An Act To Ensure Protection of Patients in Medical Reviews by Health Insurance Carriers
Be it enacted by the People of the State of Maine as follows:
Sec. 1. 24-A MRSA §4301-A, sub-§4, as enacted by PL 1999, c. 742, §3, is amended to read:
4. Clinical peer. "Clinical peer" means a physician or other licensed health care practitioner who holds a nonrestricted license in a state of the United States and is both board certified and in active medical practice in the same or similar specialty as typically manages the medical condition, procedure or treatment under review , or other physician or health care practitioner with demonstrable expertise necessary to review a case.
Sec. 2. 24-A MRSA §4304, sub-§1, as amended by PL 2007, c. 199, Pt. B, §13, is further amended to read:
1. Requirements for medical review or utilization review practices. A carrier must appoint a medical director who is responsible for reviewing and approving the carrier's policies governing the clinical aspects of coverage determinations by any health plan that it offers or renews. A carrier's medical review or utilization review practices must be governed by the standard of medically necessary health care as defined in this chapter. All of a carrier's medical reviews, including utilization reviews, case management or any other type of medical review, must be conducted by a clinical peer.
summary
This bill requires that a health insurance carrier's medical reviews, including utilization reviews and case management, be conducted by a health care practitioner who is board certified and in active medical practice in the same specialty as typically manages the medical condition, procedure or treatment under review.