958 Mass. Reg. 3.310

Current through Register 1504, September 15, 2023
Section 3.310 - Right to Request a Conference

If the expedited review process affirms the denial of coverage or treatment, the carrier or utilization review organization shall allow the insured or the insured's authorized representative, if any, to request a conference.

(a) The conference shall be scheduled within ten days of receiving a request from an insured; provided however that the conference shall be held within five business days of the request if the treating physician determines, after consultation with the carrier's medical director or his designee, and based on standard medical practice, that the effectiveness of either the proposed treatment, services or supplies or any alternative treatment, services or supplies covered by the carrier, would be materially reduced if not provided at the earliest possible date.
(b) At the conference, the carrier shall permit attendance of the insured, the authorized representatives of the insured, if any, or both.
(c) At the request of the insured or the insured's authorized representative, the carrier may permit attendance at the conference of the insured's treating health care professional or other providers.
(d) At the conference, the insured and/or the insured's authorized representative, if any, and a representative of the carrier who has authority to determine the disposition of the grievance shall review the information provided to the insured under 958 CMR 3.09(l)(b) and (c).

958 CMR 3.310

Amended by Mass Register Issue 1494, eff. 4/28/2023.