CurrentHealth Care Access Bureau and Bureau of Managed Care, Division of InsurancePolicy C9mmissi

Disclosure of medical necessity and utilization review criteria

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This bulletin explains Massachusetts statutory requirements for insurers to provide access to utilization review and medical necessity criteria and protocols to the public, insureds/prospective insureds, providers, and state agencies; it applies to commercial health insurers and HMOs operating in Massachusetts.

Policy Summary

PayerHealth Care Access Bureau and Bureau of Managed Care, Division of Insurance

PolicyDisclosure of medical necessity and utilization review criteria

Policy CodePolicy C9mmissi

Change TypeInformationalno material coverage changes

Effective DateNov 4, 2014

Next Review Date

Key ActionCarriers shall provide criteria and protocols to health care providers upon request and free of charge.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Jan 1, 2015deadline for posting non‑proprietary criteria on a public website

Aug 1, 2014effective date for posting requirement

freecost to requestors

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CurrentHealth Care Access Bureau and Bureau of Managed Care, Division of InsurancePolicy C9mmissi

Disclosure of medical necessity and utilization review criteria

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Sign up for Health Care Access Bureau and Bureau of Managed Care, Division of Insurance Policy C9mmissi alerts

Get alerted when Policy C9mmissi changes without checking for updates manually.

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Policy Summary

PayerHealth Care Access Bureau and Bureau of Managed Care, Division of Insurance

PolicyDisclosure of medical necessity and utilization review criteria

Policy CodePolicy C9mmissi

Change TypeInformationalno material coverage changes

Effective DateNov 4, 2014

Next Review Date

Key ActionCarriers shall provide criteria and protocols to health care providers upon request and free of charge.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Jan 1, 2015deadline for posting non‑proprietary criteria on a public website

Aug 1, 2014effective date for posting requirement

freecost to requestors

Disclosure and Access Requirements

Disclosure and access criteria

Access requirements established by the amended statutes:

Carriers must make utilization review criteria, medical necessity criteria and protocols available to the public at no charge

Non‑proprietary criteria and protocols must be posted on a public website, be easily accessible and kept up‑to‑date; posting must occur as soon as possible and no later than January 1, 2015.

Licensed proprietary criteria purchased by a carrier shall not be made available to the public

Licensed proprietary materials may be withheld from public posting but are subject to the access rules below for agencies and may be limited for insureds/providers to information relevant to the identified treatment or service.

ALL of the following

Carriers shall provide criteria and protocols to insureds and prospective insureds upon request and free of charge
If the request is for licensed proprietary criteria, the carrier may limit disclosure to information relevant to the particular treatments or services identified by the insured or prospective insured

ALL of the following

Carriers shall provide criteria and protocols to health care providers upon request and free of charge
If the request is for licensed proprietary criteria, the carrier may limit disclosure to information relevant to the particular treatments or services identified by the health care provider

Carriers shall provide copies of non‑proprietary criteria and protocols upon request to the public free of charge

Criteria and protocols posted on a public website must be easily accessible and up‑to‑date; posting deadline January 1, 2015 (Chapter 176O, §12 effective August 1, 2014).

Codes and Coding Notes

Not applicablemixed

No codes listed

Provider Access and Obligations

Documentation Required

Provide criteria and protocols to providers on request

Carriers must provide utilization review and medical necessity criteria and protocols to health care providers upon request and free of charge. If the provider requests licensed, proprietary criteria, the carrier may limit disclosure to information relevant to the particular treatments or services identified by the provider.

Provision must be free of charge.
Licensed/proprietary criteria may be limited to relevant information only.

Key Definitions

Licensed, proprietary criteria

DefinitionLicensed, proprietary criteria are utilization review or medical necessity criteria purchased by a carrier or utilization review organization that are proprietary and may be withheld from public posting.

Public access restrictionLicensed, proprietary criteria shall not be made available to the public.

Agency access (highlight)Carriers must provide all licensed, proprietary criteria and protocols to the Health Policy Commission's Office of Patient Protection (OPP) and the Division of Insurance upon request, free of charge; such materials are not public records and are exempt from disclosure under public records laws.

Limited disclosure to insureds/providersWhen an insured, prospective insured, or health care provider requests licensed, proprietary criteria, the carrier may limit disclosure to information relevant to the particular treatment(s) or service(s) identified.

Source statutesDefined and governed by amendments to Chapter 6D, §16 and Chapter 176O (effective Aug 1, 2014), per Ch. 165 of the Acts of 2014.

Non-proprietary criteria and protocols

DefinitionNon-proprietary criteria and protocols are utilization review and medical necessity criteria that are not proprietary and must be made available to the public.

Public posting requirement (highlight)Carriers shall post non-proprietary criteria and protocols on a public website, ensure they are easily accessible and up-to-date, and do so as soon as possible but no later than January 1, 2015.

Free copies on requestCarriers must provide copies of non-proprietary criteria and protocols upon request and free of charge.

Access for insureds/providersCarriers shall provide non-proprietary criteria and protocols to insureds, prospective insureds, and health care providers upon request and free of charge.

Effective dateRequirement to post criteria on a public website is pursuant to Chapter 176O, §12, which became effective August 1, 2014.