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HOUSE DOCKET, NO. 3755 FILED ON: 1/20/2023
HOUSE . . . . . . . . . . . . . . . No. 1087
The Commonwealth of Massachusetts
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PRESENTED BY:
Kate Lipper-Garabedian
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To the Honorable Senate and House of Representatives of the Commonwealth of Massachusetts in General
Court assembled:
The undersigned legislators and/or citizens respectfully petition for the adoption of the accompanying bill:
An Act preventing inappropriate denials by insurers for medically necessary services.
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PETITION OF:
NAME:DISTRICT/ADDRESS :DATE ADDED:Kate Lipper-Garabedian32nd Middlesex1/20/2023Jason M. LewisFifth Middlesex2/7/2023 1 of 3
HOUSE DOCKET, NO. 3755 FILED ON: 1/20/2023
HOUSE . . . . . . . . . . . . . . . No. 1087
By Representative Lipper-Garabedian of Melrose, a petition (accompanied by bill, House, No.
1087) of Kate Lipper-Garabedian and Jason M. Lewis relative to preventing denials by insurers
for medically necessary services. Financial Services.
The Commonwealth of Massachusetts
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In the One Hundred and Ninety-Third General Court
(2023-2024)
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An Act preventing inappropriate denials by insurers for medically necessary services.
Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority
of the same, as follows:
1 SECTION 1. Section 24B of chapter 175 of the General Laws, as appearing in the 2018
2Official Edition, is hereby amended by inserting after the first paragraph the following
3paragraphs:
4 A carrier, as defined in section 1 of chapter 176O, shall be required to pay for health care
5services ordered by the treating health care provider if (1) the services are a covered benefit
6under the insured’s health benefit plan; and (2) the services follow the carrier’s clinical review
7criteria. Provided however, a claim for treatment of medically necessary services may not be
8denied if the treating health care provider follows the carrier’s approved method for securing
9authorization for a covered service for the insured at the time the service was provided.
10 A carrier shall not deny payment for a claim for medically necessary covered services on
11the basis of an administrative or technical defect in the claim except in the case where the carrier
12has a reasonable basis, supported by specific information available for review, that the claim for 2 of 3
13health care services rendered was submitted fraudulently. A carrier shall have no more than
14twelve months after the original payment was received by the provider to recoup a full or partial
15payment for a claim for services rendered, or to adjust a subsequent payment to reflect a
16recoupment of a full or partial payment. However, a carrier shall not recoup payments more than
17ninety days after the original payment was received by a provider for services provided to an
18insured that the carrier deems ineligible for coverage because the insured was retroactively
19terminated or retroactively disenrolled for services, provided that the provider can document that
20it received verification of an insured’s eligibility status using the carrier's approved method for
21verifying eligibility at the time service was provided. Claims may also not be recouped for
22utilization review purposes if the services were already deemed medically necessary or the
23manner in which the services were accessed or provided were previously approved by the carrier
24or its contractor.
25 A carrier which seeks to make an adjustment pursuant to this section shall provide the
26health care provider with written notice that explains in detail the reasons for the recoupment,
27identifies each previously paid claim for which a recoupment is sought and provides the health
28care provider with thirty days to challenge the request for recoupment. Such written notice shall
29be made to the health provider not less than thirty days prior to the seeking of a recoupment or
30the making of an adjustment.
31 If a claim is denied because the provider, due to an unintentional act of error or omission,
32obtained no authorizations or only a partial authorization, the provider may appeal the denial and
33the carrier must conduct and complete within thirty days of the provider’s submitted appeal a
34retrospective review of the medical necessity of the service. If the carrier determines that the
35service is medically necessary, the carrier must reverse the denial and pay the claim. If the carrier 3 of 3
36determines that the service does not meet its clinical review criteria, the carrier shall provide the
37provider with specific written clinical justification for the determination and a process for
38appealing the determination.
39 SECTION 2. The commissioner of insurance shall promulgate regulations to enforce the
40provisions of this act no later than 90 days after the effective date of the act, which shall be
41effective for provider contracts which are entered into, renewed or amended on or after the
42effective date of said regulations.