| 1 | 1 | | General Assembly Raised Bill No. 1082 |
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| 2 | 2 | | January Session, 2011 LCO No. 3534 |
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| 3 | 3 | | *03534_______INS* |
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| 4 | 4 | | Referred to Committee on Insurance and Real Estate |
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| 5 | 5 | | Introduced by: |
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| 6 | 6 | | (INS) |
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| 7 | 7 | | |
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| 8 | 8 | | General Assembly |
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| 9 | 9 | | |
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| 10 | 10 | | Raised Bill No. 1082 |
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| 11 | 11 | | |
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| 12 | 12 | | January Session, 2011 |
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| 13 | 13 | | |
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| 14 | 14 | | LCO No. 3534 |
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| 15 | 15 | | |
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| 16 | 16 | | *03534_______INS* |
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| 17 | 17 | | |
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| 18 | 18 | | Referred to Committee on Insurance and Real Estate |
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| 19 | 19 | | |
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| 20 | 20 | | Introduced by: |
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| 21 | 21 | | |
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| 22 | 22 | | (INS) |
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| 23 | 23 | | |
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| 24 | 24 | | AN ACT CONCERNING UTILIZATION REVIEW. |
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| 25 | 25 | | |
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| 26 | 26 | | Be it enacted by the Senate and House of Representatives in General Assembly convened: |
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| 27 | 27 | | |
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| 28 | 28 | | Section 1. Section 38a-226 of the general statutes is repealed and the following is substituted in lieu thereof (Effective October 1, 2011): |
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| 29 | 29 | | |
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| 30 | 30 | | For purposes of sections 38a-226 to 38a-226d, inclusive, as amended by this act: |
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| 31 | 31 | | |
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| 32 | 32 | | (1) "Utilization review" means the prospective, [or] concurrent or retrospective assessment of the necessity and appropriateness of the allocation of health care resources and services given or proposed to be given to an individual within this state. [Utilization review shall not include elective requests for clarification of coverage.] |
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| 33 | 33 | | |
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| 34 | 34 | | (2) "Utilization review company" means any company, organization or other entity performing utilization review, except: |
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| 35 | 35 | | |
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| 36 | 36 | | (A) An agency of the federal government; |
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| 37 | 37 | | |
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| 38 | 38 | | (B) An agent acting on behalf of the federal government, but only to the extent that the agent is providing services to the federal government; |
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| 39 | 39 | | |
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| 40 | 40 | | (C) Any agency of the state of Connecticut; or |
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| 41 | 41 | | |
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| 42 | 42 | | (D) A hospital's internal quality assurance program except if associated with a health care financing mechanism. |
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| 43 | 43 | | |
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| 44 | 44 | | (3) "Adverse determination" means a utilization review company's decision that an admission, service, procedure or extension of stay is not medically necessary. |
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| 45 | 45 | | |
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| 46 | 46 | | [(3)] (4) "Commissioner" means the Insurance Commissioner. |
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| 47 | 47 | | |
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| 48 | 48 | | (5) "Concurrent determination" means a utilization review company's decision of the medical necessity of an admission, service, procedure or extension of stay while such admission, service, procedure or extension of stay is being provided. |
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| 49 | 49 | | |
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| 50 | 50 | | [(4)] (6) "Enrollee" means an individual [who has contracted for or] patient who participates in coverage under an insurance policy, a health care center contract, an employee welfare benefits plan, a hospital or medical services plan contract or any other benefit program providing payment, reimbursement or indemnification for health care costs for an individual or his eligible dependents. |
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| 51 | 51 | | |
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| 52 | 52 | | (7) "Enrollee's representative" means a legal guardian or agent of an enrollee. |
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| 53 | 53 | | |
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| 54 | 54 | | (8) "Final adjudication" means a utilization review company's decision that is not subject to any further internal appeal. |
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| 55 | 55 | | |
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| 56 | 56 | | (9) "Medically necessary" or "medical necessity" means health care services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: (A) In accordance with generally accepted standards of medical practice; (B) clinically appropriate, in terms of type, frequency, extent, site and duration and considered effective for the patient's illness, injury or disease; and (C) not primarily for the convenience of the patient, physician or other health care provider and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease. For the purposes of this subdivision, "generally accepted standards of medical practice" means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community or otherwise consistent with the standards set forth in policy issues involving clinical judgment. |
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| 57 | 57 | | |
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| 58 | 58 | | (10) "Prospective determination" means a utilization review company's decision of the medical necessity of an admission, service, procedure or extension of stay to be provided to the enrollee. |
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| 59 | 59 | | |
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| 60 | 60 | | [(5)] (11) "Provider of record" or "provider" means the physician or other licensed practitioner identified to the utilization review [agent] company as having primary responsibility for the care, treatment and services rendered to an individual. |
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| 61 | 61 | | |
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| 62 | 62 | | (12) "Retrospective determination" means a utilization review company's decision of the medical necessity of an admission, service, procedure or extension of stay that has been provided to the enrollee. |
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| 63 | 63 | | |
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| 64 | 64 | | Sec. 2. Subsection (a) of section 38a-226c of the general statutes is repealed and the following is substituted in lieu thereof (Effective October 1, 2011): |
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| 65 | 65 | | |
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| 66 | 66 | | (a) All utilization review companies shall meet the following minimum standards: |
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| 67 | 67 | | |
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| 68 | 68 | | (1) Each utilization review company shall maintain and make available procedures for [providing notification of] its determinations [regarding certification] in accordance with the following: |
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| 69 | 69 | | |
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| 70 | 70 | | (A) [Notification] (i) Written notification of any prospective, concurrent or retrospective determination by the utilization review company shall be mailed or otherwise communicated to [the provider of record or] the enrollee, [or other appropriate individual within] the enrollee's representative or the provider of record not later than two business days [of] after the receipt of all information necessary to complete the review. [, provided any determination not to certify an admission, service, procedure or extension of stay shall be in writing.] |
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| 71 | 71 | | |
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| 72 | 72 | | (ii) In addition to providing written notification of a determination, the utilization review company may give authorization orally or through a communication other than in writing. If the determination is an approval for a request, the company shall provide a confirmation number corresponding to the authorization. |
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| 73 | 73 | | |
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| 74 | 74 | | (B) (i) After a prospective determination that authorizes an admission, service, procedure or extension of stay has been communicated by the utilization review company to the [appropriate individual, based on accurate information from the] enrollee or the enrollee's representative and the enrollee's provider, the utilization review company [may] shall not reverse such determination if such admission, service, procedure or extension of stay has taken place in reliance on such determination, unless the determination was based on inaccurate information from the provider. |
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| 75 | 75 | | |
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| 76 | 76 | | (ii) Regardless of whether a prospective determination is required by contract, a utilization review company shall provide such prospective determination upon request by an enrollee, an enrollee's representative or an enrollee's provider. |
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| 77 | 77 | | |
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| 78 | 78 | | [(B) Notification of a concurrent determination shall be mailed or otherwise communicated to the provider of record within two business days of receipt of all information necessary to complete the review or, provided all information necessary to perform the review has been received, prior to the end of the current certified period and provided any determination not to certify an admission, service, procedure or extension of stay shall be in writing.] |
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| 79 | 79 | | |
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| 80 | 80 | | (C) [The utilization review company shall not make a determination not to certify based on incomplete information unless it has clearly indicated, in writing, to the provider of record or the enrollee all the information that is needed to make such determination.] If an enrollee's provider requests a concurrent determination, the utilization review company shall provide, if requested by such provider, an opportunity for such provider to discuss the request for concurrent determination with the health care professional making the decision. |
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| 81 | 81 | | |
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| 82 | 82 | | (D) [Notwithstanding subparagraphs (A) to (C), inclusive, of this subdivision, the utilization review company may give authorization orally, electronically or communicated other than in writing. If the determination is an approval for a request, the company shall provide a confirmation number corresponding to the authorization.] If an enrollee, an enrollee's representative or an enrollee's provider requests a prospective or retrospective determination and the utilization review company does not possess all the information necessary to make such determination, the utilization review company shall request from the appropriate individual all such information in writing it requires and shall provide a copy of such request to the enrollee or the enrollee's representative. The utilization review company shall maintain a record of all such requests for additional information. The utilization review company shall not issue any notification declining certification or authorization of an admission, service, procedure or extension of stay prior to receiving and evaluating the requested information, and shall not render a determination based on a lack of necessary information without having first issued a written request for additional information and providing a reasonable opportunity to comply with such request. |
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| 83 | 83 | | |
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| 84 | 84 | | (E) [Except as provided in subparagraph (F) of this subdivision with respect to a final notice, each] Each notice of a determination not to certify or authorize an admission, service, procedure or extension of stay shall include in writing (i) the principal reasons for the determination, (ii) the procedures to initiate an appeal of the determination or the name and telephone number of the person to contact with regard to an appeal pursuant to the provisions of this section, or a statement that all applicable internal appeals have been exhausted, and (iii) the procedure to appeal to the commissioner pursuant to section 38a-478n, as amended by this act. |
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| 85 | 85 | | |
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| 86 | 86 | | (F) [Each notice of a final determination not to certify an admission, service, procedure or extension of stay shall include in writing (i) the principal reasons for the determination, (ii) a statement that all internal appeal mechanisms have been exhausted, and (iii) a copy of the application and procedures prescribed by the commissioner for filing an appeal to the commissioner pursuant to section 38a-478n.] Any adverse determination shall be made by a licensed health care professional. Except for final adjudications as set forth in subparagraph (F) of subdivision (2) of this subsection, physicians, nurses and other licensed health care professionals making utilization review decisions shall have current licenses from a state licensing agency in the United States or appropriate certification from a recognized accreditation agency in the United States. |
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| 87 | 87 | | |
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| 88 | 88 | | (2) Each utilization review company shall maintain and make available a written description of the [appeal procedure] utilization review company's procedures for appeals by which [either] the enrollee, the enrollee's representative or the provider of record may seek review of determinations not to certify or authorize an admission, service, procedure or extension of stay. [An appeal by the provider of record shall be deemed to be made on behalf of the enrollee and with the consent of such enrollee if the admission, service, procedure or extension of stay has not yet been provided or if such determination not to certify creates a financial liability to the enrollee.] The procedures for appeals shall include the following: |
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| 89 | 89 | | |
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| 90 | 90 | | (A) Each utilization review company shall notify in writing the enrollee or the enrollee's representative and provider of record of its [determination on] adjudication of the appeal as soon as practical, but in no case later than [thirty] fifteen days after receiving the required documentation on the appeal. |
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| 91 | 91 | | |
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| 92 | 92 | | (B) On appeal, all determinations not to certify or authorize an admission, service, procedure or extension of stay shall be made by a licensed practitioner of the healing arts who has a current license from a state licensing agency in the United States or appropriate certification from a recognized accreditation agency in the United States. |
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| 93 | 93 | | |
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| 94 | 94 | | (C) An appeal filed by an enrollee's provider shall not preclude such enrollee or enrollee's representative from filing a separate appeal of the same determination. |
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| 95 | 95 | | |
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| 96 | 96 | | [(3)] (D) The process established by each utilization review company [may] shall include a reasonable period within which an appeal [must be filed to be considered] shall be filed, provided such period is not less than ninety days after the issuance of the determination. Any such period may be extended by the utilization review company upon a showing of a justifiable reason for the enrollee's failure or inability to request an appeal in a timely fashion, including, but not limited to, illness, incapacity, hospitalization or failure to receive the determination within the time period set forth in this section. |
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| 97 | 97 | | |
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| 98 | 98 | | [(4)] (E) Each utilization review company shall also provide for an expedited appeals process for emergency or [life threatening] life- threatening situations, as determined by the enrollee's provider. Each utilization review company shall complete the adjudication of such expedited appeals [within two] not later than one business [days of] day after the date the appeal is filed and all information necessary to complete the appeal is received by the utilization review company. If the utilization review company does not possess all information necessary to complete the appeal, the utilization review company shall request from the appropriate individual all such information in writing it requires and shall provide a copy of such request to the enrollee or the enrollee's representative. The utilization review company shall maintain a record of all such requests for additional information. The utilization review company shall not render an adjudication based on a lack of necessary information without first having issued a written request for additional information and providing a reasonable opportunity to comply with such request. |
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| 99 | 99 | | |
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| 100 | 100 | | (F) (i) If the appeal is for a final adjudication, the utilization review company shall, at its expense, have the case reviewed by a physician who is a specialist in the same specialty or subspecialty as the provider of the requested treatment. Except as set forth in subparagraph (E) of this subdivision, such review shall be completed not later then thirty days after the date such review was requested by the utilization review company. The reviewing physician shall issue a written report of the findings to the utilization review company, which shall maintain documentation of such review for the commissioner's verification, including the name of such reviewing physician. |
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| 101 | 101 | | |
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| 102 | 102 | | (ii) Except for a claim brought pursuant to chapter 568, a final adjudication that upholds an adverse determination shall have been made by a physician, nurse or other licensed health care professional who is under the authority of a physician, nurse or other licensed health care professional who holds a current Connecticut license from the Department of Public Health. |
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| 103 | 103 | | |
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| 104 | 104 | | (iii) Upon request by an enrollee, an enrollee's representative or an enrollee's provider, the utilization review company shall provide a hearing prior to the final adjudication of an appeal. Such hearing may be conducted in person, by telephone or by other means at the enrollee's discretion. |
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| 105 | 105 | | |
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| 106 | 106 | | (I) The enrollee, the enrollee's representative, the enrollee's provider and such other persons as requested by the enrollee may participate in such hearing. |
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| 107 | 107 | | |
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| 108 | 108 | | (II) The reviewing physician specified in subparagraph (F)(i) of this subdivision shall participate in such hearing. |
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| 109 | 109 | | |
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| 110 | 110 | | (III) Voting members of the utilization review company's review panel shall participate in such hearing and in the deliberations on the final adjudication. |
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| 111 | 111 | | |
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| 112 | 112 | | (IV) No other person shall participate in such hearing or deliberations unless approved by the enrollee or the enrollee's representative and the utilization review company. |
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| 113 | 113 | | |
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| 114 | 114 | | (iv) The utilization review company shall prepare a video or audio recording of such hearing and shall provide a copy of such recording to the enrollee or the enrollee's representative and the enrollee's provider if such enrollee, enrollee's representative or enrollee's provider appeals the final adjudication to the commissioner pursuant to section 38a-478n, as amended by this act. |
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| 115 | 115 | | |
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| 116 | 116 | | (G) If an adjudication upholds a determination not to certify or authorize an admission, service, procedure or extension of stay, the utilization review company shall notify the enrollee or the enrollee's representative and the enrollee's provider in writing of such adjudication. Such notification shall include: (i) The principal reasons for the adjudication, provided in the case of an adverse determination, the utilization review company shall include the specific reasons why the admission, service, procedure or extension of stay is not medically necessary, along with a summary of all information relied upon in making such a finding; (ii) the procedures to initiate an appeal of such adjudication or the name and telephone number of the person to contact with regard to an appeal pursuant to the provisions of this section; and (iii) in the case of a final adjudication, the procedure to appeal to the commissioner pursuant to section 38a-478n, as amended by this act. |
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| 117 | 117 | | |
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| 118 | 118 | | [(5)] (3) Each utilization review company shall utilize written clinical criteria and review procedures [which] that are established and periodically evaluated and updated with appropriate involvement from practitioners. Such criteria and procedures shall be consistent with the definition of "medical necessity" set forth in section 38a-226, as amended by this act, and such definition shall control in the event of a conflict. |
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| 119 | 119 | | |
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| 120 | 120 | | [(6) Physicians, nurses and other licensed health professionals making utilization review decisions shall have current licenses from a state licensing agency in the United States or appropriate certification from a recognized accreditation agency in the United States, provided, any final determination not to certify an admission, service, procedure or extension of stay for an enrollee within this state, except for a claim brought pursuant to chapter 568, shall be made by a physician, nurse or other licensed health professional under the authority of a physician, nurse or other licensed health professional who has a current Connecticut license from the Department of Public Health. |
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| 121 | 121 | | |
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| 122 | 122 | | (7) In cases where an appeal to reverse a determination not to certify is unsuccessful, each utilization review company shall assure that a practitioner in a specialty related to the condition is reasonably available to review the case. When the reason for the determination not to certify is based on medical necessity, including whether a treatment is experimental or investigational, each utilization review company shall have the case reviewed by a physician who is a specialist in the field related to the condition that is the subject of the appeal. Any such review, except for a claim brought pursuant to chapter 568, that upholds a final determination not to certify in the case of an enrollee within this state shall be conducted by such practitioner or physician under the authority of a practitioner or physician who has a current Connecticut license from the Department of Public Health. The review shall be completed within thirty days of the request for review. The utilization review company shall be financially responsible for the review and shall maintain, for the commissioner's verification, documentation of the review, including the name of the reviewing physician.] |
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| 123 | 123 | | |
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| 124 | 124 | | [(8)] (4) Except as provided in subsection (e) of this section, each utilization review company shall make review staff available by toll-free telephone, at least forty hours per week during normal business hours. |
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| 125 | 125 | | |
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| 126 | 126 | | [(9)] (5) Each utilization review company shall comply with all applicable federal and state laws to protect the confidentiality of individual medical records. Summary and aggregate data shall not be considered confidential if [it does] they do not provide sufficient information to allow identification of individual patients. |
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| 127 | 127 | | |
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| 128 | 128 | | [(10)] (6) Each utilization review company shall allow a minimum of twenty-four hours following an emergency admission, service or procedure for an enrollee or his representative to notify the utilization review company and request certification or continuing treatment for that condition. |
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| 129 | 129 | | |
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| 130 | 130 | | [(11)] (7) No utilization review company [may] shall give an employee any financial incentive based on the number of denials of certification such employee makes. |
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| 131 | 131 | | |
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| 132 | 132 | | [(12)] (8) Each utilization review company shall annually file with the commissioner: |
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| 133 | 133 | | |
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| 134 | 134 | | (A) The names of all managed care organizations, as defined in section 38a-478, that the utilization review company services in Connecticut; |
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| 135 | 135 | | |
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| 136 | 136 | | (B) Any utilization review services for which the utilization review company has contracted out for services and the name of such company providing the services; |
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| 137 | 137 | | |
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| 138 | 138 | | (C) The number of utilization review determinations not to certify or authorize an admission, service, procedure or extension of stay and the outcome of such determination upon appeal within the utilization review company. Determinations related to mental or nervous conditions, as defined in section 38a-514, shall be reported separately from all other determinations reported under this subdivision; and |
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| 139 | 139 | | |
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| 140 | 140 | | (D) The following information relative to requests for utilization review of mental health services for enrollees of fully insured health benefit plans or self-insured or self-funded employee health benefit plans, separately and by category: (i) The reason for the request, including, but not limited to, an inpatient admission, service, procedure or extension of inpatient stay or an outpatient treatment, (ii) the number of requests denied by type of request, and (iii) whether the request was denied or partially denied. |
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| 141 | 141 | | |
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| 142 | 142 | | [(13) Any utilization review decision to initially deny services shall be made by a licensed health professional.] |
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| 143 | 143 | | |
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| 144 | 144 | | Sec. 3. Subsection (c) of section 38a-226c of the general statutes is repealed and the following is substituted in lieu thereof (Effective October 1, 2011): |
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| 145 | 145 | | |
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| 146 | 146 | | (c) The provider of record shall provide to each utilization review company, within a reasonable period of time, all relevant information necessary for the utilization review company to certify or authorize the admission, procedure, treatment or length of stay. Failure of the provider to provide such documentation for review shall be grounds for a denial of certification or authorization in accordance with the policy of the utilization review company or the health benefit plan. |
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| 147 | 147 | | |
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| 148 | 148 | | Sec. 4. Subsection (m) of section 38a-479aa of the general statutes is repealed and the following is substituted in lieu thereof (Effective October 1, 2011): |
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| 149 | 149 | | |
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| 150 | 150 | | (m) Each utilization review determination made by or on behalf of a preferred provider network shall be made in accordance with sections 38a-226 to 38a-226d, inclusive, [except that any] as amended by this act. Any initial appeal of a determination not to certify or authorize an admission, service, procedure or extension of stay shall be conducted in accordance with subdivision [(7)] (2) of subsection (a) of section 38a-226c, as amended by this act, and any subsequent appeal shall be referred to the managed care organization on whose behalf the preferred provider network provides services. The managed care organization shall conduct the subsequent appeal in accordance with said subdivision. |
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| 151 | 151 | | |
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| 152 | 152 | | Sec. 5. Subdivision (12) of subsection (d) of section 38a-479bb of the general statutes is repealed and the following is substituted in lieu thereof (Effective October 1, 2011): |
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| 153 | 153 | | |
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| 154 | 154 | | (12) A provision that the preferred provider network shall ensure that utilization review determinations are made in accordance with sections 38a-226 to 38a-226d, inclusive, [except that any] as amended by this act. Any initial appeal of a determination not to certify or authorize an admission, service, procedure or extension of stay shall be made in accordance with subdivision [(7)] (2) of subsection (a) of section 38a-226c, as amended by this act. In cases where an appeal to reverse a determination not to certify or authorize is unsuccessful, the preferred provider network shall refer the case to the managed care organization which shall conduct the subsequent appeal, if any, in accordance with said subdivision. |
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| 155 | 155 | | |
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| 156 | 156 | | |
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| 157 | 157 | | |
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| 158 | 158 | | |
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| 159 | 159 | | This act shall take effect as follows and shall amend the following sections: |
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| 160 | 160 | | Section 1 October 1, 2011 38a-226 |
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| 161 | 161 | | Sec. 2 October 1, 2011 38a-226c(a) |
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| 162 | 162 | | Sec. 3 October 1, 2011 38a-226c(c) |
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| 163 | 163 | | Sec. 4 October 1, 2011 38a-479aa(m) |
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| 164 | 164 | | Sec. 5 October 1, 2011 38a-479bb(d)(12) |
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| 165 | 165 | | |
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| 166 | 166 | | This act shall take effect as follows and shall amend the following sections: |
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| 167 | 167 | | |
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| 168 | 168 | | Section 1 |
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| 169 | 169 | | |
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| 170 | 170 | | October 1, 2011 |
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| 171 | 171 | | |
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| 172 | 172 | | 38a-226 |
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| 173 | 173 | | |
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| 174 | 174 | | Sec. 2 |
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| 175 | 175 | | |
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| 176 | 176 | | October 1, 2011 |
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| 177 | 177 | | |
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| 178 | 178 | | 38a-226c(a) |
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| 179 | 179 | | |
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| 180 | 180 | | Sec. 3 |
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| 181 | 181 | | |
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| 182 | 182 | | October 1, 2011 |
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| 183 | 183 | | |
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| 184 | 184 | | 38a-226c(c) |
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| 185 | 185 | | |
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| 186 | 186 | | Sec. 4 |
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| 187 | 187 | | |
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| 188 | 188 | | October 1, 2011 |
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| 189 | 189 | | |
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| 190 | 190 | | 38a-479aa(m) |
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| 191 | 191 | | |
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| 192 | 192 | | Sec. 5 |
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| 193 | 193 | | |
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| 194 | 194 | | October 1, 2011 |
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| 195 | 195 | | |
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| 196 | 196 | | 38a-479bb(d)(12) |
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| 197 | 197 | | |
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| 198 | 198 | | Statement of Purpose: |
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| 199 | 199 | | |
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| 200 | 200 | | To clarify the requirements and standards for utilization review companies and the reviews such companies perform. |
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| 201 | 201 | | |
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| 202 | 202 | | [Proposed deletions are enclosed in brackets. Proposed additions are indicated by underline, except that when the entire text of a bill or resolution or a section of a bill or resolution is new, it is not underlined.] |
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