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General Assembly Committee Bill No. 38
January Session, 2019
LCO No. 5468
Referred to Committee on INSURANCE AND REAL ESTATE
Introduced by:
(INS)
AN ACT REDUCING THE TIME FRAME FOR URGENT CAR E
ADVERSE DETERMINATIO N REVIEW REQUESTS AN D EXPEDITED
EXTERNAL REVIEWS.
Be it enacted by the Senate and House of Representatives in General
Assembly convened:
Section 1. Subdivision (1) of subsection (c) of section 38a-591d of the 1
general statutes is repealed and the following is substituted in lieu 2
thereof (Effective January 1, 2020): 3
(1) (A) Unless the covered person or the covered person's 4
authorized representative has failed to provide information necessary 5
for the health carrier to make a determination and except as specified 6
under subparagraph (B) of this subdivision, the health carrier shall 7
make a determination as soon as possible, taking into account the 8
covered person's medical condition, but not later than [seventy-two] 9
forty-eight hours after the health carrier receives such request, 10
provided, if the urgent care request is a concurrent review request to 11
extend a course of treatment beyond the initial period of time or the 12
number of treatments, such request is made at least twenty-four hours 13
prior to the expiration of the prescribed period of time or number of 14
treatments. 15
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(B) Unless the covered person or the covered person's authorized 16
representative has failed to provide information necessary for the 17
health carrier to make a determination, for an urgent care request 18
specified under subparagraph (B) or (C) of subdivision (38) of section 19
38a-591a, the health carrier shall make a determination as soon as 20
possible, taking into account the covered person's medical condition, 21
but not later than twenty-four hours after the health carrier receives 22
such request, provided, if the urgent care request is a concurrent 23
review request to extend a course of treatment beyond the initial 24
period of time or the number of treatments, such request is made at 25
least twenty-four hours prior to the expiration of the prescribed period 26
of time or number of treatments. 27
Sec. 2. Subdivision (1) of subsection (d) of section 38a-591e of the 28
general statutes is repealed and the following is substituted in lieu 29
thereof (Effective January 1, 2020): 30
(d) (1) The health carrier shall notify the covered person and, if 31
applicable, the covered person's authorized representative, in writing 32
or by electronic means, of its decision within a reasonable period of 33
time appropriate to the covered person's medical condition, but not 34
later than: 35
(A) For prospective review and concurrent review requests, thirty 36
calendar days after the health carrier receives the grievance; 37
(B) For retrospective review requests, sixty calendar days after the 38
health carrier receives the grievance; 39
(C) For expedited review requests, except as specified under 40
subparagraph (D) of this subdivision, [seventy-two] forty-eight hours 41
after the health carrier receives the grievance; and 42
(D) For expedited review requests of a health care service or course 43
of treatment specified under subparagraph (B) or (C) of subdivision 44
(38) of section 38a-591a, twenty-four hours after the health carrier 45
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receives the grievance. 46
Sec. 3. Subdivision (1) of subsection (i) of section 38a-591g of the 47
general statutes is repealed and the following is substituted in lieu 48
thereof (Effective January 1, 2020): 49
(i) (1) The independent review organization shall notify the 50
commissioner, the health carrier, the covered person and, if applicable, 51
the covered person's authorized representative in writing of its 52
decision to uphold, reverse or revise the adverse determination or the 53
final adverse determination, not later than: 54
(A) For external reviews, forty-five calendar days after such 55
organization receives the assignment from the commissioner to 56
conduct such review; 57
(B) For external reviews involving a determination that the 58
recommended or requested health care service or treatment is 59
experimental or investigational, twenty calendar days after such 60
organization receives the assignment from the commissioner to 61
conduct such review; 62
(C) For expedited external reviews, except as specified under 63
subparagraph (D) of this subdivision, as expeditiously as the covered 64
person's medical condition requires, but not later than [seventy-two] 65
forty-eight hours after such organization receives the assignment from 66
the commissioner to conduct such review; 67
(D) For expedited external reviews involving a health care service or 68
course of treatment specified under subparagraph (B) or (C) of 69
subdivision (38) of section 38a-591a, as expeditiously as the covered 70
person's medical condition requires, but not later than twenty-four 71
hours after such organization receives the assignment from the 72
commissioner to conduct such review; and 73
(E) For expedited external reviews involving a determination that 74
the recommended or requested health care service or treatment is 75
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experimental or investigational, as expeditiously as the covered 76
person's medical condition requires, but not later than five calendar 77
days after such organization receives the assignment from the 78
commissioner to conduct such review. 79
This act shall take effect as follows and shall amend the following
sections:
Section 1 January 1, 2020 38a-591d(c)(1)
Sec. 2 January 1, 2020 38a-591e(d)(1)
Sec. 3 January 1, 2020 38a-591g(i)(1)
Statement of Purpose:
To reduce the time frame for urgent care adverse determination review
requests and expedited external reviews from seventy-two to forty-
eight hours.
[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.]
Co-Sponsors: SEN. LOONEY, 11th Dist.
S.B. 38