Raised Bill No. 321 Summary

• Establishes a rebuttable presumption that health care services ordered by a licensed professional are medically necessary, shifting the burden of proof to health carriers to demonstrate services are not medically necessary during utilization reviews and adverse determinations.

• Requires health carriers to use documented clinical review criteria based on sound clinical evidence for utilization reviews, which must be periodically evaluated and posted on the carrier's website along with links to applicable rules and guidelines.

• Mandates specific evidence-based clinical review criteria for substance use disorder treatment (American Society of Addiction Medicine standards), child/adolescent mental disorders (American Academy of Child and Adolescent Psychiatry guidelines), and adult mental disorders (American Psychiatric Association or Association for Ambulatory Behavioral Healthcare standards).

• Requires that clinical peers conducting adverse determination reviews be independent from those involved in the initial determination and must consider all relevant documents, records, and information submitted by the covered person, regardless of whether they were considered in the initial decision.

• Mandates that health carriers provide covered persons with advance notice of any new documents, evidence, or clinical rationale being relied upon before issuing a review decision, allowing reasonable time for response.

• Effective January 1, 2021.