Chapter 176O

Section 1. As used in this chapter, the following words shall have the following meanings:— ''Adverse determination'', based upon a review of information provided by a carrier or its designated utilization review organization, to deny, reduce, modify, or terminate an admission, c…

Section 10. (a) No contract between a carrier, including a dental or vision carrier, and a licensed health, dental or vision care provider group shall contain any incentive plan that includes a specific payment made to a health, dental or vision care professional as an inducement…

Section 11. Nothing in this chapter shall be construed to restrict or limit the rights of health benefit plans to include as providers religious non-medical providers, require such health benefit plans to utilize medically based eligibility standards or criteria in deciding provi…

Section 12. (a) Utilization review conducted by a carrier or a utilization review organization shall be conducted under a written plan, under the supervision of a physician and staffed by appropriately trained and qualified personnel and shall include a documented process to: (i)…

Section 12A. (a) For the purposes of this section, the following term shall have the following meanings unless the context clearly requires otherwise: ''Step therapy protocol'', a utilization management policy or program that establishes the specific sequence in which a prescript…

Section 12B. (a) There shall be a commission on step therapy protocols within the division. The commission shall consist of: the commissioner of insurance or a designee, who shall serve as chair; the executive director of the health policy commission or a designee; the assistant …

Section 13. (a) A carrier or utilization review organization shall maintain a formal internal grievance process that is compliant with the Patient Protection and Affordable Care Act, Public Law 111–148, as amended, as well as with any rules, regulations or guidance applicable the…

Section 14. (a) An insured who remains aggrieved by an adverse determination and has exhausted all remedies available from the formal internal grievance process required pursuant to section 13, may seek further review of the grievance by a review panel established by the office o…

Section 15. (a) A carrier that allows or requires the designation of a primary care provider shall notify an insured at least 30 days before the disenrollment of such insured's primary care provider and shall permit such insured to continue to be covered for health services, cons…

Section 16. (a) The physician treating an insured, shall, consistent with generally accepted principles of professional medical practice and in consultation with the insured, make all clinical decisions regarding medical treatment to be provided to the insured, including the prov…

Section 17. The commissioner shall promulgate regulations to enforce sections 2 to 12, inclusive. The health policy commission shall promulgate regulations to enforce sections 13, 14, 15 and 16.

Section 18. A carrier for whom a behavioral health manager is administering behavioral health services shall be responsible for the behavioral health manager's failure to comply with the requirements of this chapter in the same manner as if the carrier failed to comply.

Section 19. A carrier for whom a behavioral health manager is administering behavioral health services shall state on its new enrollment cards issued in the normal course of business, within one year, the name and telephone number of the behavioral health manager.

Section 2. (a) There is hereby established within the division a bureau of managed care. Said bureau shall by regulation establish minimum standards for the accreditation of carriers in the following areas: (1) utilization review; (2) quality management and improvement; (3) crede…

Section 20. (a) A behavioral health manager shall provide the following information to at least 1 adult insured in each household covered by their services: (1) a notice to the insured regarding emergency mental health services that states: (i) that the insured may obtain emergen…

Section 21. [There is no subsection (a).] (b)(1) In this subsection, the following words shall have the following meanings:— ''Carrier'', an insurer licensed or otherwise authorized to transact accident or health insurance under chapter 175; a nonprofit hospital service corporati…

Section 22. Notwithstanding any other general or special law to the contrary, each carrier shall require, as a condition of participation in the carrier's provider network by a physician, dentist, optometrist, podiatrist, nurse practicing in an advance practice nursing role, inte…

Section 23. All carriers shall establish a toll-free telephone number and website that enables consumers to request and obtain from the carrier, in real time, the network status of an identified health care provider, the estimated or maximum allowed amount or charge for a propose…

Section 24. (a) All risk-bearing provider organizations certified under chapter 176U shall create internal appeals processes. The appeals processes shall be available to the public in written format and, by request, in electronic format. (b) The internal appeals processes in subs…

Section 25. (a) A payer or any entity acting for a payer under contract, when requiring prior authorization for a health care service or benefit, shall use and accept only the prior authorization forms designated for the specific types of services and benefits developed under sub…

Section 26. The commissioner shall establish standardized processes and procedures applicable to all health care providers and payers for the determination of a patient's health benefit plan eligibility at or prior to the time of service. As part of such processes and procedures,…

Section 27. (a) The division shall develop a common summary of payments form to be used by all carriers in the commonwealth and provided to health care consumers with respect to provider claims submitted to a payer. The common summary of payments form shall be written in an easil…

Section 28. (a) A carrier shall ensure the accuracy of the information concerning each provider listed in the carrier's provider directories for each network plan and shall review and update the entire provider directory for each network plan. A provider directory that is electro…

Section 29. (a) The bureau of managed care shall develop and implement standard credentialing forms for health care providers. A carrier, or any entity that manages or administers benefits for a carrier, shall accept the standard credentialing form for contracting providers as su…

Section 3. (a) The bureau shall investigate all complaints made against a carrier or any entity with which it contracts for allegations of noncompliance with the accreditation requirements established by section 2. The bureau shall notify a carrier when, in the opinion of the bur…

Section 30. (a) On an annual basis, each carrier shall report to the division the drugs selected to be provided with no or limited cost-sharing under section 47CCC of chapter 175, section 8DDD of chapter 176A, section 4DDD of chapter 176B and section 4VV of chapter 176G. The comm…

Section 4. A carrier, including a dental or vision carrier, shall not refuse to contract with or compensate for covered services an otherwise eligible health, dental or vision care provider solely because such provider has in good faith communicated with or advocated on behalf of…

Section 5. No contract between a carrier, including a dental or vision carrier, and a health, dental or vision care provider for the provision of services to insureds may require the provider to indemnify the carrier for any expenses and liabilities, including, without limitation…

Section 5A. (a) Subject to subsection (c), for the purposes of processing claims for health care services submitted by a health care provider and to provide uniformity and consistency in the reporting of patient diagnostic information, patient care service and procedure informati…

Section 5B. To ensure uniformity and consistency in the submission and processing of claims for health care services pursuant to section 5A, the bureau of managed care within the division of insurance, after consultation with a statewide advisory committee including, but not limi…

Section 5C. If the commissioner determines that a carrier is neglecting to comply with the coding standards and guidelines under this chapter in the form and within the time required the commissioner shall notify the carrier of such neglect. If the carrier does not come into comp…

Section 5D. For the purposes of this section, the term ''base fee schedule'' shall mean the minimum rates, typically set forth in fee schedules, paid by the carrier to an in-network health care provider who is not paid under an alternative payment arrangement for covered health c…

Section 6. (a) A carrier shall issue and deliver to at least one adult insured in each household residing in the commonwealth, upon enrollment, an evidence of coverage and any amendments thereto. Said evidence of coverage shall contain a clear, concise and complete statement of: …

Section 7. (a) A carrier shall provide to at least one adult insured in each household upon enrollment, and to a prospective insured upon request, the following information: (1) a list of health care providers in the carrier's network, organized by specialty and by location and s…

Section 8. A carrier neglecting to make and file its annual statement or the materials required by the commissioner to be filed with the division under this chapter or under chapter 176G in the form and within the time required thereby shall be fined $5,000 for each day during wh…

Section 9. A carrier shall annually provide a written attestation to the commissioner that the utilization review program of the carrier or its designee complies with all applicable state and federal laws concerning confidentiality and reporting requirements.

Section 9A. A carrier shall not enter into an agreement or contract with a health care provider if the agreement or contract contains a provision that: (a)(i) limits the ability of the carrier to introduce or modify a select network plan or tiered network plan by granting the hea…

Section 9B. Carriers shall not be permitted to enter into or continue alternate payment arrangements involving downside risk with provider organizations that have not received a risk certificate under chapter 176U.