An Act administering national standards to Medicaid medical necessity reviews

This bill updates Massachusetts Medicaid rules to require that decisions denying or limiting medical care follow specific national standards and be made by independent, board-certified doctors. When a provider's request for services is rejected, the state must provide a written explanation that details the specific medical reasons for the denial based on national evidence-based criteria and suggests any available alternative treatments. The legislation also mandates a rapid reconsideration process where the provider can review the decision within one working day, with the option to pursue a formal appeal if the initial rejection stands. These changes aim to increase transparency and consistency in how Medicaid evaluates the medical necessity of inpatient stays and other health services.