2012 Connecticut General Statutes
Title 38a - Insurance
Chapter 700c - Health Insurance
Section 38a-591b - Health carrier responsibilities re utilization review. Disclosures. Annual report. Regulations.

(a) Sections 38a-591a to 38a-591n, inclusive, shall apply to (1) any health carrier offering a health benefit plan and that provides or performs utilization review including prospective, concurrent or retrospective review benefit determinations, and (2) any utilization review company or designee of a health carrier that performs utilization review on the health carrier’s behalf, including prospective, concurrent or retrospective review benefit determinations.

(b) Each health carrier shall be responsible for monitoring all utilization review program activities carried out by or on behalf of such health carrier. Such health carrier shall comply with the provisions of sections 38a-591a to 38a-591n, inclusive, and any regulations adopted thereunder, and shall be responsible for ensuring that any utilization review company or other entity such health carrier contracts with to perform utilization review complies with said sections and regulations. Each health carrier shall ensure that appropriate personnel have operational responsibility for the activities of the health carrier’s utilization review program.

(c) (1) A health carrier that requires utilization review of a benefit request under a health benefit plan shall implement a utilization review program and develop a written document that describes all utilization review activities and procedures, whether or not delegated, for (A) the filing of benefit requests, (B) the notification to covered persons of utilization review and benefit determinations, and (C) the review of adverse determinations and grievances in accordance with sections 38a-591e and 38a-591f.

(2) Such document shall describe the following:

(A) Procedures to evaluate the medical necessity, appropriateness, health care setting, level of care or effectiveness of health care services;

(B) Data sources and clinical review criteria used in making determinations;

(C) Procedures to ensure consistent application of clinical review criteria and compatible determinations;

(D) Data collection processes and analytical methods used to assess utilization of health care services;

(E) Provisions to ensure the confidentiality of clinical, proprietary and protected health information;

(F) The health carrier’s organizational mechanism, such as a utilization review committee or quality assurance or other committee, that periodically assesses the health carrier’s utilization review program and reports to the health carrier’s governing body; and

(G) The health carrier’s staff position that is responsible for the day-to-day management of the utilization review program.

(d) Each health carrier shall:

(1) Include in the insurance policy, certificate of coverage or handbook provided to covered persons a clear and comprehensive description of:

(A) Its utilization review and benefit determination procedures;

(B) Its grievance procedures, including the grievance procedures for requesting a review of an adverse determination;

(C) A description of the external review procedures set forth in section 38a-591g, in a format prescribed by the commissioner and including a statement that discloses that:

(i) A covered person may file a request for an external review of an adverse determination or a final adverse determination with the commissioner and that such review is available when the adverse determination or the final adverse determination involves an issue of medical necessity, appropriateness, health care setting, level of care or effectiveness. Such disclosure shall include the contact information of the commissioner; and

(ii) When filing a request for an external review of an adverse determination or a final adverse determination, the covered person shall be required to authorize the release of any medical records that may be required to be reviewed for the purpose of making a decision on such request;

(D) A statement of the rights and responsibilities of covered persons with respect to each of the procedures under subparagraphs (A) to (C), inclusive, of this subdivision. Such statement shall include a disclosure that a covered person has the right to contact the commissioner’s office or the Office of Healthcare Advocate at any time for assistance and shall include the contact information for said offices;

(2) Inform its covered persons, at the time of initial enrollment and at least annually thereafter, of its grievance procedures. This requirement may be fulfilled by including such procedures in an enrollment agreement or update to such agreement;

(3) Inform a covered person and the covered person’s health care professional of the health carrier’s grievance procedures whenever the health carrier denies certification of a benefit requested by a covered person’s health care professional;

(4) Include in materials intended for prospective covered persons a summary of its utilization review and benefit determination procedures;

(5) Print on its membership or identification cards a toll-free telephone number for utilization review and benefit determinations;

(6) Maintain records of all benefit requests, claims and notices associated with utilization review and benefit determinations made in accordance with section 38a-591d for not less than six years after such requests, claims and notices were made. Each health carrier shall make such records available for examination by the commissioner and appropriate federal oversight agencies upon request; and

(7) Maintain records in accordance with section 38a-591h of all grievances received. Each health carrier shall make such records available for examination by covered persons, to the extent such records are permitted to be disclosed by law, the commissioner and appropriate federal oversight agencies upon request.

(e) (1) On or before March first annually, each health carrier shall file with the commissioner:

(A) A summary report of its utilization review program activities in the calendar year immediately preceding; and

(B) A report that includes for each type of health benefit plan offered by the health carrier:

(i) A certificate of compliance certifying that the utilization review program of the health carrier or its designee complies with all applicable state and federal laws concerning confidentiality and reporting requirements;

(ii) The number of covered lives;

(iii) The total number of grievances received;

(iv) The number of grievances resolved at each level, if applicable, and their resolution;

(v) The number of grievances appealed to the commissioner of which the health carrier has been informed;

(vi) The number of grievances referred to alternative dispute resolution procedures or resulting in litigation; and

(vii) A synopsis of actions being taken to correct any problems identified.

(2) The commissioner shall adopt regulations, in accordance with chapter 54, to establish the form and content of the reports specified in subdivision (1) of this subsection.

(P.A. 11-58, S. 55; P.A. 12-102, S. 7.)

History: P.A. 11-58 effective July 1, 2011; P.A. 12-102 amended Subsecs. (a) and (b) to replace references to Sec. 38a-591m with references to Sec. 38a-591n.