LD 249
PUBLIC Law, Chapter 171

on - Session - 129th Maine Legislature
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An Act To Ensure Protection of Patients in Medical Reviews by Health Insurance Carriers

Be it enacted by the People of the State of Maine as follows:

Sec. 1. 24-A MRSA §4301-A, sub-§4,  as enacted by PL 1999, c. 742, §3, is amended to read:

4. Clinical peer.   "Clinical peer" means a physician or other licensed health care practitioner who holds a nonrestricted license in a state of the United States , is board certified in the same or similar specialty as typically manages the medical condition, procedure or treatment under review , or other physician or health care practitioner with demonstrable expertise necessary to review a case and whose compensation does not depend, directly or indirectly, upon the quantity, type or cost of the medical condition, procedure or treatment that the physician or other licensed health care practitioner approves or denies on behalf of a carrier.

Sec. 2. 24-A MRSA §4304, sub-§7  is enacted to read:

7 Requirements for an appeal of adverse health care treatment decision.   An appeal of a carrier's adverse health care treatment decision must be conducted by a clinical peer. The clinical peer may not have been involved in making the initial adverse health care treatment decision unless additional information not previously considered during the initial review is provided on appeal. For the purposes of this subsection, "adverse health care treatment decision" does not include a carrier's rescission determination or a carrier's determination of initial coverage eligibility for coverage.

Sec. 3. Rules. Notwithstanding the Maine Revised Statutes, Title 24-A, section 4309, any rules adopted by the Bureau of Insurance to conform as necessary to this Act are routine technical rules as defined in Title 5, chapter 375, subchapter 2-A.

Effective 90 days following adjournment of the 129th Legislature, First Regular Session, unless otherwise indicated.

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