SB 230 – AS AMENDED BY THE SENATE
03/22/06 1368s
03/22/06 1483s
2006 SESSION
08/01
SENATE BILL 230
AN ACT relative to the qualifications and liability of the medical director responsible for utilization review under the managed care law.
SPONSORS: Sen. Clegg, Dist 14; Sen. Green, Dist 6; Sen. Morse, Dist 22; Sen. Foster, Dist 13; Sen. Gottesman, Dist 12; Rep. Craig, Hills 9; Rep. DeJoie, Merr 11; Rep. Marshall Quandt, Rock 13; Rep. O’Neil, Rock 15; Rep. Newton, Straf 1
This bill clarifies the qualifications and duties of a medical director.
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Explanation: Matter added to current law appears in bold italics.
Matter removed from current law appears [in brackets and struckthrough.]
Matter which is either (a) all new or (b) repealed and reenacted appears in regular type.
03/22/06 1368s
03/22/06 1483s
06-2010
08/01
STATE OF NEW HAMPSHIRE
In the Year of Our Lord Two Thousand Six
AN ACT relative to the qualifications and liability of the medical director responsible for utilization review under the managed care law.
Be it Enacted by the Senate and House of Representatives in General Court convened:
1 Utilization Review; Qualifications of Medical Director; Duties. Amend RSA 420-J:6, V to read as follows:
V.(a) Each health carrier that conducts utilization review shall employ a medical director who shall have responsibility for all utilization review techniques and methods and their administration and implementation. The medical director shall:
(1) Be licensed to practice medicine under RSA 329;
(2) Possess the education, training, and expertise to evaluate the medical condition of the insured; and
(3) Review the available medical documentation, notes of the attending physician, and test results and other relevant medical records of the insured.
(b) Nothing in this section shall be construed to preclude a medical director from consulting with or relying on the advice of a physician licensed in this state or any other state. Nothing in this section shall be construed as creating any civil liability to the medical director for the medical director’s alleged negligent performance of the aforementioned responsibilities for utilization review.
(c) Any decision not to authorize coverage and the reason for the decision, including whether the coverage is included in the policy, shall be transmitted in writing in a timely manner to the insured, the provider of health care who recommended the service, and the primary care physician of the insured, if any. Any denial on a medical necessity basis shall be based on the review under subparagraph (a)(3) and include an explanation and specific reference with citation to the scientific basis or clinical judgment for the determination, applying the terms of the plan or the policy to the claimant’s medical circumstances.
2 Accident and Health Insurance; Minimum Standards for Claim Review. Amend RSA 415-A:4-a, I(c)(4) to read as follows:
(4) If the claim denial is based on a medical necessity or experimental treatment or other similar exclusion or limit such denial shall only follow a complete review by the medical director of the available medical documentation, notes of the attending physician, and test results and other relevant medical records of the insured and then based upon that review, an explanation [of] and specific reference with citation to the scientific or clinical judgment for the determination, applying the terms of the plan or the policy to the claimant's medical circumstances;
3 Effective Date. This act shall take effect January 1, 2007.