958 C.M.R. 11.21 – Decisions and Notice

(1) The External Review Agency shall determine whether the requested referral, treatment or service that is the subject of the review is likely to produce a more clinically beneficial outcome for the Patient than the referral, treatment or service recommended by the RBPO or ACO.
(2) The External Review Agency shall base its determination whether the requested referral, treatment or service is likely to produce a more clinically beneficial outcome for the Patient on a review of the following factors:
1. (a) The Patient’s clinical history, including prior clinical relationships;
2. (b) The availability, within the RBPO or ACO, of a Health Care Professional with the appropriate training and experience to meet the particular health care needs of the Patient, including timely access;
3. (c) Generally accepted principles of professional medical practice;
4. (d) The efficacy of the requested treatment or service, based on scientific evidence, professional standards and expert opinion, in improving health outcomes; and
5. (e) Other factors the External Review Agency considers relevant to the Patient’s ability to access the requested referral, treatment, or service.
(3) The final decision of the External Review Agency shall be in writing and shall contain the following information:
1. (a) An analysis of the medical evidence and how the evidence supports the findings of the external reviewer;
2. (b) An explanation of why the requested referral, treatment or service was found or was not found to likely produce a more clinically beneficial outcome for the Patient than the referral, treatment or service recommended by the RBPO or ACO;
3. (c) A list of any medical literature or references relied upon in making the decision; and
4. (d) A statement that the decision is final and binding.
(4) The External Review Agency shall provide a final copy of the decision to the Patient, and the Patient’s Authorized Representative and the RBPO or ACO. Where the Patient is a minor or person with a legal guardian, the External Review Agency shall provide the Patient’s copy of the final decision to the Patient’s parent or legal guardian.
(5) For non-expedited reviews, the External Review Agency shall issue its final disposition within 21 calendar days from its receipt of assignment from the Office of Patient Protection.
(6) For expedited reviews, the External Review Agency shall issue its final disposition within 72 hours of receipt of the assignment from the Office of Patient Protection.
(7) Each External Review Agency shall retain records of all external review requests, decisions, and notices for three years from the date of the final disposition, and shall make these records available upon request to the Office of Patient Protection.
(8) The decision of the External Review Agency shall be binding on the RBPO and the Patient, or the ACO and the Patient as to the matter that is the subject of the appeal. The decision does not prohibit the patient from requesting an internal appeal or requesting external review of a future decision of the RBPO or ACO pursuant to 958 CMR 11.00 based on materially different or changed relevant factors in 958 CMR 11.21(2).
(9) Upon a written request by the Patient, the Patient’s Authorized Representative or the RBPO or ACO, and at the sole discretion of the Director of the Office of Patient Protection, the External Review Agency may be directed to retract and revise a decision only upon a finding of material procedural error or clear factual error which is evident on the face of the decision. Any such written request must be received by the Office of Patient Protection within seven calendar days of the date of receipt of the External Review Agency’s final decision in order to be considered.
(10) If the External Review Agency overturns an RBPO or ACO decision in whole or in part, the RBPO or ACO shall notify the Patient within two business days of receipt of the written decision from the External Review Agency. Such notice shall:
1. (a) Acknowledge the decision of the External Review Agency;
2. (b) Advise the Patient of any additional procedures for obtaining the requested services; and
3. (c) Advise the Patient of the name and phone number of the person at the RBPO or ACO who will assist the Patient with obtaining the referral, treatment or service.
(11) The RBPO or ACO shall comply with the External Review Agency’s decision.