Section 3. (a) The bureau shall investigate all complaints made against a carrier or any entity with which it contracts for allegations of noncompliance with the accreditation requirements established by section 2. The bureau shall notify a carrier when, in the opinion of the bureau, the complaints made against such a carrier indicate a pattern of noncompliance with a particular accreditation requirement. The notice shall detail the alleged noncompliance and establish a hearing date for the matter, which shall be held no later than 21 days after the date of the notice. The hearing shall be conducted pursuant to chapter 30A. The hearing shall provide such a carrier with the opportunity to respond to the alleged noncompliance.
(b) The bureau may, after said hearing, suspend or revoke the accreditation of such a carrier, or reprimand, censure or impose a civil administrative penalty not to exceed $10,000 for each classification of violation.
(c) If, after said hearing, the bureau determines that such a pattern of noncompliance has been substantiated, the bureau may issue an order requesting a corrective action plan and timeframe to achieve compliance.
(d) If a national accreditation organization takes any action to revoke the accreditation or otherwise limit or negatively affect the accreditation status of a carrier, or any entity with which it contracts for services regulated under this chapter, such carrier shall promptly notify the bureau. If a national accreditation entity revokes such accreditation, the carrier shall not be eligible for deemed accreditation status, and the bureau shall initiate proceedings pursuant to chapter 30A to revoke or suspend the carrier's accreditation.
(e) Nothing in this section shall be construed to prohibit the bureau and a carrier from resolving compliance issues through informal means.
(f) Accreditation granted to carriers pursuant to this section shall be renewed every 2 years. The fee for the renewal shall be in an amount determined by the commissioner, but shall not be less than $1,000.
Structure Massachusetts General Laws
Part I - Administration of the Government
Chapter 176o - Health Insurance Consumer Protections
Section 2 - Bureau of Managed Care
Section 3 - Complaints Against Carriers; Notice; Hearing
Section 5 - Contracts; Liability
Section 5b - Policies and Procedures to Enforce Sec. 5a
Section 5c - Failure of Carrier to Comply With Coding Standards and Guidelines; Notice; Penalty
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 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 17 - Regulations; Promulgation
Section 18 - Responsibility of Carrier for Behavioral Health Services Compliance
Section 21 - Submission by Carrier of Annual Comprehensive Financial Statement
Section 25 - Use and Acceptance of Specifically Designated Prior Authorization Forms