Connecticut 2013 Regular Session

Connecticut House Bill HB06557 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1		-	General Assembly Substitute Bill No. 6557
2		-	January Session, 2013 _____HB06557PRI___031513____
	1	+	General Assembly Raised Bill No. 6557
	2	+	January Session, 2013 LCO No. 3846
	3	+	03846_______PRI
	4	+	Referred to Committee on PROGRAM REVIEW AND INVESTIGATIONS
	5	+	Introduced by:
	6	+	(PRI)
3	7
4	8		General Assembly
5	9
6		-	~~Substitute~~ Bill No. 6557
	10	+	Raised Bill No. 6557
7	11
8	12		January Session, 2013
9	13
10		-	_____HB06557PRI___031513____
	14	+	LCO No. 3846
	15	+
	16	+	03846_______PRI
	17	+
	18	+	Referred to Committee on PROGRAM REVIEW AND INVESTIGATIONS
	19	+
	20	+	Introduced by:
	21	+
	22	+	(PRI)
11	23
12	24		AN ACT IMPLEMENTING THE RECOMMENDATIONS OF THE LEGISLATIVE PROGRAM REVIEW AND INVESTIGATIONS COMMITTEE CONCERNING THE HEALTH CARRIER UTILIZATION REVIEW AND GRIEVANCE PROCESS.
13	25
14	26		Be it enacted by the Senate and House of Representatives in General Assembly convened:
15	27
16	28		Section 1. Subdivision (38) of section 38a-591a of the general statutes is repealed and the following is substituted in lieu thereof (Effective September 1, 2013):
17	29
18	30		(38) "Urgent care request" means a request for a health care service or course of treatment (A) for which the time period for making a non-urgent care request determination [(A)] (i) could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function, or [(B)] (ii) 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, or (B) for a substance use disorder, as described in section 17a-458, or for a co-occurring disorder.
19	31
20	32		Sec. 2. Section 38a-591d of the general statutes is repealed and the following is substituted in lieu thereof (Effective September 1, 2013):
21	33
22	34		(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.
23	35
24	36		(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.
25	37
26	38		(b) With respect to a nonurgent care request:
27	39
28	40		(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.
29	41
30	42		(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.
31	43
32	44		(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:
33	45
34	46		(A) Determines that an extension is necessary due to circumstances beyond the health carrier's control; and
35	47
36	48		(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.
37	49
38	50		(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:
39	51
40	52		(i) Specifically describe in the notice of extension the required information necessary to complete the request; and
41	53
42	54		(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.
43	55
44	56		(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.
45	57
46	58		(c) With respect to an urgent care request:
47	59
48	60		(1) (A) 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 and except as specified under subparagraph (B) of this subdivision, 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;
49	61
50		-	(B) 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, for an urgent care request for inpatient ~~treatment for a~~ substance use disorder ~~or detoxification in an inpatient or residential~~ treatment ~~setting~~, the health carrier shall make a determination as soon as possible, taking into account the covered person's medical condition, but not later than ~~twelve~~ 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 ~~twelve~~ hours prior to the expiration of the prescribed period of time or number of treatments.
	62	+	(B) 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, for an urgent care request for inpatient substance use disorder treatment, the health carrier shall make a determination as soon as possible, taking into account the covered person's medical condition, but not later than twenty-four 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.
51	63
52	64		(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.
53	65
54	66		(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.
55	67
56	68		(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.
57	69
58	70		(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.
59	71
60	72		(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.
61	73
62	74		(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.
63	75
64	76		(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:
65	77
66	78		(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;
67	79
68	80		(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;
69	81
70	82		(C) Reference to the specific health benefit plan provisions on which the determination is based;
71	83
72	84		(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;
73	85
74	86		(E) A description of the health carrier's internal grievance process that includes (i) the health carrier's expedited review procedures, (ii) any time limits applicable to such process or procedures, (iii) the contact information for the organizational unit designated to coordinate the review on behalf of the health carrier, and (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) 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)] receive from the health carrier, free of charge upon request, reasonable access to and copies of all documents, records, communications and other information and evidence regarding the covered person's benefit request;
75	87
76	88		(F) If the 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 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;
77	89
78	90		(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 (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) 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]
79	91
80	92		(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; [.] and
81	93
82	94		(I) A statement that if the covered person or the covered person's authorized representative chooses to file a grievance of an adverse determination, (i) such appeals are sometimes successful, (ii) such covered person or covered person's authorized representative may benefit from free assistance from the Office of the Healthcare Advocate, (iii) such covered person or covered person's authorized representative is entitled and encouraged to submit supporting documentation for the health carrier's clinical peer's or peers' consideration during the review of an adverse determination, including narratives from such covered person or covered person's authorized representative describing the problem or problems, when each arose and the covered person's symptoms, and letters and treatment notes from such covered person's health care professionals, and (iv) such covered person or covered person's authorized representative has the right to ask such covered person's health care professionals for such letters and treatment notes.
83	95
84	96		(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 38a-591n.
85	97
86	98		(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:
87	99
88	100		(1) Clear identification of the alleged fraudulent act, practice or omission or the intentional misrepresentation of material fact;
89	101
90	102		(2) An explanation as to why the act, practice or omission was fraudulent or was an intentional misrepresentation of a material fact;
91	103
92	104		(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;
93	105
94	106		(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
95	107
96	108		(5) The date such advance notice of the proposed rescission ends and the date back to which the coverage will be retroactively rescinded.
97	109
98	110		(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, 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.
99	111
100	112		(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.
101	113
102	114		Sec. 3. Section 38a-591e of the general statutes is repealed and the following is substituted in lieu thereof (Effective September 1, 2013):
103	115
104	116		(a) (1) Each health carrier shall establish and maintain written procedures for (A) the review, by one or more clinical peers, of grievances of adverse determinations that were based, in whole or in part, on medical necessity, (B) the expedited review, by one or more clinical peers, 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.
105	117
106	118		(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.
107	119
108	120		(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-591n, inclusive, as amended by this act.
109	121
110	122		(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.
111	123
112	124		(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.
113	125
114	126		(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] clinical peer or peers involved in making the review decision.
115	127
116	128		(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.
117	129
118	130		(C) The [individual or individuals] clinical peer or peers 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.
119	131
120	132		(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.
121	133
122	134		(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.
123	135
124	136		(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.
125	137
126	138		(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:
127	139
128	140		(A) For prospective review and concurrent review requests, thirty calendar days after the health carrier receives the grievance;
129	141
130	142		(B) For retrospective review requests, sixty calendar days after the health carrier receives the grievance; and
131	143
132	144		(C) For expedited review requests, seventy-two hours after the health carrier receives the grievance.
133	145
134	146		(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.
135	147
136	148		(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:
137	149
138	150		(A) The titles and qualifying credentials of the [individual or individuals] clinical peer or peers participating in the review process;
139	151
140	152		(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;
141	153
142	154		(C) A statement of such [individual's or individuals'] clinical peer's or peers' understanding of the covered person's grievance;
143	155
144	156		(D) The [individual's or individuals'] clinical peer's or peers' 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;
145	157
146	158		(E) Reference to the evidence or documentation used as the basis for the decision;
147	159
148	160		(F) For a decision that upholds the adverse determination:
149	161
150	162		(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;
151	163
152	164		(ii) Reference to the specific health benefit plan provisions on which the decision is based;
153	165
154	166		(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 and evidence not previously provided regarding the adverse determination under review;
155	167
156	168		(iv) 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;
157	169
158	170		(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) 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) 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;
159	171
160	172		(vi) A statement describing the procedures for obtaining an external review of the final adverse determination;
161	173
162	174		(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
163	175
164	176		(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.
165	177
166	178		(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 38a-591n.
167	179
168	180		(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.
169	181
170	182		(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.
171	183
172	184		(g) Notwithstanding subdivision (7) of section 38a-591a, as amended by this act, for purposes of this section, on and after September 1, 2013, and prior to January 1, 2015:
173	185
174	186		(1) "Clinical peer" means:
175	187
176	188		(A) A licensed health care professional who (i) holds a nonrestricted license in a state of the United States, (ii) holds a doctoral or medical degree, and (iii) (I) holds an appropriate national board certification including at the subspecialty level where available, or (II) actively practices and typically manages the medical condition under review or provides the procedure or treatment under review; or
177	189
178	190		(B) For a review of an adverse determination under this section concerning an adolescent substance use disorder treatment, as such disorder is described in section 17a-458, a licensed health care professional who (i) holds a nonrestricted license in a state of the United States, (ii) holds a doctoral or medical degree, and (iii) (I) holds a national board certification in child and adolescent psychiatry or child and adolescent psychology, and (II) has training or clinical experience in the treatment of adolescent substance use disorder.
179	191
180	192		(2) "Appropriate national board certification" means, for a clinical peer who conducts any reviews of adverse determinations under this section concerning adult substance use disorder treatment, as such disorder is described in section 17a-458, certification by a national addiction board.
181	193
182	194		Sec. 4. Subdivision (7) of section 38a-591a of the general statutes is repealed and the following is substituted in lieu thereof (Effective September 1, 2013):
183	195
184	196		(7) ["Clinical peer"] Except as provided in subsection (g) of section 38a-591e, as amended by this act, "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.
185	197
186	198		Sec. 5. Subsection (d) of section 38a-591f of the general statutes is repealed and the following is substituted in lieu thereof (Effective September 1, 2013):
187	199
188	200		(d) (1) The written decision issued pursuant to subsection (c) of this section shall contain:
189	201
190	202		(A) The titles and qualifying credentials of the individual or individuals participating in the review process;
191	203
192	204		(B) A statement of such individual's or individuals' understanding of the covered person's grievance;
193	205
194	206		(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;
195	207
196	208		(D) Reference to the documents, communications, information and evidence used as the basis for the decision; and
197	209
198	210		(E) For a decision that upholds the adverse determination, a statement (i) 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, and (ii) disclosing the covered person's right to contact the commissioner's office or the Office of the Healthcare Advocate at any time, and that such covered person may benefit from free assistance from the Office of the Healthcare Advocate. Such disclosure shall include the contact information for said offices.
199	211
200	212		(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 38a-591n.
201	213
202	214		Sec. 6. Section 38a-591a of the general statutes, as amended by sections 1 and 4 of this act, is repealed and the following is substituted in lieu thereof (Effective January 1, 2015):
203	215
204	216		As used in this section and sections 38a-591b to 38a-591n, inclusive:
205	217
206	218		(1) "Adverse determination" means:
207	219
208	220		(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:
209	221
210	222		(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;
211	223
212	224		(ii) Of a covered person's eligibility to participate in the health carrier's health benefit plan; or
213	225
214	226		(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.
215	227
216	228		"Adverse determination" includes a rescission of coverage determination for grievance purposes.
217	229
218	230		(2) "Appropriate national board certification" means, for a clinical peer who conducts any reviews of or benefit determinations for adult substance use disorder treatment, as such disorder is described in section 17a-458, certification by a national addiction board.
219	231
220	232		[(2)] (3) "Authorized representative" means:
221	233
222	234		(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-591n, inclusive;
223	235
224	236		(B) A person authorized by law to provide substituted consent for a covered person;
225	237
226	238		(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;
227	239
228	240		(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
229	241
230	242		(E) In the case of an urgent care request, a health care professional with knowledge of the covered person's medical condition.
231	243
232	244		[(3)] (4) "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.
233	245
234	246		[(4)] (5) "Case-control study" means a retrospective evaluation of two groups of patients with different outcomes to determine which specific interventions the patients received.
235	247
236	248		[(5)] (6) "Case-series" means an evaluation of a series of patients with a particular outcome, without the use of a control group.
237	249
238	250		[(6)] (7) "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.
239	251
240	252		[(7) Except as provided in subsection (g) of section 38a-591e, "clinical peer" means a 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.]
241	253
242	254		(8) "Clinical peer" means:
243	255
244	256		(A) A licensed health care professional who (i) holds a nonrestricted license in a state of the United States, (ii) holds a doctoral or medical degree, and (iii) (I) holds an appropriate national board certification including at the subspecialty level where available, or (II) actively practices and typically manages the medical condition under review or provides the procedure or treatment under review; or
245	257
246	258		(B) For a review or benefit determination concerning an adolescent substance use disorder treatment, as such disorder is described in section 17a-458, a licensed health care professional who (i) holds a nonrestricted license in a state of the United States, (ii) holds a doctoral or medical degree, and (iii) (I) holds a national board certification in child and adolescent psychiatry or child and adolescent psychology, and (II) has training or clinical experience in the treatment of adolescent substance use disorder.
247	259
248	260		[(8)] (9) "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.
249	261
250	262		[(9)] (10) "Cohort study" means a prospective evaluation of two groups of patients with only one group of patients receiving a specific intervention or specific interventions.
251	263
252	264		[(10)] (11) "Commissioner" means the Insurance Commissioner.
253	265
254	266		[(11)] (12) "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.
255	267
256	268		[(12)] (13) "Covered benefits" or "benefits" means health care services to which a covered person is entitled under the terms of a health benefit plan.
257	269
258	270		[(13)] (14) "Covered person" means a policyholder, subscriber, enrollee or other individual participating in a health benefit plan.
259	271
260	272		[(14)] (15) "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.
261	273
262	274		[(15)] (16) "Emergency services" means, with respect to an emergency medical condition:
263	275
264	276		(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
265	277
266	278		(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.
267	279
268	280		[(16)] (17) "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.
269	281
270	282		[(17)] (18) "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.
271	283
272	284		[(18)] (19) "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.
273	285
274	286		[(19)] (20) "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.
275	287
276	288		[(20)] (21) "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:
277	289
278	290		(A) The availability, delivery or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review;
279	291
280	292		(B) Claims payment, handling or reimbursement for health care services; or
281	293
282	294		(C) Any matter pertaining to the contractual relationship between a covered person and a health carrier.
283	295
284	296		[(21)] (22) (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;
285	297
286	298		(B) "Health benefit plan" does not include:
287	299
288	300		(i) Coverage of the type specified in subdivisions (5) to (9), inclusive, (14) and (15) of section 38a-469 or any combination thereof;
289	301
290	302		(ii) Coverage issued as a supplement to liability insurance;
291	303
292	304		(iii) Liability insurance, including general liability insurance and automobile liability insurance;
293	305
294	306		(iv) Workers' compensation insurance;
295	307
296	308		(v) Automobile medical payment insurance;
297	309
298	310		(vi) Credit insurance;
299	311
300	312		(vii) Coverage for on-site medical clinics;
301	313
302	314		(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;
303	315
304	316		(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
305	317
306	318		(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.
307	319
308	320		[(22)] (23) "Health care center" has the same meaning as provided in section 38a-175.
309	321
310	322		[(23)] (24) "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.
311	323
312	324		[(24)] (25) "Health care services" has the same meaning as provided in section 38a-478.
313	325
314	326		[(25)] (26) "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.
315	327
316	328		[(26)] (27) "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.
317	329
318	330		[(27)] (28) "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.
319	331
320	332		[(28)] (29) "Medical or scientific evidence" means evidence found in the following sources:
321	333
322	334		(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;
323	335
324	336		(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);
325	337
326	338		(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;
327	339
328	340		(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;
329	341
330	342		(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
331	343
332	344		(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.
333	345
334	346		[(29)] (30) "Medical necessity" has the same meaning as provided in sections 38a-482a and 38a-513c.
335	347
336	348		[(30)] (31) "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.
337	349
338	350		[(31)] (32) "Person" has the same meaning as provided in section 38a-1.
339	351
340	352		[(32)] (33) "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.
341	353
342	354		[(33)] (34) "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.
343	355
344	356		[(34)] (35) "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.
345	357
346	358		[(35)] (36) "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.
347	359
348	360		[(36)] (37) "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.
349	361
350	362		[(37)] (38) "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.
351	363
352	364		[(38)] (39) "Urgent care request" means a request for a health care service or course of treatment (A) for which the time period for making a non-urgent care request determination (i) could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function, or (ii) 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, or (B) for a substance use disorder, as described in section 17a-458, or for a co-occurring disorder.
353	365
354	366		[(39)] (40) "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.
355	367
356	368		[(40)] (41) "Utilization review company" means an entity that conducts utilization review.
357	369
358	370		Sec. 7. Section 38a-591e of the general statutes, as amended by section 3 of this act, is repealed and the following is substituted in lieu thereof (Effective January 1, 2015):
359	371
360	372		(a) (1) Each health carrier shall establish and maintain written procedures for (A) the review, by one or more clinical peers, of grievances of adverse determinations that were based, in whole or in part, on medical necessity, (B) the expedited review, by one or more clinical peers, 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.
361	373
362	374		(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.
363	375
364	376		(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-591n, inclusive, as amended by this act.
365	377
366	378		(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.
367	379
368	380		(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.
369	381
370	382		(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 clinical peer or peers involved in making the review decision.
371	383
372	384		(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.
373	385
374	386		(C) The clinical peer or peers 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.
375	387
376	388		(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.
377	389
378	390		(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.
379	391
380	392		(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.
381	393
382	394		(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:
383	395
384	396		(A) For prospective review and concurrent review requests, thirty calendar days after the health carrier receives the grievance;
385	397
386	398		(B) For retrospective review requests, sixty calendar days after the health carrier receives the grievance; and
387	399
388	400		(C) For expedited review requests, seventy-two hours after the health carrier receives the grievance.
389	401
390	402		(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.
391	403
392	404		(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:
393	405
394	406		(A) The titles and qualifying credentials of the clinical peer or peers participating in the review process;
395	407
396	408		(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;
397	409
398	410		(C) A statement of such clinical peer's or peers' understanding of the covered person's grievance;
399	411
400	412		(D) The clinical peer's or peers' 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;
401	413
402	414		(E) Reference to the evidence or documentation used as the basis for the decision;
403	415
404	416		(F) For a decision that upholds the adverse determination:
405	417
406	418		(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;
407	419
408	420		(ii) Reference to the specific health benefit plan provisions on which the decision is based;
409	421
410	422		(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 and evidence not previously provided regarding the adverse determination under review;
411	423
412	424		(iv) 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;
413	425
414	426		(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) 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) 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;
415	427
416	428		(vi) A statement describing the procedures for obtaining an external review of the final adverse determination;
417	429
418	430		(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
419	431
420	432		(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.
421	433
422	434		(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 38a-591n.
423	435
424	436		(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.
425	437
426	438		(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.
427	439
428	440		[(g) Notwithstanding subdivision (7) of section 38a-591a, for purposes of this section, on and after September 1, 2013, and prior to January 1, 2015:
429	441
430	442		(1) "Clinical peer" means:
431	443
432	444		(A) A licensed health care professional who (i) holds a nonrestricted license in a state of the United States, (ii) holds a doctoral or medical degree, and (iii) (I) holds an appropriate national board certification including at the subspecialty level where available, or (II) actively practices and typically manages the medical condition under review or provides the procedure or treatment under review; or
433	445
434	446		(B) For a review of an adverse determination under this section concerning an adolescent substance use disorder treatment, as such disorder is described in section 17a-458, a licensed health care professional who (i) holds a nonrestricted license in a state of the United States, (ii) holds a doctoral or medical degree, and (iii) (I) holds a national board certification in child and adolescent psychiatry or child and adolescent psychology, and (II) has training or clinical experience in the treatment of adolescent substance use disorder.
435	447
436	448		(2) "Appropriate national board certification" means, for a clinical peer who conducts any reviews of adverse determinations under this section concerning adult substance use disorder treatment, as such disorder is described in section 17a-458, certification by a national addiction board.]
437	449
438	450		Sec. 8. Section 38a-591c of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2014):
439	451
440	452		(a) (1) Each health carrier shall contract with (A) health care professionals to administer such health carrier's utilization review program and oversee utilization review determinations, and (B) [with] clinical peers to evaluate the clinical appropriateness of an adverse determination.
441	453
442	454		(2) (A) Each utilization review program shall use documented clinical review criteria that are based on sound clinical evidence and are evaluated periodically by the health carrier's organizational mechanism specified in subparagraph (F) of subdivision (2) of subsection (c) of section 38a-591b to assure such program's ongoing effectiveness. A health carrier may develop its own clinical review criteria or it may purchase or license clinical review criteria from qualified vendors approved by the commissioner. Each health carrier shall make its clinical review criteria available upon request to authorized government agencies.
443	455
444	456		(B) Notwithstanding subparagraph (A) of this subdivision, for any utilization review or benefit determination for the treatment of a substance use disorder, as described in section 17a-458, or a co-occurring disorder, the clinical review criteria used shall be: (i) The most recent edition of the American Society of Addiction Medicine's Patient Placement Criteria; or (ii) clinical review criteria that are (I) developed as required under state law, and (II) reviewed and accepted by the Department of Mental Health and Addiction Services for adults and the Department of Children and Families for children and adolescents, as adhering to the prevailing standard of care.
445	457
446	458		(C) A health carrier that uses clinical review criteria as set forth in subparagraph (B)(ii) of this subdivision shall create and maintain a document that (i) compares each aspect of such clinical review criteria with the relevant provision of the American Society of Addiction Medicine's Patient Placement Criteria, and (ii) provides citations to peer-reviewed medical literature generally recognized by the relevant medical community or to professional society guidelines that justify each deviation from the American Society of Addiction Medicine's Patient Placement Criteria.
447	459
448	460		(b) Each health carrier shall:
449	461
450	462		(1) Have procedures in place to ensure that the health care professionals administering such health carrier's utilization review program are applying the clinical review criteria consistently in utilization review determinations;
451	463
452	464		(2) Have data systems sufficient to support utilization review program activities and to generate management reports to enable the health carrier to monitor and manage health care services effectively;
453	465
454	466		(3) Provide covered persons and participating providers with access to its utilization review staff through a toll-free telephone number or any other free calling option or by electronic means;
455	467
456	468		(4) Coordinate the utilization review program with other medical management activity conducted by the health carrier, such as quality assurance, credentialing, contracting with health care professionals, data reporting, grievance procedures, processes for assessing member satisfaction and risk management; and
457	469
458	470		(5) Routinely assess the effectiveness and efficiency of its utilization review program.
459	471
460	472		(c) If a health carrier delegates any utilization review activities to a utilization review company, the health carrier shall maintain adequate oversight, which shall include (1) a written description of the utilization review company's activities and responsibilities, including such company's reporting requirements, (2) evidence of the health carrier's formal approval of the utilization review company program, and (3) a process by which the health carrier shall evaluate the utilization review company's performance.
461	473
462	474		(d) When conducting utilization review, the health carrier shall (1) collect only the information necessary, including pertinent clinical information, to make the utilization review or benefit determination, and (2) ensure that such review is conducted in a manner to ensure the independence and impartiality of the individual or individuals involved in making the utilization review or benefit determination. No health carrier shall make decisions regarding the hiring, compensation, termination, promotion or other similar matters of such individual or individuals based on the likelihood that the individual or individuals will support the denial of benefits.
463	475
464	476		Sec. 9. Subdivision (1) of subsection (a) of section 38a-591c of the general statutes, as amended by section 8 of this act, is repealed and the following is substituted in lieu thereof (Effective January 1, 2015):
465	477
466	478		(a) (1) Each health carrier shall contract with (A) health care professionals to administer such health carrier's utilization review program and oversee utilization review determinations, and (B) clinical peers to [evaluate the clinical appropriateness of an] oversee and perform all reviews of adverse [determination] determinations.
467	479
468	480		Sec. 10. Subsections (h) and (i) of section 38a-591g of the general statutes are repealed and the following is substituted in lieu thereof (Effective January 1, 2015):
469	481
470	482		(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:
471	483
472	484		(1) The covered person's medical records;
473	485
474	486		(2) The attending health care professional's recommendation;
475	487
476	488		(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;
477	489
478	490		(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;
479	491
480	492		(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;
481	493
482	494		(6) Any applicable clinical review criteria developed and used by the health carrier or its designee utilization review company; and
483	495
484	496		(7) The opinion or opinions of the independent review organization's clinical [peer or peers] reviewer or reviewers, as described in subdivision (4) of subsection (c) of section 38a-591l, as amended by this act, who conducted the review after considering subdivisions (1) to (6), inclusive, of this subsection.
485	497
486	498		(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:
487	499
488	500		(A) For external reviews, forty-five calendar days after such organization receives the assignment from the commissioner to conduct such review;
489	501
490	502		(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;
491	503
492	504		(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
493	505
494	506		(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.
495	507
496	508		(2) Such notice shall include:
497	509
498	510		(A) A general description of the reason for the request for the review;
499	511
500	512		(B) The date the independent review organization received the assignment from the commissioner to conduct the review;
501	513
502	514		(C) The date the review was conducted;
503	515
504	516		(D) The date the organization made its decision;
505	517
506	518		(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;
507	519
508	520		(F) The rationale for the organization's decision;
509	521
510	522		(G) Reference to the evidence or documentation, including any evidence-based standards, considered by the organization in reaching its decision; and
511	523
512	524		(H) For a review involving a determination that the recommended or requested health care service or treatment is experimental or investigational:
513	525
514	526		(i) A description of the covered person's medical condition;
515	527
516	528		(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;
517	529
518	530		(iii) A description and analysis of any medical or scientific evidence considered in reaching the opinion;
519	531
520	532		(iv) A description and analysis of any evidence-based standard; and
521	533
522	534		(v) Information on whether the clinical [peer's] reviewer's rationale for the opinion is based on the documents and information set forth in subsection (f) of this section.
523	535
524	536		(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.
525	537
526	538		Sec. 11. Subsection (c) of section 38a-591l of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2015):
527	539
528	540		(c) To be eligible for approval by the commissioner, an independent review organization shall:
529	541
530	542		(1) Have and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process set forth in section 38a-591g, as amended by this act, that include, at a minimum:
531	543
532	544		(A) A quality assurance mechanism in place that ensures:
533	545
534	546		(i) That external reviews and expedited external reviews are conducted within the specified time frames and required notices are provided in a timely manner;
535	547
536	548		(ii) (I) The selection of qualified and impartial clinical [peers] reviewers to conduct such reviews on behalf of the independent review organization and the suitable matching of such [peers] reviewers to specific cases, and (II) the employment of or the contracting with an adequate number of clinical [peers] reviewers to meet this objective;
537	549
538	550		(iii) The confidentiality of medical and treatment records and clinical review criteria;
539	551
540	552		(iv) That any person employed by or under contract with the independent review organization adheres to the requirements of section 38a-591g, as amended by this act; and
541	553
542	554		(B) A toll-free telephone number to receive information twenty-four hours a day, seven days a week, related to external reviews and expedited external reviews and that is capable of accepting, recording or providing appropriate instruction to incoming telephone callers during other than normal business hours;
543	555
544	556		(2) Agree to maintain and provide to the commissioner the information set forth in section 38a-591m, as amended by this act;
545	557
546	558		(3) Not own or control, be a subsidiary of, be owned or controlled in any way by, or exercise control with a health benefit plan, a national, state or local trade association of health benefit plans, or a national, state or local trade association of health care professionals; and
547	559
548	560		(4) Assign as a clinical [peer] reviewer a health care professional who meets the following minimum qualifications:
549	561
550	562		(A) 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;
551	563
552	564		[(A)] (B) Is an expert in the treatment of the covered person's medical condition that is the subject of the review;
553	565
554	566		[(B)] (C) Is knowledgeable about the recommended health care service or treatment through recent or current actual clinical experience treating patients with the same or similar medical condition of the covered person;
555	567
556		-	[(C)~~] (D) [~~Holds a nonrestricted license in a state of the United States and, for] For physicians, a current certification by a recognized American medical specialty board in the area or areas appropriate to the subject of the review; and
	568	+	[(C) Holds a nonrestricted license in a state of the United States and, for] (D) For physicians, a current certification by a recognized American medical specialty board in the area or areas appropriate to the subject of the review; and
557	569
558	570		[(D)] (E) Has no history of disciplinary actions or sanctions, including loss of staff privileges or participation restrictions, that have been taken or are pending by any hospital, governmental agency or unit or regulatory body that raise a substantial question as to the clinical [peer's] reviewer's physical, mental or professional competence or moral character.
559	571
560	572		Sec. 12. Subsections (a) to (d), inclusive, of section 38a-591m of the general statutes are repealed and the following is substituted in lieu thereof (Effective January 1, 2015):
561	573
562	574		(a) The commissioner shall not assign an independent review organization, and no independent review organization shall assign a clinical [peer] reviewer, as described in subdivision (4) of subsection (c) of section 38a-591l, as amended by this act, to conduct an external review or an expedited external review of a specified case if such organization or clinical [peer] reviewer has a material professional, familial or financial conflict of interest with any of the following:
563	575
564	576		(1) The health carrier that is the subject of such review;
565	577
566	578		(2) The covered person whose treatment is the subject of such review or the covered person's authorized representative;
567	579
568	580		(3) Any officer, director or management employee of the health carrier that is the subject of such review;
569	581
570	582		(4) The health care provider, the health care provider's medical group or independent practice association recommending the health care service or treatment that is the subject of such review;
571	583
572	584		(5) The facility at which the recommended health care service or treatment would be provided; or
573	585
574	586		(6) The developer or manufacturer of the principal drug, device, procedure or other therapy being recommended for the covered person whose treatment is the subject of such review.
575	587
576	588		(b) To determine whether an independent review organization or a clinical [peer] reviewer of the independent review organization has a material professional, familial or financial conflict of interest for purposes of subsection (a) of this section, the commissioner shall consider situations in which the independent review organization to be assigned to conduct an external review or an expedited external review of a specified case or a clinical [peer] reviewer to be assigned by the independent review organization to conduct such review of a specified case may have an apparent professional, familial or financial relationship or connection with a person described in subsection (a) of this section, but the characteristics of such relationship or connection are such that they are not a material professional, familial or financial conflict of interest that results in the disapproval of the independent review organization or the clinical [peer] reviewer from conducting such review.
577	589
578	590		(c) An independent review organization shall be unbiased. In addition to any other written procedures required under section 38a-591l, as amended by this act, an independent review organization shall establish and maintain written procedures to ensure that it is unbiased.
579	591
580	592		(d) No independent review organization or clinical [peer] reviewer working on behalf of an independent review organization or an employee, agent or contractor of an independent review organization shall be liable in damages to any person for any opinions rendered or acts or omissions performed within the scope of the organization's or person's duties during or upon completion of an external review or an expedited external review conducted pursuant to section 38a-591g, as amended by this act, unless such opinion was rendered or act or omission performed in bad faith or involved gross negligence.
581	593
582	594
583	595
584	596
585	597		This act shall take effect as follows and shall amend the following sections:
586	598		Section 1 September 1, 2013 38a-591a(38)
587	599		Sec. 2 September 1, 2013 38a-591d
588	600		Sec. 3 September 1, 2013 38a-591e
589	601		Sec. 4 September 1, 2013 38a-591a(7)
590	602		Sec. 5 September 1, 2013 38a-591f(d)
591	603		Sec. 6 January 1, 2015 38a-591a
592	604		Sec. 7 January 1, 2015 38a-591e
593	605		Sec. 8 January 1, 2014 38a-591c
594	606		Sec. 9 January 1, 2015 38a-591c(a)(1)
595	607		Sec. 10 January 1, 2015 38a-591g(h) and (i)
596	608		Sec. 11 January 1, 2015 38a-591l(c)
597	609		Sec. 12 January 1, 2015 38a-591m(a) to (d)
598	610
599	611		This act shall take effect as follows and shall amend the following sections:
600	612
601	613		Section 1
602	614
603	615		September 1, 2013
604	616
605	617		38a-591a(38)
606	618
607	619		Sec. 2
608	620
609	621		September 1, 2013
610	622
611	623		38a-591d
612	624
613	625		Sec. 3
614	626
615	627		September 1, 2013
616	628
617	629		38a-591e
618	630
619	631		Sec. 4
620	632
621	633		September 1, 2013
622	634
623	635		38a-591a(7)
624	636
625	637		Sec. 5
626	638
627	639		September 1, 2013
628	640
629	641		38a-591f(d)
630	642
631	643		Sec. 6
632	644
633	645		January 1, 2015
634	646
635	647		38a-591a
636	648
637	649		Sec. 7
638	650
639	651		January 1, 2015
640	652
641	653		38a-591e
642	654
643	655		Sec. 8
644	656
645	657		January 1, 2014
646	658
647	659		38a-591c
648	660
649	661		Sec. 9
650	662
651	663		January 1, 2015
652	664
653	665		38a-591c(a)(1)
654	666
655	667		Sec. 10
656	668
657	669		January 1, 2015
658	670
659	671		38a-591g(h) and (i)
660	672
661	673		Sec. 11
662	674
663	675		January 1, 2015
664	676
665	677		38a-591l(c)
666	678
667	679		Sec. 12
668	680
669	681		January 1, 2015
670	682
671	683		38a-591m(a) to (d)
672	684
	685	+	Statement of Purpose:
673	686
	687	+	To implement the recommendations of the Legislative Program Review and Investigations Committee concerning the health carrier utilization review and grievance process.
674	688
675		-	PRI Joint Favorable Subst.
676		-
677		-	PRI
678		-
679		-	Joint Favorable Subst.
	689	+	[Proposed deletions are enclosed in brackets. Proposed additions are indicated by underline, except that when the entire text of a bill or resolution or a section of a bill or resolution is new, it is not underlined.]