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General Assembly Raised Bill No. 341
February Session, 2020
LCO No. 2033
Referred to Committee on INSURANCE AND REAL ESTATE
Introduced by:
(INS)
AN ACT CONCERNING PA RTICIPATION BY COVERED PERSONS,
AUTHORIZED REPRESENTATIVES AND HEALTH CARE
PROFESSIONALS IN UTILIZATION REVIEWS.
Be it enacted by the Senate and House of Representatives in General
Assembly convened:
Section 1. (NEW) (Effective January 1, 2021) Each health care 1
professional who submits an urgent care request for a covered person 2
shall provide, at least annually, a written notice to the covered person 3
or the covered person's authorized representative, as applicable, 4
disclosing the right to submit the covered person's story pursuant to 5
subsection (c) of section 38a-591d of the general statutes, as amended by 6
this act. For the purposes of this section, "authorized representative", 7
"health care professional", "covered person's story" and "urgent care 8
request" have the same meanings as provided in section 38a-591a of the 9
general statutes, as amended by this act. 10
Sec. 2. Section 38a-591a of the general statutes is repealed and the 11
following is substituted in lieu thereof (Effective January 1, 2021): 12
As used in this section and sections 38a-591b to 38a-591n, inclusive, 13
as amended by this act: 14 Raised Bill No. 341
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(1) "Adverse determination" means: 15
(A) The denial, reduction, termination or failure to provide or make 16
payment, in whole or in part, for a benefit under the health carrier's 17
health benefit plan requested by a covered person or a covered person's 18
treating health care professional, based on a determination by a health 19
carrier or its designee utilization review company: 20
(i) That, based upon the information provided, (I) upon application 21
of any utilization review technique, such benefit does not meet the 22
health carrier's requirements for medical necessity, appropriateness, 23
health care setting, level of care or effectiveness, or (II) is determined to 24
be experimental or investigational; 25
(ii) Of a covered person's eligibility to participate in the health 26
carrier's health benefit plan; or 27
(B) Any prospective review, concurrent review or retrospective 28
review determination that denies, reduces or terminates or fails to 29
provide or make payment, in whole or in part, for a benefit under the 30
health carrier's health benefit plan requested by a covered person or a 31
covered person's treating health care professional. 32
"Adverse determination" includes a rescission of coverage 33
determination for grievance purposes. 34
(2) "Authorized representative" means: 35
(A) A person to whom a covered person has given express written 36
consent to represent the covered person for the purposes of this section 37
and sections 38a-591b to 38a-591n, inclusive, as amended by this act; 38
(B) A person authorized by law to provide substituted consent for a 39
covered person; 40
(C) A family member of the covered person or the covered person's 41
treating health care professional when the covered person is unable to 42
provide consent; 43 Raised Bill No. 341
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(D) A health care professional when the covered person's health 44
benefit plan requires that a request for a benefit under the plan be 45
initiated by the health care professional; or 46
(E) In the case of an urgent care request, a health care professional 47
with knowledge of the covered person's medical condition. 48
(3) "Best evidence" means evidence based on (A) randomized clinical 49
trials, (B) if randomized clinical trials are not available, cohort studies or 50
case-control studies, (C) if such trials and studies are not available, case-51
series, or (D) if such trials, studies and case-series are not available, 52
expert opinion. 53
(4) "Case-control study" means a retrospective evaluation of two 54
groups of patients with different outcomes to determine which specific 55
interventions the patients received. 56
(5) "Case-series" means an evaluation of a series of patients with a 57
particular outcome, without the use of a control group. 58
(6) "Certification" means a determination by a health carrier or its 59
designee utilization review company that a request for a benefit under 60
the health carrier's health benefit plan has been reviewed and, based on 61
the information provided, satisfies the health carrier's requirements for 62
medical necessity, appropriateness, health care setting, level of care and 63
effectiveness. 64
(7) "Clinical peer" means a physician or other health care professional 65
who (A) holds a nonrestricted license in a state of the United States and 66
in the same or similar specialty as typically manages the medical 67
condition, procedure or treatment under review, and (B) for a review 68
specified under subparagraph (B) or (C) of subdivision (38) of this 69
section concerning (i) a child or adolescent substance use disorder or a 70
child or adolescent mental disorder, holds (I) a national board 71
certification in child and adolescent psychiatry, or (II) a doctoral level 72
psychology degree with training and clinical experience in the treatment 73
of child and adolescent substance use disorder or child and adolescent 74 Raised Bill No. 341
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mental disorder, as applicable, or (ii) an adult substance use disorder or 75
an adult mental disorder, holds (I) a national board certification in 76
psychiatry, or (II) a doctoral level psychology degree with training and 77
clinical experience in the treatment of adult substance use disorders or 78
adult mental disorders, as applicable. 79
(8) "Clinical review criteria" means the written screening procedures, 80
decision abstracts, clinical protocols and practice guidelines used by the 81
health carrier to determine the medical necessity and appropriateness 82
of health care services. 83
(9) "Cohort study" means a prospective evaluation of two groups of 84
patients with only one group of patients receiving a specific intervention 85
or specific interventions. 86
[(10) "Commissioner" means the Insurance Commissioner.] 87
[(11)] (10) "Concurrent review" means utilization review conducted 88
during a patient's stay or course of treatment in a facility, the office of a 89
health care professional or other inpatient or outpatient health care 90
setting, including home care. 91
[(12)] (11) "Covered benefits" or "benefits" means health care services 92
to which a covered person is entitled under the terms of a health benefit 93
plan. 94
[(13)] (12) "Covered person" means a policyholder, subscriber, 95
enrollee or other individual participating in a health benefit plan. 96
(13) "Covered person's story" means a written statement by a covered 97
person or a covered person's authorized representative containing any 98
information that the covered person or the covered person's authorized 99
representative, as applicable, wants a utilization review company to 100
consider when reviewing a nonurgent care request or an urgent care 101
request, as applicable. 102
(14) "Emergency medical condition" means a medical condition 103
manifesting itself by acute symptoms of sufficient severity, including 104 Raised Bill No. 341
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severe pain, such that a prudent layperson with an average knowledge 105
of health and medicine, acting reasonably, would have believed that the 106
absence of immediate medical attention would result in serious 107
impairment to bodily functions or serious dysfunction of a bodily organ 108
or part, or would place the person's health or, with respect to a pregnant 109
woman, the health of the woman or her unborn child, in serious 110
jeopardy. 111
(15) "Emergency services" means, with respect to an emergency 112
medical condition: 113
(A) A medical screening examination that is within the capability of 114
the emergency department of a hospital, including ancillary services 115
routinely available to the emergency department to evaluate such 116
emergency medical condition; and 117
(B) Such further medical examination and treatment, to the extent 118
they are within the capability of the staff and facilities available at a 119
hospital, to stabilize a patient. 120
(16) "Evidence-based standard" means the conscientious, explicit and 121
judicious use of the current best evidence based on an overall systematic 122
review of medical research when making determinations about the care 123
of individual patients. 124
(17) "Expert opinion" means a belief or an interpretation by specialists 125
with experience in a specific area about the scientific evidence 126
pertaining to a particular service, intervention or therapy. 127
(18) "Facility" means an institution providing health care services or 128
a health care setting. "Facility" includes a hospital and other licensed 129
inpatient center, ambulatory surgical or treatment center, skilled 130
nursing center, residential treatment center, diagnostic, laboratory and 131
imaging center, and rehabilitation and other therapeutic health care 132
setting. 133
(19) "Final adverse determination" means an adverse determination 134 Raised Bill No. 341
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(A) that has been upheld by the health carrier at the completion of its 135
internal grievance process, or (B) for which the internal grievance 136
process has been deemed exhausted. 137
(20) "Grievance" means a written complaint or, if the complaint 138
involves an urgent care request, an oral complaint, submitted by or on 139
behalf of a covered person regarding: 140
(A) The availability, delivery or quality of health care services, 141
including a complaint regarding an adverse determination made 142
pursuant to utilization review; 143
(B) Claims payment, handling or reimbursement for health care 144
services; or 145
(C) Any matter pertaining to the contractual relationship between a 146
covered person and a health carrier. 147
(21) (A) "Health benefit plan" means an insurance policy or contract, 148
certificate or agreement offered, delivered, issued for delivery, renewed, 149
amended or continued in this state to provide, deliver, arrange for, pay 150
for or reimburse any of the costs of health care services; 151
(B) "Health benefit plan" does not include: 152
(i) Coverage of the type specified in subdivisions (5) to (9), inclusive, 153
(14) and (15) of section 38a-469 or any combination thereof; 154
(ii) Coverage issued as a supplement to liability insurance; 155
(iii) Liability insurance, including general liability insurance and 156
automobile liability insurance; 157
(iv) Workers' compensation insurance; 158
(v) Automobile medical payment insurance; 159
(vi) Credit insurance; 160 Raised Bill No. 341
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(vii) Coverage for on-site medical clinics; 161
(viii) Other insurance coverage similar to the coverages specified in 162
subparagraphs (B)(ii) to (B)(vii), inclusive, of this subdivision that are 163
specified in regulations issued pursuant to the Health Insurance 164
Portability and Accountability Act of 1996, P.L. 104-191, as amended 165
from time to time, under which benefits for health care services are 166
secondary or incidental to other insurance benefits; 167
(ix) (I) Limited scope dental or vision benefits, (II) benefits for long-168
term care, nursing home care, home health care, community-based care 169
or any combination thereof, or (III) other similar, limited benefits 170
specified in regulations issued pursuant to the Health Insurance 171
Portability and Accountability Act of 1996, P.L. 104-191, as amended 172
from time to time, provided any benefits specified in subparagraphs 173
(B)(ix)(I) to (B)(ix)(III), inclusive, of this subdivision are provided under 174
a separate insurance policy, certificate or contract and are not otherwise 175
an integral part of a health benefit plan; or 176
(x) Coverage of the type specified in subdivisions (3) and (13) of 177
section 38a-469 or other fixed indemnity insurance if (I) they are 178
provided under a separate insurance policy, certificate or contract, (II) 179
there is no coordination between the provision of the benefits and any 180
exclusion of benefits under any group health plan maintained by the 181
same plan sponsor, and (III) the benefits are paid with respect to an 182
event without regard to whether benefits were also provided under any 183
group health plan maintained by the same plan sponsor. 184
(22) "Health care center" has the same meaning as provided in section 185
38a-175. 186
(23) "Health care professional" means a physician or other health care 187
practitioner licensed, accredited or certified to perform specified health 188
care services consistent with state law. 189
(24) "Health care services" has the same meaning as provided in 190
section 38a-478. 191 Raised Bill No. 341
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(25) "Health carrier" means an entity subject to the insurance laws and 192
regulations of this state or subject to the jurisdiction of the 193
commissioner, that contracts or offers to contract to provide, deliver, 194
arrange for, pay for or reimburse any of the costs of health care services, 195
including a sickness and accident insurance company, a health care 196
center, a managed care organization, a hospital service corporation, a 197
medical service corporation or any other entity providing a plan of 198
health insurance, health benefits or health care services. 199
(26) "Health information" means information or data, whether oral or 200
recorded in any form or medium, and personal facts or information 201
about events or relationships that relate to (A) the past, present or future 202
physical, mental, or behavioral health or condition of a covered person 203
or a member of the covered person's family, (B) the provision of health 204
care services to a covered person, or (C) payment for the provision of 205
health care services to a covered person. 206
(27) "Independent review organization" means an entity that 207
conducts independent external reviews of adverse determinations and 208
final adverse determinations. Such review entities include, but are not 209
limited to, medical peer review organizations, independent utilization 210
review companies, provided such organizations or companies are not 211
related to or associated with any health carrier, and nationally 212
recognized health experts or institutions approved by the Insurance 213
Commissioner. 214
(28) "Medical or scientific evidence" means evidence found in the 215
following sources: 216
(A) Peer-reviewed scientific studies published in or accepted for 217
publication by medical journals that meet nationally recognized 218
requirements for scientific manuscripts and that submit most of their 219
published articles for review by experts who are not part of the editorial 220
staff; 221
(B) Peer-reviewed medical literature, including literature relating to 222
therapies reviewed and approved by a qualified institutional review 223 Raised Bill No. 341
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board, biomedical compendia and other medical literature that meet the 224
criteria of the National Institutes of Health's Library of Medicine for 225
indexing in Index Medicus (Medline) or Elsevier Science for indexing in 226
Excerpta Medicus (EMBASE); 227
(C) Medical journals recognized by the Secretary of the United States 228
Department of Health and Human Services under Section 1861(t)(2) of 229
the Social Security Act; 230
(D) The following standard reference compendia: (i) The American 231
Hospital Formulary Service - Drug Information; (ii) Drug Facts and 232
Comparisons; (iii) The American Dental Association's Accepted Dental 233
Therapeutics; and (iv) The United States Pharmacopoeia - Drug 234
Information; 235
(E) Findings, studies or research conducted by or under the auspices 236
of federal government agencies and nationally recognized federal 237
research institutes, including: (i) The Agency for Healthcare Research 238
and Quality; (ii) the National Institutes of Health; (iii) the National 239
Cancer Institute; (iv) the National Academy of Sciences; (v) the Centers 240
for Medicare and Medicaid Services; (vi) the Food and Drug 241
Administration; and (vii) any national board recognized by the National 242
Institutes of Health for the purpose of evaluating the medical value of 243
health care services; or 244
(F) Any other findings, studies or research conducted by or under the 245
auspices of a source comparable to those listed in subparagraphs (E)(i) 246
to (E)(v), inclusive, of this subdivision. 247
(29) "Medical necessity" has the same meaning as provided in 248
sections 38a-482a and 38a-513c. 249
(30) "Participating provider" means a health care professional who, 250
under a contract with the health carrier, its contractor or subcontractor, 251
has agreed to provide health care services to covered persons, with an 252
expectation of receiving payment or reimbursement directly or 253
indirectly from the health carrier, other than coinsurance, copayments 254 Raised Bill No. 341
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or deductibles. 255
(31) "Person" has the same meaning as provided in section 38a-1. 256
(32) "Prospective review" means utilization review conducted prior 257
to an admission or the provision of a health care service or a course of 258
treatment, in accordance with a health carrier's requirement that such 259
service or treatment be approved, in whole or in part, prior to such 260
service's or treatment's provision. 261
(33) "Protected health information" means health information (A) that 262
identifies an individual who is the subject of the information, or (B) for 263
which there is a reasonable basis to believe that such information could 264
be used to identify such individual. 265
(34) "Randomized clinical trial" means a controlled, prospective 266
study of patients that have been randomized into an experimental 267
group and a control group at the beginning of the study, with only the 268
experimental group of patients receiving a specific intervention, and 269
that includes study of the groups for variables and anticipated outcomes 270
over time. 271
(35) "Rescission" means a cancellation or discontinuance of coverage 272
under a health benefit plan that has a retroactive effect. "Rescission" 273
does not include a cancellation or discontinuance of coverage under a 274
health benefit plan if (A) such cancellation or discontinuance has a 275
prospective effect only, or (B) such cancellation or discontinuance is 276
effective retroactively to the extent it is attributable to the covered 277
person's failure to timely pay required premiums or contributions 278
towards the cost of such coverage. 279
(36) "Retrospective review" means any review of a request for a 280
benefit that is not a prospective review or concurrent review. 281
"Retrospective review" does not include a review of a request that is 282
limited to the veracity of documentation or the accuracy of coding. 283
(37) "Stabilize" means, with respect to an emergency medical 284 Raised Bill No. 341
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condition, that (A) no material deterioration of such condition is likely, 285
within reasonable medical probability, to result from or occur during 286
the transfer of the individual from a facility, or (B) with respect to a 287
pregnant woman, the woman has delivered, including the placenta. 288
(38) "Urgent care request" means a request for a health care service or 289
course of treatment (A) for which the time period for making a non-290
urgent care request determination (i) could seriously jeopardize the life 291
or health of the covered person or the ability of the covered person to 292
regain maximum function, or (ii) in the opinion of a health care 293
professional with knowledge of the covered person's medical condition, 294
would subject the covered person to severe pain that cannot be 295
adequately managed without the health care service or treatment being 296
requested, or (B) for a substance use disorder, as described in section 297
17a-458, or for a co-occurring mental disorder, or (C) for a mental 298
disorder requiring (i) inpatient services, (ii) partial hospitalization, as 299
defined in section 38a-496, (iii) residential treatment, or (iv) intensive 300
outpatient services necessary to keep a covered person from requiring 301
an inpatient setting. 302
(39) "Utilization review" means the use of a set of formal techniques 303
designed to monitor the use of, or evaluate the medical necessity, 304
appropriateness, efficacy or efficiency of, health care services, health 305
care procedures or health care settings. Such techniques may include the 306
monitoring of or evaluation of (A) health care services performed or 307
provided in an outpatient setting, (B) the formal process for 308
determining, prior to discharge from a facility, the coordination and 309
management of the care that a patient receives following discharge from 310
a facility, (C) opportunities or requirements to obtain a clinical 311
evaluation by a health care professional other than the one originally 312
making a recommendation for a proposed health care service, (D) 313
coordinated sets of activities conducted for individual patient 314
management of serious, complicated, protracted or other health 315
conditions, or (E) prospective review, concurrent review, retrospective 316
review or certification. 317 Raised Bill No. 341
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(40) "Utilization review company" means an entity that conducts 318
utilization review. 319
Sec. 3. Subsections (c) and (d) of section 38a-591b of the general 320
statutes are repealed and the following is substituted in lieu thereof 321
(Effective January 1, 2021): 322
(c) (1) A health carrier that requires utilization review of a benefit 323
request under a health benefit plan shall implement a utilization review 324
program and develop a written document that describes all utilization 325
review activities and procedures, whether or not delegated, for (A) the 326
filing of benefit requests, (B) the notification to covered persons of 327
utilization review and benefit determinations, and (C) the review of 328
adverse determinations and grievances in accordance with sections 38a-329
591e and 38a-591f. 330
(2) Such document shall describe the following: 331
(A) Procedures to evaluate the medical necessity, appropriateness, 332
health care setting, level of care or effectiveness of health care services; 333
(B) Data sources and clinical review criteria used in making 334
determinations; 335
(C) Procedures to ensure consistent application of clinical review 336
criteria and compatible determinations; 337
(D) Data collection processes and analytical methods used to assess 338
utilization of health care services; 339
(E) Provisions to ensure the confidentiality of clinical, proprietary 340
and protected health information; 341
(F) The health carrier's organizational mechanism, such as a 342
utilization review committee or quality assurance or other committee, 343
that periodically assesses the health carrier's utilization review program 344
and reports to the health carrier's governing body; [and] 345 Raised Bill No. 341
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(G) The health carrier's staff position that is responsible for the day-346
to-day management of the utilization review program; [.] and 347
(H) The right to submit a covered person's story pursuant to 348
subsection (b) or (c) of section 38a-591d, as amended by this act. 349
(d) Each health carrier shall: 350
(1) Include in the insurance policy, certificate of coverage or 351
handbook provided to covered persons a clear and comprehensive 352
description of: 353
(A) Its utilization review and benefit determination procedures; 354
(B) Its grievance procedures, including the grievance procedures for 355
requesting a review of an adverse determination; 356
(C) A description of the external review procedures set forth in 357
section 38a-591g, in a format prescribed by the commissioner and 358
including a statement that discloses that: 359
(i) A covered person may file a request for an external review of an 360
adverse determination or a final adverse determination with the 361
commissioner and that such review is available when the adverse 362
determination or the final adverse determination involves an issue of 363
medical necessity, appropriateness, health care setting, level of care or 364
effectiveness. Such disclosure shall include the contact information of 365
the commissioner; and 366
(ii) When filing a request for an external review of an adverse 367
determination or a final adverse determination, the covered person shall 368
be required to authorize the release of any medical records that may be 369
required to be reviewed for the purpose of making a decision on such 370
request; 371
(D) A statement of the rights and responsibilities of covered persons 372
with respect to each of the procedures under subparagraphs (A) to (C), 373
inclusive, of this subdivision. Such statement shall include a disclosure 374 Raised Bill No. 341
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that a covered person has the right to contact the commissioner's office 375
or the Office of Healthcare Advocate at any time for assistance and shall 376
include the contact information for said offices; 377
(E) A description of what constitutes a surprise bill, as defined in 378
subsection (a) of section 38a-477aa; 379
(F) The right to submit a covered person's story pursuant to 380
subsection (b) or (c) of section 38a-591d, as amended by this act; 381
(2) Inform its covered persons, at the time of initial enrollment and at 382
least annually thereafter, of its grievance procedures. This requirement 383
may be fulfilled by including such procedures in an enrollment 384
agreement or update to such agreement; 385
(3) Inform a covered person or the covered person's health care 386
professional, as applicable, at the time the covered person or the covered 387
person's health care professional requests a prospective or concurrent 388
review: (A) The network status under such covered person's health 389
benefit plan of the health care professional who will be providing the 390
health care service or course of treatment; (B) an estimate of the amount 391
the health carrier will reimburse such health care professional for such 392
service or treatment; and (C) how such amount compares to the usual, 393
customary and reasonable charge, as determined by the Centers for 394
Medicare and Medicaid Services, for such service or treatment; 395
(4) Inform a covered person and the covered person's health care 396
professional of the health carrier's grievance procedures whenever the 397
health carrier denies certification of a benefit requested by a covered 398
person's health care professional; 399
(5) Prominently post on its Internet web site the description required 400
under subparagraph (E) of subdivision (1) of this subsection; 401
(6) Include in materials intended for prospective covered persons a 402
summary of its utilization review and benefit determination 403
procedures; 404 Raised Bill No. 341
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(7) Print on its membership or identification cards a toll-free 405
telephone number for utilization review and benefit determinations; 406
(8) Maintain records of all benefit requests, claims and notices 407
associated with utilization review and benefit determinations made in 408
accordance with section 38a-591d, as amended by this act, for not less 409
than six years after such requests, claims and notices were made. Each 410
health carrier shall make such records available for examination by the 411
commissioner and appropriate federal oversight agencies upon request; 412
and 413
(9) Maintain records in accordance with section 38a-591h of all 414
grievances received. Each health carrier shall make such records 415
available for examination by covered persons, to the extent such records 416
are permitted to be disclosed by law, the commissioner and appropriate 417
federal oversight agencies upon request. 418
Sec. 4. Subsections (b) and (c) of section 38a-591d of the 2020 419
supplement to the general statutes are repealed and the following is 420
substituted in lieu thereof (Effective January 1, 2021): 421
(b) With respect to a nonurgent care request: 422
(1) (A) For a prospective or concurrent review request, [a] the health 423
carrier shall make a determination within a reasonable period of time 424
appropriate to the covered person's medical condition, but not later than 425
fifteen calendar days after the date the health carrier receives such 426
request, and shall notify the covered person and, if applicable, the 427
covered person's authorized representative of such determination, 428
whether or not the carrier certifies the provision of the benefit. 429
(B) If the review under subparagraph (A) of this subdivision is a 430
review of a grievance involving a concurrent review request, pursuant 431
to 45 CFR 147.136, as amended from time to time, the treatment shall be 432
continued without liability to the covered person until the covered 433
person has been notified of the review decision. 434 Raised Bill No. 341
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(2) For a retrospective review request, [a] the health carrier shall make 435
a determination within a reasonable period of time, but not later than 436
thirty calendar days after the date the health carrier receives such 437
request. 438
(3) The time periods specified in subdivisions (1) and (2) of this 439
subsection may be extended once by the health carrier for up to fifteen 440
calendar days, provided the health carrier: 441
(A) Determines that an extension is necessary due to circumstances 442
beyond the health carrier's control; and 443
(B) Notifies the covered person and, if applicable, the covered 444
person's authorized representative prior to the expiration of the initial 445
time period, of the circumstances requiring the extension of time and 446
the date by which the health carrier expects to make a determination. 447
(4) (A) If the extension pursuant to subdivision (3) of this subsection 448
is necessary due to the failure of the covered person or the covered 449
person's authorized representative to provide information necessary to 450
make a determination on the request, the health carrier shall: 451
(i) Specifically describe in the notice of extension the required 452
information necessary to complete the request; and 453
(ii) Provide the covered person and, if applicable, the covered 454
person's authorized representative with not less than forty-five calendar 455
days after the date of receipt of the notice to provide the specified 456
information. 457
(B) If the covered person or the covered person's authorized 458
representative fails to submit the specified information before the end 459
of the period of the extension, the health carrier may deny certification 460
of the benefit requested. 461
(5) The health carrier shall provide to the covered person or the 462
covered person's authorized representative, if applicable, the ability to 463
attach to or enclose the covered person's story with the request. 464 Raised Bill No. 341
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(c) With respect to an urgent care request: 465
(1) (A) Unless the covered person or the covered person's authorized 466
representative has failed to provide information necessary for the health 467
carrier to make a determination and except as specified under 468
subparagraph (B) of this subdivision, the health carrier shall make a 469
determination as soon as possible, taking into account the covered 470
person's medical condition, but not later than forty-eight hours after the 471
health carrier receives such request or seventy-two hours after such 472
health carrier receives such request if any portion of such forty-eight-473
hour period falls on a weekend, provided, if the urgent care request is a 474
concurrent review request to extend a course of treatment beyond the 475
initial period of time or the number of treatments, such request is made 476
at least twenty-four hours prior to the expiration of the prescribed 477
period of time or number of treatments. 478
(B) Unless the covered person or the covered person's authorized 479
representative has failed to provide information necessary for the health 480
carrier to make a determination, for an urgent care request specified 481
under subparagraph (B) or (C) of subdivision (38) of section 38a-591a, 482
as amended by this act, the health carrier shall make a determination as 483
soon as possible, taking into account the covered person's medical 484
condition, but not later than twenty-four hours after the health carrier 485
receives such request, provided, if the urgent care request is a 486
concurrent review request to extend a course of treatment beyond the 487
initial period of time or the number of treatments, such request is made 488
at least twenty-four hours prior to the expiration of the prescribed 489
period of time or number of treatments. 490
(2) (A) If the covered person or the covered person's authorized 491
representative has failed to provide information necessary for the health 492
carrier to make a determination, the health carrier shall notify the 493
covered person or the covered person's representative, as applicable, as 494
soon as possible, but not later than twenty-four hours after the health 495
carrier receives such request. 496 Raised Bill No. 341
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(B) The health carrier shall provide the covered person or the covered 497
person's authorized representative, as applicable, a reasonable period of 498
time to submit the specified information, taking into account the 499
covered person's medical condition, but not less than forty-eight hours 500
after notifying the covered person or the covered person's authorized 501
representative, as applicable. 502
(3) The health carrier shall notify the covered person and, if 503
applicable, the covered person's authorized representative of its 504
determination as soon as possible, but not later than forty-eight hours 505
after the earlier of (A) the date on which the covered person and the 506
covered person's authorized representative, as applicable, provides the 507
specified information to the health carrier, or (B) the date on which the 508
specified information was to have been submitted. 509
(4) The health carrier shall permit the covered person's treating health 510
care professional to attach or enclose the covered person's story with 511
such request. 512
This act shall take effect as follows and shall amend the following
sections:
Section 1 January 1, 2021 New section
Sec. 2 January 1, 2021 38a-591a
Sec. 3 January 1, 2021 38a-591b(c) and (d)
Sec. 4 January 1, 2021 38a-591d(b) and (c)
Statement of Purpose:
To: (1) Require health care professionals to notify covered persons and
their authorized representatives of their right to submit additional
information for consideration as part of a utilization review; and (2)
provide covered persons, authorized representatives and health care
professionals with a right to submit such additional information.
[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.]