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OLR Bill Analysis
SB 180
AN ACT CONCERNING ADVERSE DETERMINATION AND
UTILIZATION REVIEWS.
SUMMARY
For insurance utilization or adverse determination reviews, this bill
establishes a rebuttable presumption that a health care service is
medically necessary if it was ordered by a health professional acting
within his or her scope of practice (see BACKGROUND). For utilization
reviews, the bill imposes on health carriers or utilization review
companies the burden of proving a health care service is not medically
necessary. For adverse determination reviews, a carrier may rebut the
presumption by reasonably substantiating to the clinical peers doing the
review that the service is not medically necessary. (Utilization and
adverse determination reviews are steps in determining whether a
specific service is covered and reimbursed.)
The bill generally increases the requirements to qualify as a “clinical
peer” for adverse determination reviews, by requiring the person to be
licensed in the same specialty, rather than a similar one, as the
professional under review. (It does not change existing, generally
comparable requirements that apply in cases involving the urgent
treatment of substance use or mental disorders.)
The bill also requires health carriers to authorize clinical peers to
reverse initial adverse determinations that were based on medical
necessity. This applies when the carrier, as required by law, offers a
covered person’s health care professional the opportunity to confer with
a clinical peer of the carrier following the adverse determination (see
BACKGROUND).
EFFECTIVE DATE: January 1, 2025 2024SB-00180-R000018-BA.DOCX
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§ 1 — CLINICAL PEER QUALIFICATIONS
Under current law, clinical peers doing adverse determination
reviews generally must have a nonrestricted license (in any U.S. state)
in the same or similar specialty that typically manages the medical
condition, procedures, or treatment under review. The bill instead
generally requires these clinical peers to have a nonrestricted license in
the same specialty as the treating physician or other health care
professional under review.
By law, unchanged by the bill, for urgent care requests of substance
use or mental health disorders under certain circumstances, the clinical
peer must be a (1) psychologist with relevant training and clinical
experience or (2) psychiatrist.
BACKGROUND
Utilization and Adverse Determination Reviews
Generally, reviews have up to three steps: (1) an initial utilization
review to determine if the procedure is covered; (2) a grievance review
(i.e., internal review), which occurs when a covered person appeals a
benefit denial (i.e., adverse determination); and (3) an external review,
which is done when a covered person exhausts a health carrier’s internal
process and appeals the carrier’s adverse determination to the Insurance
Department. External reviews, also called final adverse determination
reviews, are done by an independent review organization assigned by
the department.
Medically Necessary
State law specifies the definition of “medically necessary” that health
policies must include. In general, a health care service is medically
necessary if it would be provided by a physician exercising prudent
clinical judgment for the purposes of preventing, evaluating,
diagnosing, or treating an illness, injury, disease, or its symptoms, and
it is:
1. in keeping with generally accepted medical standards;
2. clinically appropriate and considered effective for the illness, 2024SB-00180-R000018-BA.DOCX
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injury, or disease;
3. not primarily for the convenience of the patient, physician, or
other health care provider; and
4. not more costly than therapeutically equivalent alternative
treatments (CGS §§ 38a-482a and 38a-513c).
Conference With Clinical Peer Following Adverse Determination
The law requires a carrier to offer a covered person’s health care
professional an opportunity to confer with a clinical peer of the carrier
under certain circumstances. This applies:
1. after a covered person or his or her representative or health care
professional is notified of an initial adverse determination of a
concurrent or prospective utilization review, or of a benefit
request, that was at least partially based on medical necessity and
2. as long as the covered person, representative, or health care
professional has not already filed a grievance of the initial
adverse determination.
COMMITTEE ACTION
Public Health Committee
Joint Favorable
Yea 30 Nay 7 (03/04/2024)