Section 3.312 - Coverage or Treatment Pending Resolution of Internal Grievance(1) If a grievance is filed concerning the termination of ongoing coverage or treatment, the disputed coverage or treatment shall remain in effect at the carrier's expense through completion of the internal grievance process regardless of the final internal grievance decision, provided that the grievance is filed on a timely basis, based on the course of treatment. For the purposes of 958 CMR 3.312, ongoing coverage or treatment includes only that medical care that, at the time it was initiated, was authorized by the carrier or utilization review organization and does not include medical care that was terminated pursuant to a specific time or episode-related exclusion from the insured's contract for benefits.(2) The carrier's internal grievance process shall include provision for automatic reversal of the carrier's or utilization review organization's adverse determinations denying coverage for services, pending the outcome of the internal grievance process, within 48 hours of receipt by the carrier or utilization review organization of certification by the physician responsible for the insured's treatment or proposed treatment, which states the physician's opinion that the following factors are present: (a) the service at issue in the grievance is medically necessary;(b) denial of coverage for these services would create a substantial risk of serious harm to the patient; and(c) the risk of that harm is so immediate that the provision of such services should not await the outcome of the normal grievance process.(3) The carrier's internal grievance process shall include provision for automatic reversal of the carrier's or utilization review organization's adverse determinations denying coverage for durable medical equipment, pending the outcome of the internal grievance process, within 48 hours or earlier, of receipt by the carrier or utilization review organization of certification by the physician responsible for the insured's treatment or proposed treatment, which states the physician's opinion that the following factors are present:(a) the durable medical equipment at issue in the grievance is medically necessary;(b) denial of coverage for the durable medical equipment would create a substantial risk of serious harm to the patient;(c) the risk of that harm is so immediate that the provision of such durable medical equipment should not await the outcome of the normal grievance process; and(d) if the physician certifies that the coverage decision should be reversed earlier than 48 hours after the carrier's or utilization review organization's adverse determination, a certification as to the specific, immediate and severe harm that will result to the insured absent action within the 48-hour time period.Amended by Mass Register Issue 1494, eff. 4/28/2023.