DOI Issues Bulletin to Make Medical Necessity Criteria Easily Findable

November 4, 2014

Advanced Practice Psychiatric Nurses working in private practice or in health care facilities will welcome the DOI Bulletin that requires that private insurance companies make their medical necessity criteria findable and accessible on web sites by January 1, 2015.

The DOI announced these changes in today’s ‘Listening Session’ for Transparency of Medical Necessity Criteria.  While other DOI Listening Sessions have focused on the process steps in authorization, appeals and denials, today’s session was used to announce the release of Bulletin 2014-10.  Participants in today’s session included private insurance carriers, state agencies, providers and advocacy groups.  Transparency of medical necessity criteria has been a simmering issue between providers and carriers with complaints aimed at each other on both sides of the divide. Carriers complain that they have no access to the medical doctor or provider who knows the most about what is clinically necessary. Providers are critical of carriers who seem to make subjective denials of care without understanding the needs of the client.

The DOI while responsible for overseeing private carrier compliance with state and federal laws, also receives information, concerns and complaints directly from consumers, advocates, providers and other state agencies(such as the OPP).  The DOI’s intention with Listening Sessions is to clarify the issues, promote solutions and define strategies fair to all concerns.  In today’s session, opportunities were provided to the carriers to describe the changes they have made in transparency since the law went into effect on July 1, 2014.  Other stakeholders went on to discuss concerns about how far or limited the Bulletin goes in resolving conflicts associated with getting services and treatments approved for patients.

The issue of Proprietary (purchased) Criteria was also addressed and prominently mentioned in Bulletin 2014-10.  Proprietary criteria (i.e.McKesson Interqual)  is treated differently then other medical necessity criteria because of its commercial value to the carriers and its exemption from public sharing.  However, Bulletin 2014-10 states that proprietary criteria MUST be shared with providers as it is relevant to the particulars of a patient situation.  While not publicly shared and only shared as relevant to specific patient needs, this does represent a step forward. Still, proprietary data can present difficulties such as with subjective interpretation and provider access to full criteria documentation (especially in appeals situations).

Key Aspects of Bulletin 2014-10

Non-Proprietary Medical Necessity Criteria: 
Where the insured or prospective insured, health care provider is seeking non-proprietary criteria: 
  • Utilization review criteria, medical necessity criteria and protocols shall be made available to the public at no charge;
  • Carriers shall provide access to non-proprietary criteria and protocols by posting the criteria and protocols on a public website.
  • Carriers shall make such criteria and protocols available on a public website as soon as possible but no later than January 1, 2015.
  • Criteria and protocols posted on a public website must be easily accessible and up-to-date.
Licensed, Proprietary Medical Necessity Criteria:
 Where the insured or prospective insured, health care provider, Office of Patient Protection or the Division of Insurance is seeking licensed, proprietary criteria:
  • the carrier may limit the information provided to that which is relevant to the particular treatments or services identified by the insured or prospective insured or the services identified by the health care provider.
  • Access for OPP and the Division:  Carriers shall provide all criteria and protocols upon request to OPP and the Division free of charge, including licensed, proprietary criteria and protocols purchased by a carrier.
  • Any such licensed, proprietary criteria and protocols purchased by a carrier provided to OPP and the Division shall not be public records and shall be exempt from disclosure under the public records laws.
  • OPP and the Division may request the entire set of utilization review criteria, medical necessity criteria and protocols, and in response to such a request the carrier shall provide all requested documents.

Lingering Issues:  Questions and concerns remain going forward…

Participants identified that there are still issues with respect to details published in rejection letters, participant selection of criteria Panels and subjectivity  in interpreting criteria.

  1. Adverse Determination Letters:  when services are denied, what information goes into the letter?  How is the proper balance struck between publishing the specific particulars of the case (that another family member might see) or general statements about why there was an adverse determination?
  2. Criteria Development Panels: Who is represented on panels deciding criteria?, who is qualified, who is not represented, who is excluded?
  3. Subjectivity in Criteria Interpretation Risk:  Is criteria used narrowly or broadly? as a ceiling or a guideline? Who is making decisions on the phone and what happens when the decision is made without adequate information? Are service requests unfairly labeled as ‘futile’ and thus denied?and how can all involved in the process be knowledgeable and aware of criteria before they get on the phone ?

The DOI reminded participants that its authority is only over insured plans (not MASS health, self funded, out of state or government plans).  The DOI further emphasized that they intend to monitor the compliance of carriers to accomplish the public access by January 1, 2015 and to further monitor the key aspects of the Bulletin such as findability, the presence or absence of up-to-date information and consistent terminology across carriers.  The DOI remain open to filing further regulations should they be required.

Feedback is welcome to the attention of


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