Connecticut 2013 Regular Session

Connecticut Senate Bill SB01089 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	General Assembly Raised Bill No. 1089
2	2	January Session, 2013 LCO No. 2575
3	3	02575_______INS
4	4	Referred to Committee on INSURANCE AND REAL ESTATE
5	5	Introduced by:
6	6	(INS)
7	7
8	8	General Assembly
9	9
10	10	Raised Bill No. 1089
11	11
12	12	January Session, 2013
13	13
14	14	LCO No. 2575
15	15
16	16	02575_______INS
17	17
18	18	Referred to Committee on INSURANCE AND REAL ESTATE
19	19
20	20	Introduced by:
21	21
22	22	(INS)
23	23
24	24	AN ACT CONCERNING THE QUALIFICATIONS OF CLINICAL PEERS FOR ADVERSE DETERMINATION REVIEWS.
25	25
26	26	Be it enacted by the Senate and House of Representatives in General Assembly convened:
27	27
28	28	Section 1. Subdivision (7) of section 38a-591a of the general statutes is repealed and the following is substituted in lieu thereof (Effective October 1, 2013):
29	29
30	30	(7) "Clinical peer" means a [physician or other] licensed health care professional who (A) holds a [nonrestricted license in a state of the United States and in the same or similar specialty as] doctoral or medical degree, and (B) (i) holds an appropriate national board certification including at the subspecialty level where available, or (ii) actively practices and typically manages the medical condition [, procedure or treatment] under review or provides the procedure or treatment under review.
31	31
32	32	Sec. 2. Subsection (c) of section 38a-591l of the general statutes is repealed and the following is substituted in lieu thereof (Effective October 1, 2013):
33	33
34	34	(c) To be eligible for approval by the commissioner, an independent review organization shall:
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36	36	(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 that include, at a minimum:
37	37
38	38	(A) A quality assurance mechanism in place that ensures:
39	39
40	40	(i) That external reviews and expedited external reviews are conducted within the specified time frames and required notices are provided in a timely manner;
41	41
42	42	(ii) (I) The selection of qualified and impartial clinical peers to conduct such reviews on behalf of the independent review organization and the suitable matching of such peers to specific cases, and (II) the employment of or the contracting with an adequate number of clinical peers to meet this objective;
43	43
44	44	(iii) The confidentiality of medical and treatment records and clinical review criteria;
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46	46	(iv) That any person employed by or under contract with the independent review organization adheres to the requirements of section 38a-591g; and
47	47
48	48	(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;
49	49
50	50	(2) Agree to maintain and provide to the commissioner the information set forth in section 38a-591m; and
51	51
52	52	(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
53	53
54	54	(4) Assign as a clinical peer a health care professional who meets the following minimum qualifications:
55	55
56	56	(A) Is an expert in the treatment of the covered person's medical condition that is the subject of the review;
57	57
58	58	(B) 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;
59	59
60	60	(C) Holds a nonrestricted license in a state of the United States and, 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
61	61
62	62	(D) 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 physical, mental or professional competence or moral character.]
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64	64
65	65
66	66
67	67	This act shall take effect as follows and shall amend the following sections:
68	68	Section 1 October 1, 2013 38a-591a(7)
69	69	Sec. 2 October 1, 2013 38a-591l(c)
70	70
71	71	This act shall take effect as follows and shall amend the following sections:
72	72
73	73	Section 1
74	74
75	75	October 1, 2013
76	76
77	77	38a-591a(7)
78	78
79	79	Sec. 2
80	80
81	81	October 1, 2013
82	82
83	83	38a-591l(c)
84	84
85	85	Statement of Purpose:
86	86
87	87	To redefine the qualifications of a clinical peer for purposes of reviews of adverse determination grievances.
88	88
89	89	[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.]