment for a work related injury under MGL c. 152, it must issue the employee a card listing the employee name, an identification number assigned to the employee, the name and telephone number of the utilization review agent, and the name of the insurer. The employee must seek approval from the insurer/utilization review agent before receiving medical services. In the case of an emergency, utilization review agents shall allow a minimum of 24 hours after an emergency admission, service, or procedure for an injured employee or injured employee's representative to notify the utilization review agent and request approval for treatment.
(j) Initial level reviews must be conducted at the location of the approved utilization review site.
(6) After exhaustion of the process set forth in 452 CMR 6.04(5)(d), a party may file a claim or complaint in accordance with 452 CMR 1.07: Claims And Complaints under the provisions of MGL c. 152, 10.
(7) Injured employees may be liable for care subsequent to the adverse determination after they have been notified of that adverse determination.
(8) Ancillary Services. 452 CMR 6.00 concerns the requirements for the performance of utilization review. Should an insurer or self‑insurer provide ancillary services such as managed care, case management, independent medical exams, or rehabilitation services from vendors who are also approved as utilization review agents, said ancillary services are not to be considered utilization review requirements or expenses. Ancillary services must remain separate and distinct from the utilization review services. Moreover, these ancillary services should not be construed as approved by the OHP by virtue of the OHP's approval of the same vendor to perform utilization review.
(9) Each insurer/self‑insurer is required to inform the OHP of the name of the approved utilization review agent currently responsible for conducting the reviews.