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General Assembly Raised Bill No. 180
February Session, 2024
LCO No. 1486
Referred to Committee on PUBLIC HEALTH
Introduced by:
(PH)
AN ACT CONCERNING ADVERSE DETERMINATION AND
UTILIZATION REVIEWS.
Be it enacted by the Senate and House of Representatives in General
Assembly convened:
Section 1. Subdivision (7) of section 38a-591a of the 2024 supplement 1
to the general statutes is repealed and the following is substituted in lieu 2
thereof (Effective January 1, 2025): 3
(7) "Clinical peer" means a physician or other health care professional 4
who: 5
(A) [holds] For a review other than one specified under subparagraph 6
(B) or (C) of subdivision (38) of this section, holds a nonrestricted license 7
in a state of the United States [and] in the same [or similar] specialty as 8
[typically manages the medical condition, procedure or treatment] the 9
treating physician or other health care professional under review; [, and] 10
or 11
(B) [for] For a review specified under subparagraph (B) or (C) of 12
subdivision (38) of this section concerning: 13 Raised Bill No. 180
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(i) [a] A child or adolescent substance use disorder or a child or 14
adolescent mental disorder, holds (I) a national board certification in 15
child and adolescent psychiatry, or (II) a doctoral level psychology 16
degree with training and clinical experience in the treatment of child 17
and adolescent substance use disorder or child and adolescent mental 18
disorder, as applicable; [,] or 19
(ii) [an] An adult substance use disorder or an adult mental disorder, 20
holds (I) a national board certification in psychiatry, or (II) a doctoral 21
level psychology degree with training and clinical experience in the 22
treatment of adult substance use disorders or adult mental disorders, as 23
applicable. 24
Sec. 2. Subsection (a) of section 38a-591c of the 2024 supplement to 25
the general statutes is repealed and the following is substituted in lieu 26
thereof (Effective January 1, 2025): 27
(a) (1) Each health carrier shall contract with (A) health care 28
professionals to administer such health carrier's utilization review 29
program, and (B) clinical peers to evaluate the clinical appropriateness 30
of an adverse determination. 31
(2) (A) Each utilization review program shall use documented clinical 32
review criteria that are based on sound clinical evidence and are 33
evaluated periodically by the health carrier's organizational mechanism 34
specified in subparagraph (F) of subdivision (2) of subsection (c) of 35
section 38a-591b to [assure] ensure such program's ongoing 36
effectiveness. 37
(B) Except as provided in subdivisions (3), (4) and (5) of this 38
subsection, a health carrier may develop its own clinical review criteria 39
or it may purchase or license clinical review criteria from qualified 40
vendors approved by the commissioner, provided such clinical review 41
criteria conform to the requirements of subparagraph (A) of this 42
subdivision. 43
(C) Each health carrier shall (i) post on its Internet web site (I) any 44 Raised Bill No. 180
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clinical review criteria it uses, and (II) links to any rule, guideline, 45
protocol or other similar criterion a health carrier may rely upon to make 46
an adverse determination as described in subparagraph (F) of 47
subdivision (1) of subsection (e) of section 38a-591d, and (ii) make its 48
clinical review criteria available upon request to authorized government 49
agencies. 50
(D) For each utilization review, there shall be a rebuttable 51
presumption that each health care service under review is medically 52
necessary if such health care service was ordered by a health care 53
professional acting within the health care professional's scope of 54
practice. A health carrier, or any utilization review company or designee 55
of a health carrier that performs utilization review on behalf of the 56
health carrier, shall have the burden of proving that a health care service 57
is not medically necessary. 58
(3) For any utilization review for the treatment of a substance use 59
disorder, as described in section 17a-458, the clinical review criteria used 60
shall be: (A) The most recent edition of the American Society of 61
Addiction Medicine Treatment Criteria for Addictive, Substance-62
Related, and Co-Occurring Conditions; or (B) clinical review criteria that 63
the health carrier demonstrates to the Insurance Department is 64
consistent with the most recent edition of the American Society of 65
Addiction Medicine Treatment Criteria for Addictive, Substance-66
Related, and Co-Occurring Conditions, except that nothing in this 67
subdivision shall prohibit a health carrier from developing its own 68
clinical review criteria or purchasing or licensing additional clinical 69
review criteria from qualified vendors approved by the commissioner, 70
to address advancements in technology or types of care for the 71
treatment of a substance use disorder, that are not covered in the most 72
recent edition of the American Society of Addiction Medicine Treatment 73
Criteria for Addictive, Substance-Related, and Co-Occurring 74
Conditions. Any such clinical review criteria developed by a health 75
carrier or purchased or licensed from a qualified vendor shall conform 76
to the requirements of subparagraph (A) of subdivision (2) of this 77
subsection. 78 Raised Bill No. 180
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(4) For any utilization review for the treatment of a child or 79
adolescent mental disorder, the clinical review criteria used shall be: (A) 80
The most recent guidelines of the American Academy of Child and 81
Adolescent Psychiatry's Child and Adolescent Service Intensity 82
Instrument; or (B) clinical review criteria that the health carrier 83
demonstrates to the Insurance Department is consistent with the most 84
recent guidelines of the American Academy of Child and Adolescent 85
Psychiatry's Child and Adolescent Service Intensity Instrument, except 86
that nothing in this subdivision shall prohibit a health carrier from 87
developing its own clinical review criteria or purchasing or licensing 88
additional clinical review criteria from qualified vendors approved by 89
the commissioner, to address advancements in technology or types of 90
care for the treatment of a child or adolescent mental disorder, that are 91
not covered in the most recent guidelines of the American Academy of 92
Child and Adolescent Psychiatry's Child and Adolescent Service 93
Intensity Instrument. Any such clinical review criteria developed by a 94
health carrier or purchased or licensed from a qualified vendor shall 95
conform to the requirements of subparagraph (A) of subdivision (2) of 96
this subsection. 97
(5) For any utilization review for the treatment of an adult mental 98
disorder, the clinical review criteria used shall be: (A) The most recent 99
guidelines of the American Psychiatric Association or the most recent 100
Standards and Guidelines of the Association for Ambulatory Behavioral 101
Healthcare; or (B) clinical review criteria that the health carrier 102
demonstrates to the Insurance Department is consistent with the most 103
recent guidelines of the American Psychiatric Association or the most 104
recent Standards and Guidelines of the Association for Ambulatory 105
Behavioral Healthcare, except that nothing in this subdivision shall 106
prohibit a health carrier from developing its own clinical review criteria 107
or purchasing or licensing additional clinical review criteria from 108
qualified vendors approved by the commissioner, to address 109
advancements in technology or types of care for the treatment of an 110
adult mental disorder, that are not covered in the most recent guidelines 111
of the American Psychiatric Association or the most recent Standards 112 Raised Bill No. 180
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and Guidelines of the Association for Ambulatory Behavioral 113
Healthcare. Any such clinical review criteria developed by a health 114
carrier or purchased or licensed from a qualified vendor shall conform 115
to the requirements of subparagraph (A) of subdivision (2) of this 116
subsection. 117
Sec. 3. Subsection (a) of section 38a-591d of the 2024 supplement to 118
the general statutes is repealed and the following is substituted in lieu 119
thereof (Effective January 1, 2025): 120
(a) (1) Each health carrier shall maintain written procedures for (A) 121
utilization review and benefit determinations, (B) expedited utilization 122
review and benefit determinations with respect to prospective urgent 123
care requests and concurrent review urgent care requests, and (C) 124
notifying covered persons or covered persons ' authorized 125
representatives of such review and benefit determinations. Each health 126
carrier shall make such review and benefit determinations within the 127
specified time periods under this section. 128
(2) In determining whether a benefit request shall be considered an 129
urgent care request, an individual acting on behalf of a health carrier 130
shall apply the judgment of a prudent layperson who possesses an 131
average knowledge of health and medicine, except that any benefit 132
request (A) determined to be an urgent care request by a health care 133
professional with knowledge of the covered person's medical condition, 134
or (B) specified under subparagraph (B) or (C) of subdivision (38) of 135
section 38a-591a shall be deemed an urgent care request. 136
(3) (A) At the time a health carrier notifies a covered person, a covered 137
person's authorized representative or a covered person's health care 138
professional of an initial adverse determination that was based, in whole 139
or in part, on medical necessity, of a concurrent or prospective 140
utilization review or of a benefit request, the health carrier shall notify 141
the covered person's health care professional (i) of the opportunity for a 142
conference as provided in subparagraph (B) of this subdivision, and (ii) 143
that such conference shall not be considered a grievance of such initial 144 Raised Bill No. 180
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adverse determination as long as a grievance has not been filed as set 145
forth in subparagraph (B) of this subdivision. 146
(B) After a health carrier notifies a covered person, a covered person's 147
authorized representative or a covered person's health care professional 148
of an initial adverse determination that was based, in whole or in part, 149
on medical necessity, of a concurrent or prospective utilization review 150
or of a benefit request, the health carrier shall offer a covered person's 151
health care professional the opportunity to confer, at the request of the 152
covered person's health care professional, with a clinical peer of such 153
health carrier, provided such covered person, covered person's 154
authorized representative or covered person's health care professional 155
has not filed a grievance of such initial adverse determination prior to 156
such conference. Such conference shall not be considered a grievance of 157
such initial adverse determination. Such health carrier shall grant such 158
clinical peer the authority to reverse such initial adverse determination. 159
Sec. 4. Subsection (c) of section 38a-591e of the general statutes is 160
repealed and the following is substituted in lieu thereof (Effective January 161
1, 2025): 162
(c) (1) (A) When conducting a review of an adverse determination 163
under this section, the health carrier shall ensure that such review is 164
conducted in a manner to ensure the independence and impartiality of 165
the clinical peer or peers involved in making the review decision. 166
(B) If the adverse determination involves utilization review, the 167
health carrier shall designate an appropriate clinical peer or peers to 168
review such adverse determination. Such clinical peer or peers shall not 169
have been involved in the initial adverse determination. 170
(C) (i) For each review of an adverse determination under this section, 171
there shall be a rebuttable presumption that each health care service 172
under review is medically necessary if such health care service was 173
ordered by a health care professional acting within the scope of the 174
health care professional's practice. The health carrier may rebut such 175
presumption by reasonably substantiating to the clinical peer or peers 176 Raised Bill No. 180
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conducting the review under this section that such health care service is 177
not medically necessary. 178
[(C)] (ii) The clinical peer or peers conducting a review under this 179
section shall take into consideration all comments, documents, records 180
and other information relevant to the covered person's benefit request 181
that is the subject of the adverse determination under review, that are 182
submitted by the covered person or the covered person's authorized 183
representative, regardless of whether such information was submitted 184
or considered in making the initial adverse determination. 185
(D) Prior to issuing a decision, the health carrier shall provide free of 186
charge, by facsimile, electronic means or any other expeditious method 187
available, to the covered person or the covered person's authorized 188
representative, as applicable, any new or additional documents, 189
communications, information and evidence relied upon and any new or 190
additional scientific or clinical rationale used by the health carrier in 191
connection with the grievance. Such documents, communications, 192
information, evidence and rationale shall be provided sufficiently in 193
advance of the date the health carrier is required to issue a decision to 194
permit the covered person or the covered person's authorized 195
representative, as applicable, a reasonable opportunity to respond prior 196
to such date. 197
(2) If the review under subdivision (1) of this subsection is an 198
expedited review, all necessary information, including the health 199
carrier's decision, shall be transmitted between the health carrier and the 200
covered person or the covered person's authorized representative, as 201
applicable, by telephone, facsimile, electronic means or any other 202
expeditious method available. 203
(3) If the review under subdivision (1) of this subsection is an 204
expedited review of a grievance involving an adverse determination of 205
a concurrent review request, pursuant to 45 CFR 147.136, as amended 206
from time to time, the treatment shall be continued without liability to 207
the covered person until the covered person has been notified of the 208 Raised Bill No. 180
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review decision. 209
This act shall take effect as follows and shall amend the following
sections:
Section 1 January 1, 2025 38a-591a(7)
Sec. 2 January 1, 2025 38a-591c(a)
Sec. 3 January 1, 2025 38a-591d(a)
Sec. 4 January 1, 2025 38a-591e(c)
Statement of Purpose:
To (1) redefine "clinical peer" for the purposes of adverse determination
and utilization reviews; (2) require health carriers to bear the burden of
proving that certain health care services under adverse determination
or utilization review are not medically necessary; and (3) require health
carriers to provide certain clinical peers with authority to reverse initial
adverse determinations.
[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.]