Section 3.412 - Additional Medical or Other Information(1) The insured or the insured's authorized representative may submit additional medical evidence or other relevant information to the external review agency. (a) The Office of Patient Protection will notify the insured or insured's authorized representative of the right to submit additional medical evidence or other relevant information in its letter to the insured or insured's authorized representative acknowledging the receipt and assignment of the request for external review. The Office of Patient Protection will include in its letter instructions for submitting any additional medical evidence or other relevant information to the external review agency.(b) In a non-expedited review, any such additional medical evidence or other relevant information shall be reviewed by the external review agency if received within ten days from the date of the notice from the Office of Patient Protection. Any such additional medical evidence or other relevant information may be reviewed by the external review agency if received more than ten days from the date of the notice from the Office of Patient Protection but before the decision is rendered.(c) In an expedited review, any such additional medical evidence or other relevant information shall be reviewed by the external review agency if received within 24 hours of the insured's or insured's authorized representative's filing of the request for expedited external review. Any such additional medical evidence or other relevant information may be reviewed by the external review agency if received more than 24 hours after the insured's or insured's authorized representative's filing of the request for expedited external review but before the decision is rendered.(d) The external review agency shall forward a copy of any additional medical evidence or other relevant information submitted by the insured or the insured's authorized representative to the carrier within one business day of receipt.(2) The assigned external review agency may request the carrier to provide such additional information or documentation as the external review agency deems necessary in order to render a decision. Such additional information shall be provided within 24 hours of the request in expedited review cases and within three business days for all other reviews.(a) Carriers shall make good faith efforts to obtain any such additional information requested by the external review agency that is not in the possession of the carrier.(b) Failure by the carrier to make good faith efforts to supply information requested pursuant to 958 CMR 3.409 or 3.412 may result in penalties to carriers including action by the Division of Insurance pursuant to 211 CMR 52.17: Noncompliance with 211 CMR 52.00. In addition, where a carrier has failed to make good faith efforts to supply information pursuant to 958 CMR 3.409 or 3.412, the external review agency may in its discretion order the grievance in dispute to be resolved in favor of the insured.(c) For the purposes of 958 CMR 3.409 or 3.412, "good faith efforts" shall be defined as no fewer than three reasonable documented attempts by the carrier to obtain the information from a provider or the provider's designee.(3) The assigned external review agency may request the insured, or where applicable the insured's authorized representative, to provide such additional information or documentation as the external review agency deems necessary in order to render a decision. Such additional information shall be provided within 24 hours of the request in expedited review cases and within ten days for all other reviews, in order to be considered by the external review agency.(4) The external review agency shall consider any related right to the requested treatment or service under any related state statute or regulation as directed by the Office of Patient Protection.Amended by Mass Register Issue 1494, eff. 4/28/2023.