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Connecticut Senate Bill SB00410

Connecticut 2012 Regular Session

Connecticut Senate Bill SB00410 Compare Versions

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1-Substitute Senate Bill No. 410
1+General Assembly Substitute Bill No. 410
2+February Session, 2012 *_____SB00410INS___032012____*
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3-Public Act No. 12-102
4+General Assembly
5+
6+Substitute Bill No. 410
7+
8+February Session, 2012
9+
10+*_____SB00410INS___032012____*
411
512 AN ACT CONCERNING ADVERSE DETERMINATION REVIEWS.
613
714 Be it enacted by the Senate and House of Representatives in General Assembly convened:
815
916 Section 1. Section 38a-591d of the 2012 supplement to the general statutes is repealed and the following is substituted in lieu thereof (Effective October 1, 2012):
1017
1118 (a) (1) Each health carrier shall maintain written procedures for (A) utilization review and benefit determinations, (B) expedited utilization review and benefit determinations with respect to prospective urgent care requests and concurrent review urgent care requests, and (C) notifying covered persons or covered persons' authorized representatives of such review and benefit determinations. Each health carrier shall make such review and benefit determinations within the specified time periods under this section.
1219
1320 (2) In determining whether a benefit request shall be considered an urgent care request, an individual acting on behalf of a health carrier shall apply the judgment of a prudent layperson who possesses an average knowledge of health and medicine, except that any benefit request determined to be an urgent care request by a health care professional with knowledge of the covered person's medical condition shall be deemed an urgent care request.
1421
1522 (b) With respect to a nonurgent care request:
1623
1724 (1) For a prospective or concurrent review request, a health carrier shall make a determination within a reasonable period of time appropriate to the covered person's medical condition, but not later than fifteen calendar days after the date the health carrier receives such request, and shall notify the covered person and, if applicable, the covered person's authorized representative of such determination, whether or not the carrier certifies the provision of the benefit.
1825
1926 (2) For a retrospective review request, a health carrier shall make a determination within a reasonable period of time, but not later than thirty calendar days after the date the health carrier receives such request.
2027
2128 (3) The time periods specified in subdivisions (1) and (2) of this subsection may be extended once by the health carrier for up to fifteen calendar days, provided the health carrier:
2229
2330 (A) Determines that an extension is necessary due to circumstances beyond the health carrier's control; and
2431
2532 (B) Notifies the covered person and, if applicable, the covered person's authorized representative prior to the expiration of the initial time period, of the circumstances requiring the extension of time and the date by which the health carrier expects to make a determination.
2633
2734 (4) (A) If the extension pursuant to subdivision (3) of this subsection is necessary due to the failure of the covered person or the covered person's authorized representative to provide information necessary to make a determination on the request, the health carrier shall:
2835
2936 (i) Specifically describe in the notice of extension the required information necessary to complete the request; and
3037
3138 (ii) Provide the covered person and, if applicable, the covered person's authorized representative with not less than forty-five calendar days after the date of receipt of the notice to provide the specified information.
3239
3340 (B) If the covered person or the covered person's authorized representative fails to submit the specified information before the end of the period of the extension, the health carrier may deny certification of the benefit requested.
3441
3542 (c) With respect to an urgent care request:
3643
3744 (1) Unless the covered person or the covered person's authorized representative has failed to provide information necessary for the health carrier to make a determination, the health carrier shall make a determination as soon as possible, taking into account the covered person's medical condition, but not later than seventy-two hours after the health carrier receives such request, provided, if the urgent care request is a concurrent review request to extend a course of treatment beyond the initial period of time or the number of treatments, such request is made at least twenty-four hours prior to the expiration of the prescribed period of time or number of treatments;
3845
3946 (2) (A) If the covered person or the covered person's authorized representative has failed to provide information necessary for the health carrier to make a determination, the health carrier shall notify the covered person or the covered person's representative, as applicable, as soon as possible, but not later than twenty-four hours after the health carrier receives such request.
4047
4148 (B) The health carrier shall provide the covered person or the covered person's authorized representative, as applicable, a reasonable period of time to submit the specified information, taking into account the covered person's medical condition, but not less than forty-eight hours after notifying the covered person or the covered person's authorized representative, as applicable.
4249
4350 (3) The health carrier shall notify the covered person and, if applicable, the covered person's authorized representative of its determination as soon as possible, but not later than forty-eight hours after the earlier of (A) the date on which the covered person and the covered person's authorized representative, as applicable, provides the specified information to the health carrier, or (B) the date on which the specified information was to have been submitted.
4451
4552 (d) (1) Whenever a health carrier receives a review request from a covered person or a covered person's authorized representative that fails to meet the health carrier's filing procedures, the health carrier shall notify the covered person and, if applicable, the covered person's authorized representative of such failure not later than five calendar days after the health carrier receives such request, except that for an urgent care request, the health carrier shall notify the covered person and, if applicable, the covered person's authorized representative of such failure not later than twenty-four hours after the health carrier receives such request.
4653
4754 (2) If the health carrier provides such notice orally, the health carrier shall provide confirmation in writing to the covered person and the covered person's health care professional of record not later than five calendar days after providing the oral notice.
4855
4956 (e) Each health carrier shall provide promptly to a covered person and, if applicable, the covered person's authorized representative a notice of an adverse determination.
5057
5158 (1) Such notice may be provided in writing or by electronic means and shall set forth, in a manner calculated to be understood by the covered person or the covered person's authorized representative:
5259
5360 [(1)] (A) Information sufficient to identify the benefit request or claim involved, including the date of service, if applicable, the health care professional and the claim amount;
5461
5562 [(2)] (B) The specific reason or reasons for the adverse determination and a description of the health carrier's standard, if any, that was used in reaching the denial;
5663
5764 [(3)] (C) Reference to the specific health benefit plan provisions on which the determination is based;
5865
5966 [(4)] (D) A description of any additional material or information necessary for the covered person to perfect the benefit request or claim, including an explanation of why the material or information is necessary to perfect the request or claim;
6067
61-[(5)] (E) A description of the health carrier's internal grievance process that includes [(A)] (i) the health carrier's expedited review procedures, [(B)] (ii) any time limits applicable to such process or procedures, [(C)] (iii) the contact information for the organizational unit designated to coordinate the review on behalf of the health carrier, and [(D)] (iv) a statement that the covered person or, if applicable, the covered person's authorized representative is entitled, pursuant to the requirements of the health carrier's internal grievance process, to [(i)] (I) submit written comments, documents, records and other material relating to the covered person's benefit request for consideration by the individual or individuals conducting the review, and [(ii)] (II) receive from the health carrier, free of charge upon request, reasonable access to and copies of all documents, records, communications and other information [relevant to] and evidence regarding the covered person's benefit request;
68+[(5)] (E) A description of the health carrier's internal grievance process that includes [(A)] (i) the health carrier's expedited review procedures, [(B)] (ii) any time limits applicable to such process or procedures, [(C)] (iii) the contact information for the organizational unit designated to coordinate the review on behalf of the health carrier, and [(D)] (iv) a statement that the covered person or, if applicable, the covered person's authorized representative is entitled, pursuant to the requirements of the health carrier's internal grievance process, to [(i)] (I) submit written comments, documents, records and other material relating to the covered person's benefit request for consideration by the individual or individuals conducting the review, and [(ii)] (II) receive from the health carrier, free of charge, [upon request,] reasonable access to and copies of all documents, records and other information relevant to the covered person's benefit request;
6269
63-[(6)] (F) If the adverse determination is based on a health carrier's internal rule, guideline, protocol or other similar criterion, [(A)] (i) the specific rule, guideline, protocol or other similar criterion, or [(B)] (ii) a statement that a specific rule, guideline, protocol or other similar criterion of the health carrier was relied upon to make the adverse determination and that a copy of such rule, guideline, protocol or other similar criterion will be provided to the covered person free of charge upon request, and instructions for requesting such copy;
70+[(6)] (F) If the adverse determination is based on a health carrier's internal rule, guideline, protocol or other similar criterion, [(A)] the specific rule, guideline, protocol or other similar criterion; [, or (B) a statement that a specific rule, guideline, protocol or other similar criterion of the health carrier was relied upon to make the adverse determination and that a copy of such rule, guideline, protocol or other similar criterion will be provided to the covered person free of charge upon request, and instructions for requesting such copy;]
6471
65-[(7)] (G) If the adverse determination is based on medical necessity or an experimental or investigational treatment or similar exclusion or limit, the written statement of the scientific or clinical rationale for the adverse determination and [(A)] (i) an explanation of the scientific or clinical rationale used to make the determination that applies the terms of the health benefit plan to the covered person's medical circumstances or [(B)] (ii) a statement that an explanation will be provided to the covered person free of charge upon request, and instructions for requesting a copy of such explanation; and
72+[(7)] (G) If the adverse determination is based on medical necessity or an experimental or investigational treatment or similar exclusion or limit, the written statement of the scientific or clinical rationale for the adverse determination and [(A)] an explanation of the scientific or clinical rationale used to make the determination that applies the terms of the health benefit plan to the covered person's medical circumstances; [, or (B) a statement that an explanation will be provided to the covered person free of charge upon request, and instructions for requesting a copy of such explanation;] and
6673
6774 [(8)] (H) A statement explaining the right of the covered person to contact the commissioner's office or the Office of the Healthcare Advocate at any time for assistance or, upon completion of the health carrier's internal grievance process, to file a civil suit in a court of competent jurisdiction. Such statement shall include the contact information for said offices.
6875
69-(2) Upon request pursuant to subparagraph (E) of subdivision (1) of this subsection, the health carrier shall provide such copies in accordance with subsection (a) of section 5 of this act.
76+(2) The health carrier shall include, free of charge, with such notice a copy of all documents, communications, information, evidence and rationale regarding the adverse determination, whether or not the health carrier considered such documents, communications, information, evidence or rationale in making the adverse determination.
7077
7178 (f) If the adverse determination is a rescission, the health carrier shall include with the advance notice of the application for rescission required to be sent to the covered person, a written statement that includes:
7279
7380 (1) Clear identification of the alleged fraudulent act, practice or omission or the intentional misrepresentation of material fact;
7481
7582 (2) An explanation as to why the act, practice or omission was fraudulent or was an intentional misrepresentation of a material fact;
7683
7784 (3) A disclosure that the covered person or the covered person's authorized representative may file immediately, without waiting for the date such advance notice of the proposed rescission ends, a grievance with the health carrier to request a review of the adverse determination to rescind coverage, pursuant to sections 38a-591e and 38a-591f, as amended by this act;
7885
7986 (4) A description of the health carrier's grievance procedures established under sections 38a-591e and 38a-591f, as amended by this act, including [,] any time limits applicable to those procedures; and
8087
8188 (5) The date such advance notice of the proposed rescission ends and the date back to which the coverage will be retroactively rescinded.
8289
8390 (g) (1) Whenever a health carrier fails to strictly adhere to the requirements of this section with respect to making utilization review and benefit determinations of a benefit request or claim, the covered person shall be deemed to have exhausted the internal grievance process of such health carrier and may file a request for an external review in accordance with the provisions of section 38a-591g, as amended by this act, regardless of whether the health carrier asserts it substantially complied with the requirements of this section or that any error it committed was de minimis.
8491
8592 (2) A covered person who has exhausted the internal grievance process of a health carrier may, in addition to filing a request for an external review, pursue any available remedies under state or federal law on the basis that the health carrier failed to provide a reasonable internal grievance process that would yield a decision on the merits of the claim.
8693
94+(h) Notwithstanding subdivision (3) of subsection (c) of section 38a-591e, as amended by this act, if a covered person or the covered person's authorized representative files any grievance or requests any review of an adverse determination or a final adverse determination pursuant to section 38a-591e, 38a-591f or 38a-591g, as amended by this act, relating to the dispensation of a drug prescribed by a licensed participating provider, the health carrier shall issue immediate electronic authorization to the covered person's pharmacy for such drug for the duration of any such grievance or review. Such authorization shall include confirmation of the availability of payment for such supply of such drug.
95+
8796 Sec. 2. Section 38a-591e of the 2012 supplement to the general statutes is repealed and the following is substituted in lieu thereof (Effective October 1, 2012):
8897
8998 (a) (1) Each health carrier shall establish and maintain written procedures for (A) the review of grievances of adverse determinations that were based, in whole or in part, on medical necessity, (B) the expedited review of grievances of adverse determinations of urgent care requests, including concurrent review urgent care requests involving an admission, availability of care, continued stay or health care service for a covered person who has received emergency services but has not been discharged from a facility, and (C) notifying covered persons or covered persons' authorized representatives of such adverse determinations.
9099
91100 (2) Each health carrier shall file with the commissioner a copy of such procedures, including all forms used to process requests, and any subsequent material modifications to such procedures.
92101
93-(3) In addition to a copy of such procedures, each health carrier shall file annually with the commissioner, as part of its annual report required under subsection (e) of section 38a-591b, a certificate of compliance stating that the health carrier has established and maintains grievance procedures for each of its health benefit plans that are fully compliant with the provisions of sections 38a-591a to 38a-591m, inclusive, as amended by this act, and section 5 of this act.
102+(3) In addition to a copy of such procedures, each health carrier shall file annually with the commissioner, as part of its annual report required under subsection (e) of section 38a-591b, a certificate of compliance stating that the health carrier has established and maintains grievance procedures for each of its health benefit plans that are fully compliant with the provisions of sections 38a-591a to 38a-591m, inclusive, as amended by this act.
94103
95104 (b) (1) A covered person or a covered person's authorized representative may file a grievance of an adverse determination that was based, in whole or in part, on medical necessity with the health carrier not later than one hundred eighty calendar days after the covered person or the covered person's authorized representative, as applicable, receives the notice of an adverse determination.
96105
97106 (2) For prospective or concurrent urgent care requests, a covered person or a covered person's authorized representative may make a request for an expedited review orally or in writing.
98107
99108 (c) (1) (A) When conducting a review of an adverse determination under this section, the health carrier shall ensure that such review is conducted in a manner to ensure the independence and impartiality of the individual or individuals involved in making the review decision.
100109
101110 (B) If the adverse determination involves utilization review, the health carrier shall designate an appropriate clinical peer or peers to review such adverse determination. Such clinical peer or peers shall not have been involved in the initial adverse determination.
102111
103112 (C) The individual or individuals conducting a review under this section shall take into consideration all comments, documents, records and other information relevant to the covered person's benefit request that is the subject of the adverse determination under review, that are submitted by the covered person or the covered person's authorized representative, regardless of whether such information was submitted or considered in making the initial adverse determination.
104113
105114 (D) Prior to issuing a decision, the health carrier shall provide free of charge, by facsimile, electronic means or any other expeditious method available, to the covered person or the covered person's authorized representative, as applicable, any new or additional documents, communications, information and evidence relied upon and any new or additional scientific or clinical rationale used by the health carrier in connection with the grievance. Such documents, communications, information, evidence and rationale shall be provided sufficiently in advance of the date the health carrier is required to issue a decision to permit the covered person or the covered person's authorized representative, as applicable, a reasonable opportunity to respond prior to such date.
106115
107116 (2) If the review under subdivision (1) of this subsection is an expedited review, all necessary information, including the health carrier's decision, shall be transmitted between the health carrier and the covered person or the covered person's authorized representative, as applicable, by telephone, facsimile, electronic means or any other expeditious method available.
108117
109118 (3) If the review under subdivision (1) of this subsection is an expedited review of a grievance involving an adverse determination of a concurrent review urgent care request, the treatment shall be continued without liability to the covered person until the covered person has been notified of the review decision.
110119
111120 (d) (1) The health carrier shall notify the covered person and, if applicable, the covered person's authorized representative, in writing or by electronic means, of its decision within a reasonable period of time appropriate to the covered person's medical condition, but not later than:
112121
113122 (A) For prospective review and concurrent review requests, thirty calendar days after the health carrier receives the grievance;
114123
115124 (B) For retrospective review requests, sixty calendar days after the health carrier receives the grievance; and
116125
117126 (C) For expedited review requests, seventy-two hours after the health carrier receives the grievance.
118127
119128 (2) The time periods set forth in subdivision (1) of this subsection shall apply regardless of whether all of the information necessary to make a decision accompanies the filing.
120129
121130 (e) (1) The notice required under subsection (d) of this section shall set forth, in a manner calculated to be understood by the covered person or the covered person's authorized representative:
122131
123132 [(1)] (A) The titles and qualifying credentials of the individual or individuals participating in the review process;
124133
125134 [(2)] (B) Information sufficient to identify the claim involved with respect to the grievance, including the date of service, if applicable, the health care professional and the claim amount;
126135
127136 [(3)] (C) A statement of such individual's or individuals' understanding of the covered person's grievance;
128137
129138 [(4)] (D) The individual's or individuals' decision in clear terms and the health benefit plan contract basis or scientific or clinical rationale for such decision in sufficient detail for the covered person to respond further to the health carrier's position;
130139
131140 [(5)] (E) Reference to the evidence or documentation used as the basis for the decision;
132141
133142 [(6)] (F) For a decision that upholds the adverse determination:
134143
135144 [(A)] (i) The specific reason or reasons for the final adverse determination, including the denial code and its corresponding meaning, as well as a description of the health carrier's standard, if any, that was used in reaching the denial;
136145
137146 [(B)] (ii) Reference to the specific health benefit plan provisions on which the decision is based;
138147
139-[(C)] (iii) A statement that the covered person may receive from the health carrier, free of charge and upon request, reasonable access to and copies of, all documents, records, communications and other information [relevant to] and evidence not previously provided regarding the adverse determination under review;
148+[(C) A statement that the covered person may receive from the health carrier, free of charge and upon request, reasonable access to and copies of, all documents, records and other information relevant to the adverse determination under review;]
140149
141-[(D)] (iv) If the final adverse determination is based on a health carrier's internal rule, guideline, protocol or other similar criterion, [(i)] (I) the specific rule, guideline, protocol or other similar criterion, or [(ii)] (II) a statement that a specific rule, guideline, protocol or other similar criterion of the health carrier was relied upon to make the final adverse determination and that a copy of such rule, guideline, protocol or other similar criterion will be provided to the covered person free of charge upon request and instructions for requesting such copy;
150+[(D)] (iii) If the final adverse determination is based on a health carrier's internal rule, guideline, protocol or other similar criterion, [(i)] the specific rule, guideline, protocol or other similar criterion; [, or (ii) a statement that a specific rule, guideline, protocol or other similar criterion of the health carrier was relied upon to make the final adverse determination and that a copy of such rule, guideline, protocol or other similar criterion will be provided to the covered person free of charge upon request and instructions for requesting such copy;]
142151
143-[(E)] (v) If the final adverse determination is based on medical necessity or an experimental or investigational treatment or similar exclusion or limit, the written statement of the scientific or clinical rationale for the final adverse determination and [(i)] (I) an explanation of the scientific or clinical rationale used to make the determination that applies the terms of the health benefit plan to the covered person's medical circumstances, or [(ii)] (II) a statement that an explanation will be provided to the covered person free of charge upon request and instructions for requesting a copy of such explanation;
152+[(E)] (iv) If the final adverse determination is based on medical necessity or an experimental or investigational treatment or similar exclusion or limit, the written statement of the scientific or clinical rationale for the final adverse determination and [(i)] an explanation of the scientific or clinical rationale used to make the determination that applies the terms of the health benefit plan to the covered person's medical circumstances, including citations to any medical journal articles or scientific or clinical evidence relied upon; [or (ii) a statement that an explanation will be provided to the covered person free of charge upon request and instructions for requesting a copy of such explanation;]
144153
145-[(F)] (vi) A statement describing the procedures for obtaining an external review of the final adverse determination;
154+[(F)] (v) A statement describing the procedures for obtaining an external review of the final adverse determination;
146155
147156 [(7)] (G) If applicable, the following statement: "You and your plan may have other voluntary alternative dispute resolution options such as mediation. One way to find out what may be available is to contact your state Insurance Commissioner."; and
148157
149158 [(8)] (H) A statement disclosing the covered person's right to contact the commissioner's office or the Office of the Healthcare Advocate at any time. Such disclosure shall include the contact information for said offices.
150159
151-(2) Upon request pursuant to subparagraph (F)(iii) of subdivision (1) of this subsection, the health carrier shall provide such copies in accordance with subsection (b) of section 5 of this act.
160+(2) For a decision that upholds the adverse determination, the health carrier shall include, free of charge, with such notice copies of all documents, communications, information, evidence and rationale regarding the adverse determination, whether or not the individual or individuals conducting a review under this section considered such documents, communications, information, evidence or rationale in making the final adverse determination, that were not provided to the covered person or the covered person's authorized representative pursuant to subdivision (2) of subsection (e) of section 38a-591d, as amended by this act, or subparagraph (D) of subdivision (1) of subsection (c) of this section. The health carrier shall not be required to include the comments, documents, records or other information submitted by the covered person or the covered person's authorized representative pursuant to subparagraph (C) of subdivision (1) of subsection (c) of this section.
152161
153162 (f) (1) Whenever a health carrier fails to strictly adhere to the requirements of this section with respect to receiving and resolving grievances involving an adverse determination, the covered person shall be deemed to have exhausted the internal grievance process of such health carrier and may file a request for an external review, regardless of whether the health carrier asserts that it substantially complied with the requirements of this section, or that any error it committed was de minimis.
154163
155164 (2) A covered person who has exhausted the internal grievance process of a health carrier may, in addition to filing a request for an external review, pursue any available remedies under state or federal law on the basis that the health carrier failed to provide a reasonable internal grievance process that would yield a decision on the merits of the claim.
156165
157166 Sec. 3. Section 38a-591f of the 2012 supplement to the general statutes is repealed and the following is substituted in lieu thereof (Effective October 1, 2012):
158167
159168 (a) Each health carrier shall establish and maintain written procedures (1) for the review of grievances of adverse determinations that were not based on medical necessity, and (2) notifying covered persons or covered persons' authorized representatives of such adverse determinations.
160169
161170 (b) (1) A covered person or the covered person's authorized representative may file a grievance of an adverse determination that was not based on medical necessity with the health carrier not later than one hundred eighty calendar days after the covered person or the covered person's representative, as applicable, receives the notice of an adverse determination.
162171
163172 (2) The health carrier shall notify the covered person and, if applicable, the covered person's authorized representative not later than three business days after the health carrier receives a grievance that the covered person or the covered person's authorized representative, as applicable, is entitled to submit written material to the health carrier to be considered when conducting a review of the grievance.
164173
165174 (3) (A) Upon receipt of a grievance, a health carrier shall designate an individual or individuals to conduct a review of the grievance.
166175
167176 (B) The health carrier shall not designate the same individual or individuals who denied the claim or handled the matter that is the subject of the grievance to conduct the review of the grievance.
168177
169178 (C) The health carrier shall provide the covered person and, if applicable, the covered person's authorized representative with the name, address and telephone number of the individual or the organizational unit designated to coordinate the review on behalf of the health carrier.
170179
171180 (c) (1) The health carrier shall notify the covered person and, if applicable, the covered person's authorized representative in writing, of its decision not later than twenty business days after the health carrier received the grievance.
172181
173182 (2) If the health carrier is unable to comply with the time period specified in subdivision (1) of this subsection due to circumstances beyond the health carrier's control, the time period may be extended by the health carrier for up to ten business days, provided that on or before the twentieth business day after the health carrier received the grievance, the health carrier provides written notice to the covered person and, if applicable, the covered person's authorized representative of the extension and the reasons for the delay.
174183
175184 (d) (1) The written decision issued pursuant to subsection (c) of this section shall contain:
176185
177186 [(1)] (A) The titles and qualifying credentials of the individual or individuals participating in the review process;
178187
179188 [(2)] (B) A statement of such individual's or individuals' understanding of the covered person's grievance;
180189
181-[(3)] (C) The individual's or individuals' decision in clear terms and the health benefit plan contract basis for such decision in sufficient detail for the covered person to respond further to the health carrier's position; [and]
190+[(3)] (C) The individual's or individuals' decision in clear terms and the health benefit plan contract basis for such decision in sufficient detail for the covered person to respond further to the health carrier's position; and
182191
183-[(4)] (D) Reference to the documents, communications, information and evidence [or documentation] used as the basis for the decision; and
192+[(4)] (D) Reference to the evidence or documentation used as the basis for the decision.
184193
185-(E) For a decision that upholds the adverse determination, a statement that the covered person may receive from the health carrier, free of charge and upon request, reasonable access to and copies of, all documents, communications, information and evidence regarding the adverse determination that is the subject of the final adverse determination.
186-
187-(2) Upon request pursuant to subparagraph (E) of subdivision (1) of this subsection, the health carrier shall provide such copies in accordance with subsection (b) of section 5 of this act.
194+(2) For a decision that upholds the adverse determination, the health carrier shall include, free of charge, with such notice copies of all documents, communications, information and evidence regarding the adverse determination, whether or not the individual or individuals conducting a review under this section considered such documents, communications, information or evidence in making the final adverse determination, that were not provided to the covered person or the covered person's authorized representative pursuant to subdivision (2) of subsection (e) of section 38a-591d, as amended by this act.
188195
189196 Sec. 4. Section 38a-591g of the 2012 supplement to the general statutes is repealed and the following is substituted in lieu thereof (Effective October 1, 2012):
190197
191198 (a) (1) A covered person or a covered person's authorized representative may file a request for an external review or an expedited external review of an adverse determination or a final adverse determination in accordance with the provisions of this section. All requests for external review or expedited external review shall be made in writing to the commissioner. The commissioner may prescribe the form and content of such requests.
192199
193200 (2) (A) All requests for external review or expedited external review shall be accompanied by a filing fee of twenty-five dollars, except that no covered person or covered person's authorized representative shall pay more than seventy-five dollars in a calendar year for such covered person. Any filing fee paid by a covered person's authorized representative shall be deemed to have been paid by the covered person. If the commissioner finds that the covered person is indigent or unable to pay the filing fee, the commissioner shall waive such fee. Any such fees shall be deposited in the Insurance Fund established under section 38a-52a.
194201
195202 (B) The commissioner shall refund any paid filing fee to the covered person or the covered person's authorized representative, as applicable, or the health care professional if the adverse determination or the final adverse determination that is the subject of the external review request or expedited external review request is reversed or revised.
196203
197204 (3) The health carrier that issued the adverse determination or the final adverse determination that is the subject of the external review request or the expedited external review request shall pay the independent review organization for the cost of conducting the review.
198205
199206 (4) An external review decision, whether such review is a standard external review or an expedited external review, shall be binding on the health carrier or a self-insured governmental plan and the covered person, except to the extent such health carrier or covered person has other remedies available under federal or state law. A covered person or a covered person's authorized representative shall not file a subsequent request for an external review or an expedited external review that involves the same adverse determination or final adverse determination for which the covered person or the covered person's authorized representative already received an external review decision or an expedited external review decision.
200207
201208 (5) Each health carrier shall maintain written records of external reviews as set forth in section 38a-591h.
202209
203210 (6) Each independent review organization shall maintain written records as set forth in subsection (e) of section 38a-591m.
204211
205212 (b) (1) Except as otherwise provided under subdivision (2) of this subsection or subsection (d) of this section, a covered person or a covered person's authorized representative shall not file a request for an external review or an expedited external review until the covered person or the covered person's authorized representative has exhausted the health carrier's internal grievance process.
206213
207214 (2) A health carrier may waive its internal grievance process and the requirement for a covered person to exhaust such process prior to filing a request for an external review or an expedited external review.
208215
209216 (c) (1) At the same time a health carrier sends to a covered person or a covered person's authorized representative a written notice of an adverse determination or a final adverse determination issued by the health carrier, the health carrier shall include a written disclosure to the covered person and, if applicable, the covered person's authorized representative of the covered person's right to request an external review.
210217
211218 (2) The written notice shall include:
212219
213220 (A) The following statement or a statement in substantially similar language: "We have denied your request for benefit approval for a health care service or course of treatment. You may have the right to have our decision reviewed by health care professionals who have no association with us by submitting a request for external review to the office of the Insurance Commissioner, if our decision involved making a judgment as to the medical necessity, appropriateness, health care setting, level of care or effectiveness of the health care service or treatment you requested.";
214221
215222 (B) For a notice related to an adverse determination, a statement informing the covered person that:
216223
217224 (i) If the covered person has a medical condition for which the time period for completion of an expedited internal review of a grievance involving an adverse determination would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function, the covered person or the covered person's authorized representative may (I) file a request for an expedited external review, or (II) file a request for an expedited external review if the adverse determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person's treating health care professional certifies in writing that such recommended or requested health care service or treatment would be significantly less effective if not promptly initiated; and
218225
219226 (ii) Such request for expedited external review may be filed at the same time the covered person or the covered person's authorized representative files a request for an expedited internal review of a grievance involving an adverse determination, except that the independent review organization assigned to conduct the expedited external review shall determine whether the covered person shall be required to complete the expedited internal review of the grievance prior to conducting the expedited external review;
220227
221228 (C) For a notice related to a final adverse determination, a statement informing the covered person that:
222229
223230 (i) If the covered person has a medical condition for which the time period for completion of an external review would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function, the covered person or the covered person's authorized representative may file a request for an expedited external review; or
224231
225232 (ii) If the final adverse determination concerns (I) an admission, availability of care, continued stay or health care service for which the covered person received emergency services but has not been discharged from a facility, the covered person or the covered person's authorized representative may file a request for an expedited external review, or (II) a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person's treating health care professional certifies in writing that such recommended or requested health care service or treatment would be significantly less effective if not promptly initiated, the covered person or the covered person's authorized representative may file a request for an expedited external review;
226233
227234 (D) (i) A copy of the description of both the standard and expedited external review procedures the health carrier is required to provide, highlighting the provisions in the external review procedures that give the covered person or the covered person's authorized representative the opportunity to submit additional information and including any forms used to process an external review or an expedited external review;
228235
229-(ii) As part of any forms provided under subparagraph (D)(i) of this subdivision, an authorization form or other document approved by the commissioner that complies with the requirements of 45 CFR 164. 508, as amended from time to time, by which the covered person shall authorize the health carrier and the covered person's treating health care professional to release, transfer or otherwise divulge, in accordance with sections 38a-975 to 38a-999a, inclusive, the covered person's protected health information including medical records for purposes of conducting an external review or an expedited external review;
230-
231-(E) A statement that the covered person or the covered person's authorized representative may request, free of charge, copies of all documents, communications, information and evidence regarding the adverse determination or the final adverse determination that were not previously provided to the covered person or the covered person's authorized representative.
232-
233-(3) Upon request pursuant to subparagraph (E) of subdivision (2) of this subsection, the health carrier shall provide such copies in accordance with subsection (b) of section 5 of this act.
236+(ii) As part of any forms provided under subparagraph (D)(i) of this subdivision, an authorization form or other document approved by the commissioner that complies with the requirements of 45 CFR 164.508, as amended from time to time, by which the covered person shall authorize the health carrier and the covered person's treating health care professional to release, transfer or otherwise divulge, in accordance with sections 38a-975 to 38a-999a, inclusive, the covered person's protected health information including medical records for purposes of conducting an external review or an expedited external review.
234237
235238 (d) (1) A covered person or a covered person's authorized representative may file a request for an expedited external review of an adverse determination or a final adverse determination with the commissioner, except that an expedited external review shall not be provided for a retrospective review request of an adverse determination or a final adverse determination.
236239
237240 (2) Such request may be filed at the time the covered person receives:
238241
239242 (A) An adverse determination, if:
240243
241244 (i) (I) The covered person has a medical condition for which the time period for completion of an expedited internal review of the adverse determination would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function; or
242245
243246 (II) The denial of coverage is based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person's treating health care professional certifies in writing that such recommended or requested health care service or treatment would be significantly less effective if not promptly initiated; and
244247
245248 (ii) The covered person or the covered person's authorized representative has filed a request for an expedited internal review of the adverse determination; or
246249
247250 (B) A final adverse determination if:
248251
249252 (i) The covered person has a medical condition where the time period for completion of a standard external review would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function;
250253
251254 (ii) The final adverse determination concerns an admission, availability of care, continued stay or health care service for which the covered person received emergency services but has not been discharged from a facility; or
252255
253256 (iii) The denial of coverage is based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person's treating health care professional certifies in writing that such recommended or requested health care service or treatment would be significantly less effective if not promptly initiated.
254257
255258 (3) Such covered person or covered person's authorized representative shall not be required to file a request for an external review prior to, or at the same time as, the filing of a request for an expedited external review and shall not be precluded from filing a request for an external review, within the time periods set forth in subsection (e) of this section, if the request for an expedited external review is determined to be ineligible for such review.
256259
257260 (e) (1) Not later than one hundred twenty calendar days after a covered person or a covered person's authorized representative receives a notice of an adverse determination or a final adverse determination, the covered person or the covered person's authorized representative may file a request for an external review or an expedited external review with the commissioner in accordance with this section.
258261
259262 (2) Not later than one business day after the commissioner receives a request that is complete, the commissioner shall send a copy of such request to the health carrier that issued the adverse determination or the final adverse determination that is the subject of the request.
260263
261264 (3) Not later than [(A)] five business days after the health carrier receives the copy of an external review request [,] or [(B)] one calendar day after the health carrier receives the copy of an expedited external review request, from the commissioner, the health carrier shall complete a preliminary review of the request to determine whether:
262265
263266 (A) The individual is or was a covered person under the health benefit plan at the time the health care service was requested or, in the case of an external review of a retrospective review request, was a covered person in the health benefit plan at the time the health care service was provided;
264267
265268 (B) The health care service that is the subject of the adverse determination or the final adverse determination is a covered service under the covered person's health benefit plan but for the health carrier's determination that the health care service is not covered because it does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness;
266269
267270 (C) If the health care service or treatment is experimental or investigational:
268271
269272 (i) Is a covered benefit under the covered person's health benefit plan but for the health carrier's determination that the service or treatment is experimental or investigational for a particular medical condition;
270273
271274 (ii) Is not explicitly listed as an excluded benefit under the covered person's health benefit plan;
272275
273276 (iii) The covered person's treating health care professional has certified that one of the following situations is applicable:
274277
275278 (I) Standard health care services or treatments have not been effective in improving the medical condition of the covered person;
276279
277280 (II) Standard health care services or treatments are not medically appropriate for the covered person; or
278281
279282 (III) There is no available standard health care service or treatment covered by the health carrier that is more beneficial than the recommended or requested health care service or treatment; and
280283
281284 (iv) The covered person's treating health care professional:
282285
283286 (I) Has recommended a health care service or treatment that the health care professional certifies, in writing, is likely to be more beneficial to the covered person, in the health care professional's opinion, than any available standard health care services or treatments; or
284287
285288 (II) Is a licensed, board certified or board eligible health care professional qualified to practice in the area of medicine appropriate to treat the covered person's condition and has certified in writing that scientifically valid studies using accepted protocols demonstrate that the health care service or treatment requested by the covered person that is the subject of the adverse determination or the final adverse determination is likely to be more beneficial to the covered person than any available standard health care services or treatments;
286289
287290 (D) The covered person has exhausted the health carrier's internal grievance process or the covered person or the covered person's authorized representative has filed a request for an expedited external review as provided under subsection (d) of this section; and
288291
289292 (E) The covered person has provided all the information and forms required to process an external review or an expedited external review, including an authorization form as set forth in subparagraph (D)(ii) of subdivision (2) of subsection (c) of this section.
290293
291-(4) (A) Not later than [(i)] one business day after the preliminary review of an external review request [,] or [(ii)] the day the preliminary review of an expedited external review request is completed, the health carrier shall notify the commissioner, the covered person and, if applicable, the covered person's authorized representative in writing whether the request for an external review or an expedited external review is complete and eligible for such review. The commissioner may specify the form for the health carrier's notice of initial determination under this subdivision and any supporting information required to be included in the notice.
294+(4) (A) Not later than (i) one business day after the preliminary review of an external review request, or (ii) the day the preliminary review of an expedited external review request is completed, the health carrier shall notify the commissioner, the covered person and, if applicable, the covered person's authorized representative in writing whether the request for an external review or an expedited external review is complete and eligible for such review. The commissioner may specify the form for the health carrier's notice of initial determination under this subdivision and any supporting information required to be included in the notice.
292295
293296 (B) If the request:
294297
295298 (i) Is not complete, the health carrier shall notify the commissioner and the covered person and, if applicable, the covered person's authorized representative in writing and include in the notice what information or materials are needed to perfect the request; or
296299
297300 (ii) Is not eligible for external review or expedited external review, the health carrier shall notify the commissioner, the covered person and, if applicable, the covered person's authorized representative in writing and include in the notice the reasons for its ineligibility.
298301
299302 (C) The notice of initial determination shall include a statement informing the covered person and, if applicable, the covered person's authorized representative that a health carrier's initial determination that the request for an external review or an expedited external review is ineligible for review may be appealed to the commissioner.
300303
301304 (D) Notwithstanding a health carrier's initial determination that a request for an external review or an expedited external review is ineligible for review, the commissioner may determine, pursuant to the terms of the covered person's health benefit plan, that such request is eligible for such review and assign an independent review organization to conduct such review. Any such review shall be conducted in accordance with this section.
302305
303306 (f) (1) Whenever the commissioner is notified pursuant to subparagraph (A) of subdivision (4) of subsection (e) of this section that a request is eligible for external review or expedited external review, the commissioner shall, not later than [(A)] one business day after receiving such notice for an external review [,] or [(B)] one calendar day after receiving such notice for an expedited external review:
304307
305308 [(i)] (A) Assign an independent review organization from the list of approved independent review organizations compiled and maintained by the commissioner pursuant to section 38a-591l to conduct the review and notify the health carrier of the name of the assigned independent review organization. Such assignment shall be done on a random basis among those approved independent review organizations qualified to conduct the particular review based on the nature of the health care service that is the subject of the adverse determination or the final adverse determination and other circumstances, including conflict of interest concerns as set forth in section 38a-591m; and
306309
307310 [(ii)] (B) Notify the covered person and, if applicable, the covered person's authorized representative in writing of the request's eligibility and acceptance for external review or expedited external review. For an external review, the commissioner shall include in such notice [(I)] (i) a statement that the covered person or the covered person's authorized representative may submit, not later than five business days after the covered person or the covered person's authorized representative, as applicable, received such notice, additional information in writing to the assigned independent review organization that such organization shall consider when conducting the external review, and [(II)] (ii) where and how such additional information is to be submitted. If additional information is submitted later than five business days after the covered person or the covered person's authorized representative, as applicable, received such notice, the independent review organization may, but shall not be required to, accept and consider such additional information.
308311
309312 (2) Not later than [(A)] five business days for an external review [,] or [(B)] one calendar day for an expedited external review, after the health carrier receives notice of the name of the assigned independent review organization from the commissioner, the health carrier or its designee utilization review company shall provide to the assigned independent review organization the documents and any information such health carrier or utilization review company considered in making the adverse determination or the final adverse determination.
310313
311314 (3) The failure of the health carrier or its designee utilization review company to provide the documents and information within the time specified in subdivision (2) of this subsection shall not delay the conducting of the review.
312315
313316 (4) [(i)] (A) If the health carrier or its designee utilization review company fails to provide the documents and information within the time period specified in subdivision (2) of this subsection, the independent review organization may terminate the review and make a decision to reverse the adverse determination or the final adverse determination.
314317
315318 [(ii)] (B) Not later than one business day after terminating the review and making the decision to reverse the adverse determination or the final adverse determination, the independent review organization shall notify the commissioner, the health carrier, the covered person and, if applicable, the covered person's authorized representative in writing of such decision.
316319
317320 (g) (1) The assigned independent review organization shall review all the information and documents received pursuant to subsection (f) of this section. In reaching a decision, the independent review organization shall not be bound by any decisions or conclusions reached during the health carrier's utilization review process.
318321
319322 (2) Not later than one business day after receiving any information submitted by the covered person or the covered person's authorized representative pursuant to subparagraph (B) of subdivision (1) of subsection (f) of this section, the independent review organization shall forward such information to the health carrier.
320323
321324 (3) (A) Upon the receipt of any information forwarded pursuant to subdivision (2) of this subsection, the health carrier may reconsider its adverse determination or the final adverse determination that is the subject of the review. Such reconsideration shall not delay or terminate the review.
322325
323326 (B) The independent review organization shall terminate the review if the health carrier decides, upon completion of its reconsideration and notice to such organization as provided in subparagraph (C) of this subdivision, to reverse its adverse determination or its final adverse determination and provide coverage or payment for the health care service or treatment that is the subject of the adverse determination or the final adverse determination.
324327
325328 (C) Not later than one business day after making the decision to reverse its adverse determination or its final adverse determination, the health carrier shall notify the commissioner, the assigned independent review organization, the covered person and, if applicable, the covered person's authorized representative in writing of such decision.
326329
327330 (h) In addition to the documents and information received pursuant to subsection (f) of this section, the independent review organization shall consider, to the extent the documents or information are available and the independent review organization considers them appropriate, the following in reaching a decision:
328331
329332 (1) The covered person's medical records;
330333
331334 (2) The attending health care professional's recommendation;
332335
333336 (3) Consulting reports from appropriate health care professionals and other documents submitted by the health carrier, the covered person, the covered person's authorized representative or the covered person's treating health care professional;
334337
335338 (4) The terms of coverage under the covered person's health benefit plan to ensure that the independent review organization's decision is not contrary to the terms of coverage under such health benefit plan;
336339
337340 (5) The most appropriate practice guidelines, which shall include applicable evidence-based standards and may include any other practice guidelines developed by the federal government, national or professional medical societies, medical boards or medical associations;
338341
339342 (6) Any applicable clinical review criteria developed and used by the health carrier or its designee utilization review company; and
340343
341344 (7) The opinion or opinions of the independent review organization's clinical peer or peers who conducted the review after considering subdivisions (1) to (6), inclusive, of this subsection.
342345
343346 (i) (1) The independent review organization shall notify the commissioner, the health carrier, the covered person and, if applicable, the covered person's authorized representative in writing of its decision to uphold, reverse or revise the adverse determination or the final adverse determination, not later than:
344347
345348 (A) For external reviews, forty-five calendar days after such organization receives the assignment from the commissioner to conduct such review;
346349
347350 (B) For external reviews involving a determination that the recommended or requested health care service or treatment is experimental or investigational, twenty calendar days after such organization receives the assignment from the commissioner to conduct such review;
348351
349352 (C) For expedited external reviews, as expeditiously as the covered person's medical condition requires, but not later than seventy-two hours after such organization receives the assignment from the commissioner to conduct such review; and
350353
351354 (D) For expedited external reviews involving a determination that the recommended or requested health care service or treatment is experimental or investigational, as expeditiously as the covered person's medical condition requires, but not later than five calendar days after such organization receives the assignment from the commissioner to conduct such review.
352355
353356 (2) Such notice shall include:
354357
355358 (A) A general description of the reason for the request for the review;
356359
357360 (B) The date the independent review organization received the assignment from the commissioner to conduct the review;
358361
359362 (C) The date the review was conducted;
360363
361364 (D) The date the organization made its decision;
362365
363366 (E) The principal reason or reasons for its decision, including what applicable evidence-based standards, if any, were used as a basis for its decision;
364367
365368 (F) The rationale for the organization's decision;
366369
367-(G) Reference to the evidence or documentation, including any evidence-based standards, considered by the organization in reaching its decision; and
370+(G) (i) Reference to the evidence or documentation, including any evidence-based standards, considered by the organization in reaching its decision, and (ii) for a decision that upholds the adverse determination or the final adverse determination, copies of all evidence or documentation, free of charge, including any evidence-based standards, regarding the adverse determination or the final adverse determination, whether or not the organization considered such evidence or documentation in reaching its decision; and
368371
369372 (H) For a review involving a determination that the recommended or requested health care service or treatment is experimental or investigational:
370373
371374 (i) A description of the covered person's medical condition;
372375
373376 (ii) A description of the indicators relevant to determining whether there is sufficient evidence to demonstrate that (I) the recommended or requested health care service or treatment is likely to be more beneficial to the covered person than any available standard health care services or treatments, and (II) the adverse risks of the recommended or requested health care service or treatment would not be substantially increased over those of available standard health care services or treatments;
374377
375-(iii) A description and analysis of any medical or scientific evidence considered in reaching the opinion;
378+(iii) (I) A description and analysis of any medical or scientific evidence considered in reaching the opinion, and (II) for a decision that upholds the adverse determination or the final adverse determination, copies of all medical or scientific evidence, free of charge, the organization considered in reaching its decision;
376379
377-(iv) A description and analysis of any evidence-based standard; and
380+(iv) (I) A description and analysis of any evidence-based standard, and (II) for a decision that upholds the adverse determination or the final adverse determination, copies of all evidence-based standards, free of charge, the organization considered in reaching its decision; and
378381
379382 (v) Information on whether the clinical peer's rationale for the opinion is based on the documents and information set forth in subsection (f) of this section.
380383
381384 (3) Upon the receipt of a notice of the independent review organization's decision to reverse or revise an adverse determination or a final adverse determination, the health carrier shall immediately approve the coverage that was the subject of the adverse determination or the final adverse determination.
382385
383-Sec. 5. (NEW) (Effective October 1, 2012) (a) (1) Upon request pursuant to subparagraph (E) of subdivision (1) of subsection (e) of section 38a-591d of the general statutes, as amended by this act, the health carrier shall provide free of charge to a covered person or a covered person's authorized representative, as applicable, copies of all documents, communications, information and evidence, including citations to any medical journals, regarding the covered person's benefit request that is the subject of the adverse determination that were not submitted by the covered person or the covered person's authorized representative and were available to the health carrier or the utilization review entity that made the adverse determination at the time such adverse determination was made.
384386
385-(2) The health carrier shall provide such copies by facsimile, electronic means or any other expeditious method available not later than five business days after the health carrier receives such request in the case of an adverse determination of a nonurgent care request or one calendar day after the health carrier receives such request in the case of an adverse determination of an urgent care request.
386387
387-(b) (1) Upon request pursuant to subparagraph (F)(iii) of subdivision (1) of subsection (e) of section 38a-591e of the general statutes, as amended by this act, subparagraph (E) of subdivision (1) of subsection (d) of section 38a-591f of the general statutes, as amended by this act, or subparagraph (E) of subdivision (2) of subsection (c) of section 38a-591g of the general statutes, as amended by this act, the health carrier shall provide free of charge to a covered person or a covered person's authorized representative, as applicable, copies of all documents, communications, information and evidence, including citations to any medical journals, if applicable, regarding the adverse determination or the final adverse determination, as applicable, that were not submitted by the covered person or the covered person's authorized representative and were not previously provided by the health carrier to the covered person or the covered person's authorized representative.
388388
389-(2) The health carrier shall provide such copies by facsimile, electronic means or any other expeditious method available not later than:
389+This act shall take effect as follows and shall amend the following sections:
390+Section 1 October 1, 2012 38a-591d
391+Sec. 2 October 1, 2012 38a-591e
392+Sec. 3 October 1, 2012 38a-591f
393+Sec. 4 October 1, 2012 38a-591g
390394
391-(A) Five business days after the health carrier receives such request (i) in the case of a final adverse determination of a prospective, concurrent or retrospective review request under section 38a-591e of the general statutes, as amended by this act, (ii) in the case of a final adverse determination of a review request under section 38a-591f of the general statutes, as amended by this act, or (iii) pursuant to section 38a-591g of the general statutes, as amended by this act, except if the covered person or the covered person's authorized representative notifies the health carrier at the time of such request that any of the provisions set forth in subparagraph (B)(i) or subparagraph (C) of subdivision (2) of subsection (c) of section 38a-591g of the general statutes, as amended by this act, applies, the health carrier shall provide such copies by facsimile, electronic means or any other expeditious method available not later than one calendar day after the health carrier receives such request; or
395+This act shall take effect as follows and shall amend the following sections:
392396
393-(B) One calendar day after the health carrier receives such request in the case of a final adverse determination of an expedited review request under 38a-591e of the general statutes, as amended by this act.
397+Section 1
394398
395-Sec. 6. Section 38a-591a of the 2012 supplement to the general statutes is repealed and the following is substituted in lieu thereof (Effective October 1, 2012):
399+October 1, 2012
396400
397-As used in this section and sections 38a-591b to 38a-591m, inclusive, as amended by this act, and section 5 of this act:
401+38a-591d
398402
399-(1) "Adverse determination" means:
403+Sec. 2
400404
401-(A) The denial, reduction, termination or failure to provide or make payment, in whole or in part, for a benefit under the health carrier's health benefit plan requested by a covered person or a covered person's treating health care professional, based on a determination by a health carrier or its designee utilization review company:
405+October 1, 2012
402406
403-(i) That, based upon the information provided, (I) upon application of any utilization review technique, such benefit does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, or (II) is determined to be experimental or investigational;
407+38a-591e
404408
405-(ii) Of a covered person's eligibility to participate in the health carrier's health benefit plan; or
409+Sec. 3
406410
407-(B) Any prospective review, concurrent review or retrospective review determination that denies, reduces or terminates or fails to provide or make payment, in whole or in part, for a benefit under the health carrier's health benefit plan requested by a covered person or a covered person's treating health care professional.
411+October 1, 2012
408412
409-"Adverse determination" includes a rescission of coverage determination for grievance purposes.
413+38a-591f
410414
411-(2) "Authorized representative" means:
415+Sec. 4
412416
413-(A) A person to whom a covered person has given express written consent to represent the covered person for the purposes of this section and sections 38a-591b to 38a-591m, inclusive, as amended by this act, and section 5 of this act;
417+October 1, 2012
414418
415-(B) A person authorized by law to provide substituted consent for a covered person;
419+38a-591g
416420
417-(C) A family member of the covered person or the covered person's treating health care professional when the covered person is unable to provide consent;
421+Statement of Legislative Commissioners:
418422
419-(D) A health care professional when the covered person's health benefit plan requires that a request for a benefit under the plan be initiated by the health care professional; or
423+In section 4(f)(4), "(4)(i)" and "(4)(ii)" were changed to "(4)[(i)](A)" and "(4)[(ii)](B)", respectively, for accuracy.
420424
421-(E) In the case of an urgent care request, a health care professional with knowledge of the covered person's medical condition.
422425
423-(3) "Best evidence" means evidence based on (A) randomized clinical trials, (B) if randomized clinical trials are not available, cohort studies or case-control studies, (C) if such trials and studies are not available, case-series, or (D) if such trials, studies and case-series are not available, expert opinion.
424426
425-(4) "Case-control study" means a retrospective evaluation of two groups of patients with different outcomes to determine which specific interventions the patients received.
427+INS Joint Favorable Subst.-LCO
426428
427-(5) "Case-series" means an evaluation of a series of patients with a particular outcome, without the use of a control group.
429+INS
428430
429-(6) "Certification" means a determination by a health carrier or its designee utilization review company that a request for a benefit under the health carrier's health benefit plan has been reviewed and, based on the information provided, satisfies the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care and effectiveness.
430-
431-(7) "Clinical peer" means a physician or other health care professional who holds a nonrestricted license in a state of the United States and in the same or similar specialty as typically manages the medical condition, procedure or treatment under review.
432-
433-(8) "Clinical review criteria" means the written screening procedures, decision abstracts, clinical protocols and practice guidelines used by the health carrier to determine the medical necessity and appropriateness of health care services.
434-
435-(9) "Cohort study" means a prospective evaluation of two groups of patients with only one group of patients receiving a specific intervention or specific interventions.
436-
437-(10) "Commissioner" means the Insurance Commissioner.
438-
439-(11) "Concurrent review" means utilization review conducted during a patient's stay or course of treatment in a facility, the office of a health care professional or other inpatient or outpatient health care setting, including home care.
440-
441-(12) "Covered benefits" or "benefits" means health care services to which a covered person is entitled under the terms of a health benefit plan.
442-
443-(13) "Covered person" means a policyholder, subscriber, enrollee or other individual participating in a health benefit plan.
444-
445-(14) "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson with an average knowledge of health and medicine, acting reasonably, would have believed that the absence of immediate medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person's health or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy.
446-
447-(15) "Emergency services" means, with respect to an emergency medical condition:
448-
449-(A) A medical screening examination that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition; and
450-
451-(B) Such further medical examination and treatment, to the extent they are within the capability of the staff and facilities available at a hospital, to stabilize a patient.
452-
453-(16) "Evidence-based standard" means the conscientious, explicit and judicious use of the current best evidence based on an overall systematic review of medical research when making determinations about the care of individual patients.
454-
455-(17) "Expert opinion" means a belief or an interpretation by specialists with experience in a specific area about the scientific evidence pertaining to a particular service, intervention or therapy.
456-
457-(18) "Facility" means an institution providing health care services or a health care setting. "Facility" includes a hospital and other licensed inpatient center, ambulatory surgical or treatment center, skilled nursing center, residential treatment center, diagnostic, laboratory and imaging center, and rehabilitation and other therapeutic health care setting.
458-
459-(19) "Final adverse determination" means an adverse determination (A) that has been upheld by the health carrier at the completion of its internal grievance process, or (B) for which the internal grievance process has been deemed exhausted.
460-
461-(20) "Grievance" means a written complaint or, if the complaint involves an urgent care request, an oral complaint, submitted by or on behalf of a covered person regarding:
462-
463-(A) The availability, delivery or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review;
464-
465-(B) Claims payment, handling or reimbursement for health care services; or
466-
467-(C) Any matter pertaining to the contractual relationship between a covered person and a health carrier.
468-
469-(21) (A) "Health benefit plan" means an insurance policy or contract, certificate or agreement offered, delivered, issued for delivery, renewed, amended or continued in this state to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services;
470-
471-(B) "Health benefit plan" does not include:
472-
473-(i) Coverage of the type specified in subdivisions (5) to (9), inclusive, (14) and (15) of section 38a-469 or any combination thereof;
474-
475-(ii) Coverage issued as a supplement to liability insurance;
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477-(iii) Liability insurance, including general liability insurance and automobile liability insurance;
478-
479-(iv) Workers' compensation insurance;
480-
481-(v) Automobile medical payment insurance;
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483-(vi) Credit insurance;
484-
485-(vii) Coverage for on-site medical clinics;
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487-(viii) Other insurance coverage similar to the coverages specified in subparagraphs (B)(ii) to (B)(vii), inclusive, of this subdivision that are specified in regulations issued pursuant to the Health Insurance Portability and Accountability Act of 1996, P. L. 104-191, as amended from time to time, under which benefits for health care services are secondary or incidental to other insurance benefits;
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489-(ix) (I) Limited scope dental or vision benefits, (II) benefits for long-term care, nursing home care, home health care, community-based care or any combination thereof, or (III) other similar, limited benefits specified in regulations issued pursuant to the Health Insurance Portability and Accountability Act of 1996, P. L. 104-191, as amended from time to time, provided any benefits specified in subparagraphs (B)(ix)(I) to (B)(ix)(III), inclusive, of this subdivision are provided under a separate insurance policy, certificate or contract and are not otherwise an integral part of a health benefit plan; or
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491-(x) Coverage of the type specified in subdivisions (3) and (13) of section 38a-469 or other fixed indemnity insurance if (I) they are provided under a separate insurance policy, certificate or contract, (II) there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and (III) the benefits are paid with respect to an event without regard to whether benefits were also provided under any group health plan maintained by the same plan sponsor.
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493-(22) "Health care center" has the same meaning as provided in section 38a-175.
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495-(23) "Health care professional" means a physician or other health care practitioner licensed, accredited or certified to perform specified health care services consistent with state law.
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497-(24) "Health care services" has the same meaning as provided in section 38a-478.
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499-(25) "Health carrier" means an entity subject to the insurance laws and regulations of this state or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health care center, a managed care organization, a hospital service corporation, a medical service corporation or any other entity providing a plan of health insurance, health benefits or health care services.
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501-(26) "Health information" means information or data, whether oral or recorded in any form or medium, and personal facts or information about events or relationships that relate to (A) the past, present or future physical, mental, or behavioral health or condition of a covered person or a member of the covered person's family, (B) the provision of health care services to a covered person, or (C) payment for the provision of health care services to a covered person.
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503-(27) "Independent review organization" means an entity that conducts independent external reviews of adverse determinations and final adverse determinations. Such review entities include, but are not limited to, medical peer review organizations, independent utilization review companies, provided such organizations or companies are not related to or associated with any health carrier, and nationally recognized health experts or institutions approved by the Insurance Commissioner.
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505-(28) "Medical or scientific evidence" means evidence found in the following sources:
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507-(A) Peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff;
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509-(B) Peer-reviewed medical literature, including literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia and other medical literature that meet the criteria of the National Institutes of Health's Library of Medicine for indexing in Index Medicus (Medline) or Elsevier Science for indexing in Excerpta Medicus (EMBASE);
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511-(C) Medical journals recognized by the Secretary of the United States Department of Health and Human Services under Section 1861(t)(2) of the Social Security Act;
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513-(D) The following standard reference compendia: (i) The American Hospital Formulary Service - Drug Information; (ii) Drug Facts and Comparisons; (iii) The American Dental Association's Accepted Dental Therapeutics; and (iv) The United States Pharmacopoeia - Drug Information;
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515-(E) Findings, studies or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes, including: (i) The Agency for Healthcare Research and Quality; (ii) the National Institutes of Health; (iii) the National Cancer Institute; (iv) the National Academy of Sciences; (v) the Centers for Medicare and Medicaid Services; (vi) the Food and Drug Administration; and (vii) any national board recognized by the National Institutes of Health for the purpose of evaluating the medical value of health care services; or
516-
517-(F) Any other findings, studies or research conducted by or under the auspices of a source comparable to those listed in subparagraphs (E)(i) to (E)(v), inclusive, of this subdivision.
518-
519-(29) "Medical necessity" has the same meaning as provided in sections 38a-482a and 38a-513c.
520-
521-(30) "Participating provider" means a health care professional who, under a contract with the health carrier, its contractor or subcontractor, has agreed to provide health care services to covered persons, with an expectation of receiving payment or reimbursement directly or indirectly from the health carrier, other than coinsurance, copayments or deductibles.
522-
523-(31) "Person" has the same meaning as provided in section 38a-1.
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525-(32) "Prospective review" means utilization review conducted prior to an admission or the provision of a health care service or a course of treatment, in accordance with a health carrier's requirement that such service or treatment be approved, in whole or in part, prior to such service's or treatment's provision.
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527-(33) "Protected health information" means health information (A) that identifies an individual who is the subject of the information, or (B) for which there is a reasonable basis to believe that such information could be used to identify such individual.
528-
529-(34) "Randomized clinical trial" means a controlled, prospective study of patients that have been randomized into an experimental group and a control group at the beginning of the study, with only the experimental group of patients receiving a specific intervention, and that includes study of the groups for variables and anticipated outcomes over time.
530-
531-(35) "Rescission" means a cancellation or discontinuance of coverage under a health benefit plan that has a retroactive effect. "Rescission" does not include a cancellation or discontinuance of coverage under a health benefit plan if (A) such cancellation or discontinuance has a prospective effect only, or (B) such cancellation or discontinuance is effective retroactively to the extent it is attributable to the covered person's failure to timely pay required premiums or contributions towards the cost of such coverage.
532-
533-(36) "Retrospective review" means any review of a request for a benefit that is not a prospective review or concurrent review. "Retrospective review" does not include a review of a request that is limited to the veracity of documentation or the accuracy of coding.
534-
535-(37) "Stabilize" means, with respect to an emergency medical condition, that (A) no material deterioration of such condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility, or (B) with respect to a pregnant woman, the woman has delivered, including the placenta.
536-
537-(38) "Urgent care request" means a request for a health care service or course of treatment for which the time period for making a non-urgent care request determination (A) could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function, or (B) in the opinion of a health care professional with knowledge of the covered person's medical condition, would subject the covered person to severe pain that cannot be adequately managed without the health care service or treatment being requested.
538-
539-(39) "Utilization review" means the use of a set of formal techniques designed to monitor the use of, or evaluate the medical necessity, appropriateness, efficacy or efficiency of, health care services, health care procedures or health care settings. Such techniques may include the monitoring of or evaluation of (A) health care services performed or provided in an outpatient setting, (B) the formal process for determining, prior to discharge from a facility, the coordination and management of the care that a patient receives following discharge from a facility, (C) opportunities or requirements to obtain a clinical evaluation by a health care professional other than the one originally making a recommendation for a proposed health care service, (D) coordinated sets of activities conducted for individual patient management of serious, complicated, protracted or other health conditions, or (E) prospective review, concurrent review, retrospective review or certification.
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541-(40) "Utilization review company" means an entity that conducts utilization review.
542-
543-Sec. 7. Subsections (a) and (b) of section 38a-591b of the 2012 supplement to the general statutes are repealed and the following is substituted in lieu thereof (Effective October 1, 2012):
544-
545-(a) Sections 38a-591a to 38a-591m, inclusive, as amended by this act, and section 5 of this act shall apply to (1) any health carrier offering a health benefit plan and that provides or performs utilization review including prospective, concurrent or retrospective review benefit determinations, and (2) any utilization review company or designee of a health carrier that performs utilization review on the health carrier's behalf, including prospective, concurrent or retrospective review benefit determinations.
546-
547-(b) Each health carrier shall be responsible for monitoring all utilization review program activities carried out by or on behalf of such health carrier. Such health carrier shall comply with the provisions of sections 38a-591a to 38a-591m, inclusive, as amended by this act, and section 5 of this act and any regulations adopted thereunder, and shall be responsible for ensuring that any utilization review company or other entity such health carrier contracts with to perform utilization review complies with said sections and regulations. Each health carrier shall ensure that appropriate personnel have operational responsibility for the activities of the health carrier's utilization review program.
548-
549-Sec. 8. Section 38a-591i of the 2012 supplement to the general statutes is repealed and the following is substituted in lieu thereof (Effective October 1, 2012):
550-
551-The commissioner shall adopt regulations, in accordance with chapter 54, to implement the provisions of sections 38a-591a to 38a-591m, inclusive, as amended by this act, and section 5 of this act.
552-
553-Sec. 9. Section 38a-478s of the 2012 supplement to the general statutes is repealed and the following is substituted in lieu thereof (Effective October 1, 2012):
554-
555-(a) Nothing in sections 38a-478 to 38a-478o, inclusive, [or] sections 38a-591a to 38a-591h, inclusive, as amended by this act, or section 5 of this act shall be construed to apply to the arrangements of managed care organizations or health insurers offered to individuals covered under self-insured employee welfare benefit plans established pursuant to the federal Employee Retirement Income Security Act of 1974.
556-
557-(b) The provisions of sections 38a-478 to 38a-478o, inclusive, [and] sections 38a-591a to 38a-591h, inclusive, as amended by this act, and section 5 of this act shall not apply to any plan that provides for the financing or delivery of health care services solely for the purposes of workers' compensation benefits pursuant to chapter 568.
431+Joint Favorable Subst.-LCO