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SENATE DOCKET, NO. 943 FILED ON: 1/15/2025
SENATE . . . . . . . . . . . . . . No. 770
The Commonwealth of Massachusetts
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PRESENTED BY:
John F. Keenan
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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 to prevent inappropriate denials by insurers for medically necessary services.
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PETITION OF:
NAME:DISTRICT/ADDRESS :John F. KeenanNorfolk and Plymouth 1 of 3
SENATE DOCKET, NO. 943 FILED ON: 1/15/2025
SENATE . . . . . . . . . . . . . . No. 770
By Mr. Keenan, a petition (accompanied by bill, Senate, No. 770) of John F. Keenan for
legislation to prevent inappropriate denials by insurers for medically necessary services.
Financial Services.
The Commonwealth of Massachusetts
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In the One Hundred and Ninety-Fourth General Court
(2025-2026)
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An Act to prevent 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 2022
2Official Edition, is hereby amended by inserting after the first paragraph the following four
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 (i) the services are a covered benefit under
6the insured’s health benefit plan and (ii) the services follow the carrier’s clinical review criteria;
7provided further, a claim for treatment of medically necessary services may not be denied if the
8treating health care provider follows the carrier’s approved method for securing authorization for
9a covered service for the insured at the time the service were 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 was 2 of 3
13submitted fraudulently. A carrier shall have no more than twelve months after the original
14payment was received by the provider to recoup a full or partial payment for a claim for services
15rendered, or to adjust a subsequent payment to reflect a recoupment of a full or partial payment;
16provided however, a carrier shall not recoup payments more than ninety days after the original
17payment was received by a provider for services provided to an insured that the carrier deems
18ineligible for coverage because the insured was retroactively terminated or retroactively
19disenrolled for services; provided further, that the provider can document that it received
20verification of an insured’s eligibility status using the carrier's approved method for verifying
21eligibility at the time service was provided. Claims may also not be recouped for utilization
22review purposes if the services were already deemed medically necessary or the manner in which
23the services were accessed or provided were previously approved by the carrier or its contractor.
24 A carrier that seeks to make an adjustment pursuant to this section shall provide the
25health care provider with written notice that explains in detail the reasons for the recoupment,
26identifies each previously paid claim for which a recoupment is sought and provides the health
27care provider with thirty days to challenge the request for recoupment. Such written notice shall
28be made to the health provider not less than thirty days prior to the seeking of a recoupment or
29the making of an adjustment.
30 If a claim is denied because the provider, due to an unintentional act of error or omission,
31obtained no authorizations or only a partial authorization, the provider may appeal the denial and
32the carrier must conduct and complete within thirty days of the provider’s submitted appeal a
33retrospective review of the medical necessity of the service. If the carrier determines that the
34service is medically necessary, the carrier must reverse the denial and pay the claim. If the carrier
35determines that the service does not meet its clinical review criteria, the carrier shall provide the 3 of 3
36provider with specific written clinical justification for the determination and a process for
37appealing the determination.
38 SECTION 2. The commissioner of insurance shall promulgate regulations to enforce the
39provisions of this act no later than 90 days after the effective date, which shall be effective for
40provider contracts that are entered into, renewed or amended on or after the effective date of said
41regulations.