Massachusetts General Laws
Chapter 176o - Health Insurance Consumer Protections
Section 26 - Establishment of Standardized Processes and Procedures for the Determination of Patient's Health Benefit Plan Eligibility at or Prior to Time of Service

Section 26. The commissioner shall establish standardized processes and procedures applicable to all health care providers and payers for the determination of a patient's health benefit plan eligibility at or prior to the time of service. As part of such processes and procedures, the commissioner shall (i) require payers to implement automated approval systems such as decision support software in place of telephone approvals for specific types of services specified by the commissioner and (ii) require establishment of an electronic data exchange to allow providers to determine eligibility at or prior to the point of care.

Structure Massachusetts General Laws

Massachusetts General Laws

Part I - Administration of the Government

Title XXII - Corporations

Chapter 176o - Health Insurance Consumer Protections

Section 1 - Definitions

Section 2 - Bureau of Managed Care

Section 3 - Complaints Against Carriers; Notice; Hearing

Section 4 - Refusal of Carriers to Contract With Eligible Health, Dental or Vision Care Providers Solely Because Providers Have Practiced Good Faith Advocacy on Behalf of Patients

Section 5 - Contracts; Liability

Section 5a - Acceptance and Recognition of Information Submitted Pursuant to Current Coding Standards and Guidelines Required; Use of Standardized Claim Formats

Section 5b - Policies and Procedures to Enforce Sec. 5a

Section 5c - Failure of Carrier to Comply With Coding Standards and Guidelines; Notice; Penalty

Section 6 - Evidence of Coverage to Be Delivered to Covered Adults by Health, Dental and Vision Care Providers; Contents

Section 7 - Information Provided by Carrier Upon Enrollment or Upon Request

Section 8 - Failure by Carrier to File Annual Statement; Fine

Section 9 - Utilization Review Programs; Annual Attestations

Section 9a - Agreements or Contracts Between Carrier and Health Care Provider Prohibited if Containing Certain Provisions

Section 9b - Alternate Payment Arrangements Involving Downside Risk Prohibited Without Risk Certificate

Section 10 - Contractual Financial Incentive Plans

Section 11 - Rights of Health Benefit Plans to Include as Providers Religious Non-Medical Providers

Section 12 - Utilization Review

Section 13 - Formal Internal Grievance Process; Expedited Resolution Policy

Section 14 - Review Panel; Patient Protection Office

Section 15 - Disenrollment of Provider; Continuation of Treatment; Specialty Health Care Coverage

Section 16 - Clinical Decisions Regarding Medical Treatment Made by Treating Physicians; Payment for Health Care Services Ordered by Treating Physician or Primary Care Provider

Section 17 - Regulations; Promulgation

Section 18 - Responsibility of Carrier for Behavioral Health Services Compliance

Section 19 - Display of Name and Telephone Number of Health Service Manager on Enrollment Cards of Carrier

Section 20 - Information Provided to Insured Adults by Behavioral Health Manager; Submission of Material Changes; Workers' Compensation; Preferred Provider Arrangements

Section 21 - Submission by Carrier of Annual Comprehensive Financial Statement

Section 22 - Participation in Medical Assistance Program as Condition for Participation in Carrier's Provider Network

Section 23 - Disclosure by Carrier Upon Request for Network Status of Health Care Provider and Estimated or Maximum Allowed Amount or Charge for a Proposed Admission, Procedure or Service and Amount Insured Responsible to Pay; Establishment of Toll-F...

Section 24 - Internal Appeals Processes for Risk-Bearing Provider Organizations; Patient's Right to Third-Party Advocate; External Review Process

Section 25 - Use and Acceptance of Specifically Designated Prior Authorization Forms

Section 26 - Establishment of Standardized Processes and Procedures for the Determination of Patient's Health Benefit Plan Eligibility at or Prior to Time of Service

Section 27 - Development and Use of Common Summary of Payments Form; Implementation of Education Plan

Section 28 - Provider Directories; Contents; Audits; Print Copies; Customer Service Contact Information; Accommodations; Accuracy; Updates

Section 29 - Health Care Provider Credentialing