(a)(1) Each health carrier shall contract with (A) health care professionals to administer such health carrier's utilization review program, and (B) clinical peers to evaluate the clinical appropriateness of an adverse determination.
(2) (A) Each utilization review program shall use documented clinical review criteria that are based on sound clinical evidence and are evaluated periodically by the health carrier's organizational mechanism specified in subparagraph (F) of subdivision (2) of subsection (c) of section 38a-591b to assure such program's ongoing effectiveness.
(B) Except as provided in subdivisions (3), (4) and (5) of this subsection, a health carrier may develop its own clinical review criteria or it may purchase or license clinical review criteria from qualified vendors approved by the commissioner, provided such clinical review criteria conform to the requirements of subparagraph (A) of this subdivision.
(C) Each health carrier shall (i) post on its Internet web site (I) any clinical review criteria it uses, and (II) links to any rule, guideline, protocol or other similar criterion a health carrier may rely upon to make an adverse determination as described in subparagraph (F) of subdivision (1) of subsection (e) of section 38a-591d, and (ii) make its clinical review criteria available upon request to authorized government agencies.
(3) For any utilization review for the treatment of a substance use disorder, as described in section 17a-458, the clinical review criteria used shall be: (A) The most recent edition of the American Society of Addiction Medicine Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions; or (B) clinical review criteria that the health carrier demonstrates to the Insurance Department is consistent with the most recent edition of the American Society of Addiction Medicine Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, except that nothing in this subdivision shall prohibit a health carrier from developing its own clinical review criteria or purchasing or licensing additional clinical review criteria from qualified vendors approved by the commissioner, to address advancements in technology or types of care for the treatment of a substance use disorder, that are not covered in the most recent edition of the American Society of Addiction Medicine Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. Any such clinical review criteria developed by a health carrier or purchased or licensed from a qualified vendor shall conform to the requirements of subparagraph (A) of subdivision (2) of this subsection.
(4) For any utilization review for the treatment of a child or adolescent mental disorder, the clinical review criteria used shall be: (A) The most recent guidelines of the American Academy of Child and Adolescent Psychiatry's Child and Adolescent Service Intensity Instrument; or (B) clinical review criteria that the health carrier demonstrates to the Insurance Department is consistent with the most recent guidelines of the American Academy of Child and Adolescent Psychiatry's Child and Adolescent Service Intensity Instrument, except that nothing in this subdivision shall prohibit a health carrier from developing its own clinical review criteria or purchasing or licensing additional clinical review criteria from qualified vendors approved by the commissioner, to address advancements in technology or types of care for the treatment of a child or adolescent mental disorder, that are not covered in the most recent guidelines of the American Academy of Child and Adolescent Psychiatry's Child and Adolescent Service Intensity Instrument. Any such clinical review criteria developed by a health carrier or purchased or licensed from a qualified vendor shall conform to the requirements of subparagraph (A) of subdivision (2) of this subsection.
(5) For any utilization review for the treatment of an adult mental disorder, the clinical review criteria used shall be: (A) The most recent guidelines of the American Psychiatric Association or the most recent Standards and Guidelines of the Association for Ambulatory Behavioral Healthcare; or (B) clinical review criteria that the health carrier demonstrates to the Insurance Department is consistent with the most recent guidelines of the American Psychiatric Association or the most recent Standards and Guidelines of the Association for Ambulatory Behavioral Healthcare, except that nothing in this subdivision shall prohibit a health carrier from developing its own clinical review criteria or purchasing or licensing additional clinical review criteria from qualified vendors approved by the commissioner, to address advancements in technology or types of care for the treatment of an adult mental disorder, that are not covered in the most recent guidelines of the American Psychiatric Association or the most recent Standards and Guidelines of the Association for Ambulatory Behavioral Healthcare. Any such clinical review criteria developed by a health carrier or purchased or licensed from a qualified vendor shall conform to the requirements of subparagraph (A) of subdivision (2) of this subsection.
(b) Each health carrier shall:
(1) Have procedures in place to ensure that (A) the health care professionals administering such health carrier's utilization review program are applying the clinical review criteria consistently in utilization review determinations, and (B) the appropriate or required individual or individuals are being designated to conduct utilization reviews;
(2) Have data systems sufficient to support utilization review program activities and to generate management reports to enable the health carrier to monitor and manage health care services effectively;
(3) Provide covered persons and participating providers with access to its utilization review staff through a toll-free telephone number or any other free calling option or by electronic means;
(4) Coordinate the utilization review program with other medical management activity conducted by the health carrier, such as quality assurance, credentialing, contracting with health care professionals, data reporting, grievance procedures, processes for assessing member satisfaction and risk management; and
(5) Routinely assess the effectiveness and efficiency of its utilization review program.
(c) If a health carrier delegates any utilization review activities to a utilization review company, the health carrier shall maintain adequate oversight, which shall include (1) a written description of the utilization review company's activities and responsibilities, including such company's reporting requirements, (2) evidence of the health carrier's formal approval of the utilization review company program, and (3) a process by which the health carrier shall evaluate the utilization review company's performance.
(d) When conducting utilization review, the health carrier shall (1) collect only the information necessary, including pertinent clinical information, to make the utilization review or benefit determination, and (2) ensure that such review is conducted in a manner to ensure the independence and impartiality of the individual or individuals involved in making the utilization review or benefit determination. No health carrier shall make decisions regarding the hiring, compensation, termination, promotion or other similar matters of such individual or individuals based on the likelihood that the individual or individuals will support the denial of benefits.
(P.A. 11-58, S. 56; P.A. 13-3, S. 72; 13-134, S. 22; P.A. 14-40, S. 2; June Sp. Sess. P.A. 15-5, S. 352; P.A. 16-175, S. 1.)
History: P.A. 11-58 effective July 1, 2011; P.A. 13-3 amended Subsec. (a) by adding provision requiring clinical peers to conduct utilization reviews in Subdiv. (1) and adding Subdivs. (3), (4) and (5) re clinical review criteria for substance use and mental disorders, amended Subsec. (b)(1) by designating existing provision as Subpara. (A) and adding Subpara. (B) re clinical peers designated to conduct utilization reviews, and amended Subsec. (d) by replacing “individual or individuals” with “clinical peer or peers”; P.A. 13-134 made a technical change in Subsec. (a)(1); P.A. 14-40 amended Subsec. (a)(1) to delete provision re clinical peers to conduct utilization reviews, and amended Subsecs. (b)(1) and (d) to replace references to clinical peer or peers with references to individual or individuals, effective May 28, 2014; June Sp. Sess. P.A. 15-5 amended Subsec. (a)(3) to replace “American Society of Addiction Medicine's Patient Placement Criteria” with “American Society of Addiction Medicine Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions”, effective July 1, 2015; P.A. 16-175 amended Subsec. (a) by substantially revising provisions re clinical review criteria that health carriers' utilization review programs may use, including adding provisions re health carrier to post on Internet web site any clinical review criteria they use and links to any rule, guideline, protocol or other similar criterion relied upon to make adverse determination in Subdiv. (1)(C) and adding provisions re health carrier's development of clinical review criteria or purchase or licensing additional clinical review criteria from qualified vendors and deleting provisions re health carrier that uses clinical review criteria to create and maintain document on Internet web site in Subdivs. (3) to (5), effective January 1, 2017.
Structure Connecticut General Statutes
Chapter 700c - Health Insurance
Section 38a-469. - Definitions.
Section 38a-472a. - Medical provider indemnification agreements prohibited.
Section 38a-472g. - Restrictions applicable to prior authorization or precertification.
Section 38a-472j. - Restrictions applicable to cost-sharing for covered benefits. Regulations.
Section 38a-472k. - Disability income policies. Discretionary clauses prohibited. Regulations.
Section 38a-476. - Preexisting condition coverage.
Section 38a-476b. - Standards re psychotropic drug availability in health plans.
Section 38a-477. - Standardized claim forms. Information necessary for filing a claim. Regulations.
Section 38a-477a. - Notification by Insurance Commissioner of required benefits and policy forms.
Section 38a-477bb. - Cost-sharing re facility fees.
Section 38a-477f. - Contract provision prohibiting certain disclosures prohibited.
Section 38a-477ff. - Third-party discounts and payments for covered benefits. Credit required.
Section 38a-477g. - Contracts between health carriers and participating providers.
Section 38a-477h. - Participating provider directories.
Section 38a-477ll. - Coverage for health enhancement programs.
Section 38a-478. - Definitions.
Section 38a-478a. - Commissioner's report to the Governor and the General Assembly.
Section 38a-478f. - Provider profile development requirements.
Section 38a-478g. - Managed care contract requirements. Plan description requirements.
Section 38a-478i. - Limitation on enrollee rights prohibited.
Section 38a-478j. - Coinsurance and deductible payments based on negotiated discounts.
Section 38a-478k. - Gag clauses prohibited.
Section 38a-478l. - Consumer report card required. Content. Data analysis by commissioner.
Section 38a-478o. - Confidentiality and antidiscrimination procedures required.
Section 38a-478p. - Expedited utilization review. Standardized process required.
Section 38a-478q. - Use of laboratories covered by plan required.
Section 38a-478t. - Commissioner of Public Health to receive data.
Section 38a-478u. - Regulations.
Section 38a-479. - Definitions. Access to fee schedules. Fee information to be confidential.
Section 38a-479gg. - Regulations.
Section 38a-479aaa. - Pharmacy benefits managers. Definitions.
Section 38a-479ddd. - Hearing on denial of certificate. Subsequent application.
Section 38a-479eee. - Claims payment to be made by electronic funds transfer upon written request.
Section 38a-479fff. - Expiration of certificates of registration. Renewal. Fees.
Section 38a-479ggg. - Regulations.
Section 38a-479hhh. - Investigations and hearings. Powers of commissioner. Appeals.
Section 38a-479iii. - Pharmacy audits.
Section 38a-479ooo. - Definitions.
Section 38a-479qqq. - Annual report by health carriers. Regulations.
Section 38a-479rrr. - Annual certification by health carriers.
Section 38a-479qq. - Medical discount plans: Definitions, prohibited sales practices, penalties.
Section 38a-482. (Formerly Sec. 38-166). - Form of policy.
Section 38a-482c. - Annual and lifetime limits.
Section 38a-483. (Formerly Sec. 38-167). - Standard provisions of individual health policy.
Section 38a-483a. - Exclusionary riders for individual health insurance policies. Regulations.
Section 38a-483b. - Time limits for coverage determinations. Notice requirements.
Section 38a-483c. - Coverage and notice re experimental treatments. Appeals.
Section 38a-486. (Formerly Sec. 38-170). - Certain acts not to operate as waiver of rights.
Section 38a-487. (Formerly Sec. 38-171). - Coverage after termination date of policy.
Section 38a-488. (Formerly Sec. 38-172). - Discrimination.
Section 38a-488b. - Coverage for autism spectrum disorder therapies.
Section 38a-488d. - Coverage for substance abuse services provided pursuant to court order.
Section 38a-488e. - Coverage for mental health wellness examinations.
Section 38a-488f. - Coverage for services provided under the Collaborative Care Model.
Section 38a-488g. - Acute inpatient psychiatric coverage. Prior authorization not required.
Section 38a-490a. - Coverage for birth-to-three program.
Section 38a-490b. - Coverage for hearing aids.
Section 38a-490c. - Coverage for craniofacial disorders.
Section 38a-490d. - Mandatory coverage for blood lead screening and risk assessment.
Section 38a-491b. - Assignment of benefits to a dentist or oral surgeon.
Section 38a-492a. - Mandatory coverage for hypodermic needles and syringes.
Section 38a-492b. - Coverage for certain off-label drug prescriptions.
Section 38a-492d. - Mandatory coverage for diabetes screening, testing and treatment.
Section 38a-492e. - Mandatory coverage for diabetes outpatient self-management training.
Section 38a-492f. - Mandatory coverage for certain prescription drugs removed from formulary.
Section 38a-492g. - Mandatory coverage for prostate cancer screening and treatment.
Section 38a-492h. - Mandatory coverage for certain Lyme disease treatments.
Section 38a-492i. - Mandatory coverage for pain management.
Section 38a-492j. - Mandatory coverage for ostomy-related supplies.
Section 38a-492k. - Mandatory coverage for colorectal cancer screening.
Section 38a-492m. - Mandatory coverage for certain renewals of prescription eye drops.
Section 38a-492n. - Mandatory coverage for certain wound-care supplies.
Section 38a-492o. - Mandatory coverage for bone marrow testing.
Section 38a-492p. - Mandatory coverage for medically monitored inpatient detoxification.
Section 38a-492q. - Mandatory coverage for essential health benefits.
Section 38a-492t. - Mandatory coverage for prosthetic devices.
Section 38a-492u. - Coverage for psychotropic drugs. Standards re availability.
Section 38a-494. (Formerly Sec. 38-174l). - Home health care by recognized nonmedical systems.
Section 38a-495b. - Medicare supplement policies and certificates. Definitions.
Section 38a-495d. - Refund of prepaid premium for Medicare supplement policies.
Section 38a-496. (Formerly Sec. 38-174q). - Coverage for occupational therapy.
Section 38a-498a. - Prior authorization prohibited for certain 9-1-1 emergency calls.
Section 38a-498b. - Mandatory coverage for mobile field hospital.
Section 38a-503a. - Mandatory coverage for breast cancer survivors.
Section 38a-503b. - Carriers to permit direct access to obstetrician-gynecologist.
Section 38a-503e. - Mandatory coverage for contraceptives and sterilization.
Section 38a-503g. - Mandatory coverage for ovarian cancer screening and monitoring.
Section 38a-504a. - Coverage for routine patient care costs associated with certain clinical trials.
Section 38a-504b. - Clinical trial criteria.
Section 38a-504d. - Clinical trials: Routine patient care costs.
Section 38a-504e. - Clinical trials: Billing. Payments.
Section 38a-504g. - Clinical trials: Submission and certification of policy forms.
Section 38a-506. (Formerly Sec. 38-173). - Penalty.
Section 38a-507. - Coverage for services performed by chiropractors.
Section 38a-508. - Coverage for adopted children.
Section 38a-509. - Mandatory coverage for infertility diagnosis and treatment. Limitations.
Section 38a-510. - Prescription drug coverage. Mail order pharmacies. Step therapy use.
Section 38a-510a. - Prescription drug coverage. Synchronized refills.
Section 38a-511. - Copayments re in-network imaging services.
Section 38a-512. - Applicability of statutes to certain major medical expense policies.
Section 38a-512a. - Continuation of coverage.
Section 38a-512c. - Annual and lifetime limits.
Section 38a-513a. - Time limits for coverage determinations. Notice requirements.
Section 38a-513b. - Coverage and notice re experimental treatments. Appeals.
Section 38a-513f. - Claims information to be provided to certain employers. Restrictions. Subpoenas.
Section 38a-513g. - Employer submission of plan cost information to Comptroller.
Section 38a-514a. - Biologically-based mental illness. Coverage required.
Section 38a-514b. - Coverage for autism spectrum disorder.
Section 38a-514d. - Coverage for substance abuse services provided pursuant to court order.
Section 38a-514e. - Coverage for mental health wellness exams.
Section 38a-514f. - Coverage for services provided under the Collaborative Care Model.
Section 38a-514g. - Acute patient psychiatric coverage. Prior authorization not required.
Section 38a-515. - Continuation of coverage of mentally or physically handicapped children.
Section 38a-516. - Coverage for newly born children. Notification to insurer.
Section 38a-516a. - Coverage for birth-to-three program.
Section 38a-516b. - Coverage for hearing aids.
Section 38a-516c. - Coverage for craniofacial disorders.
Section 38a-516d. - Coverage for neuropsychological testing for children diagnosed with cancer.
Section 38a-517. - Coverage for services performed by dentist in certain instances.
Section 38a-517b. - Assignment of benefits to a dentist or oral surgeon.
Section 38a-518a. - Mandatory coverage for hypodermic needles and syringes.
Section 38a-518b. - Coverage for certain off-label drug prescriptions.
Section 38a-518d. - Mandatory coverage for diabetes screening, testing and treatment.
Section 38a-518e. - Mandatory coverage for diabetes outpatient self-management training.
Section 38a-518f. - Mandatory coverage for certain prescription drugs removed from formulary.
Section 38a-518g. - Mandatory coverage for prostate cancer screening and treatment.
Section 38a-518h. - Mandatory coverage for certain Lyme disease treatments.
Section 38a-518i. - Mandatory coverage for pain management.
Section 38a-518j. - Mandatory coverage for ostomy-related supplies.
Section 38a-518k. - Mandatory coverage for colorectal cancer screening.
Section 38a-518l. - Mandatory coverage for certain renewals of prescription eye drops.
Section 38a-518m. - Mandatory coverage for certain wound-care supplies.
Section 38a-518o. - Mandatory coverage for bone marrow testing.
Section 38a-518p. - Mandating coverage for medically monitored inpatient detoxification.
Section 38a-518q. - Mandatory coverage for essential health benefits.
Section 38a-518t. - Mandatory coverage for prosthetic devices.
Section 38a-518u. - Coverage for psychotropic drugs. Standards re availability.
Section 38a-521. - Home health care by recognized nonmedical systems.
Section 38a-522. - Medicare supplement policies. Coverage of home health aide service.
Section 38a-524. - Coverage for occupational therapy.
Section 38a-525a. - Prior authorization prohibited for certain 9-1-1 emergency calls.
Section 38a-525b. - Mandatory coverage for mobile field hospital.
Section 38a-526. - Coverage for services of physician assistants and certain nurses.
Section 38a-530a. - Mandatory coverage for breast cancer survivors.
Section 38a-530b. - Carriers to permit direct access to obstetrician-gynecologist.
Section 38a-530e. - Mandatory coverage for contraceptives and sterilization.
Section 38a-530g. - Mandatory coverage for ovarian cancer screening and monitoring.
Section 38a-534. - Coverage for services performed by chiropractors.
Section 38a-536. - Mandatory coverage for infertility diagnosis and treatment. Limitations.
Section 38a-542a. - Coverage for routine patient care costs associated with certain clinical trials.
Section 38a-542b. - Clinical trial criteria.
Section 38a-542d. - Clinical trials: Routine patient care costs.
Section 38a-542e. - Clinical trials: Billing. Payments.
Section 38a-542g. - Clinical trials: Submission and certification of policy forms.
Section 38a-543. (Formerly Sec. 38-262j). - Reduction of payments on basis of Medicare eligibility.
Section 38a-544. - Prescription drug coverage. Mail order pharmacies. Step therapy use.
Section 38a-544a. - Prescription drug coverage. Synchronized refills.
Section 38a-549. - Coverage for adopted children.
Section 38a-550. - Copayments re in-network imaging services.
Section 38a-551. (Formerly Sec. 38-371). - Definitions.
Section 38a-552. (Formerly Sec. 38-372). - Provision of service to certain low-income individuals.
Section 38a-556a. - Connecticut Clearinghouse.
Section 38a-558. (Formerly Sec. 38-380). - Office of Health Care Access.
Section 38a-560. - Small employer grouping for health insurance coverage.
Section 38a-564. - Definitions.
Section 38a-565. - Special health care plans.
Section 38a-567. - Provisions of small employer plans and arrangements.
Section 38a-569. - Connecticut Small Employer Health Reinsurance Pool.
Section 38a-573. - Validity of separate provisions.
Section 38a-574. - Standard family health statement.
Section 38a-577. (Formerly Sec. 38-174ii). - Consumer dental health plans. Definitions.
Section 38a-578. (Formerly Sec. 38-174jj). - Certificate of authority. Application requirements.
Section 38a-580. (Formerly Sec. 38-174ll). - General surplus required.
Section 38a-584. (Formerly Sec. 38-174pp). - Complaint system.
Section 38a-588. (Formerly Sec. 38-174tt). - Penalty. Insolvency.
Section 38a-589. (Formerly Sec. 38-174uu). - Confidentiality.
Section 38a-590. (Formerly Sec. 38-174vv). - Commissioner's power to adopt regulations.
Section 38a-591. - Compliance with the Patient Protection and Affordable Care Act. Regulations.
Section 38a-591a. - Definitions.
Section 38a-591b. - Health carrier responsibilities re utilization review.
Section 38a-591c. - Utilization review criteria and procedures.
Section 38a-591g. - External reviews and expedited external reviews.
Section 38a-591h. - Record-keeping requirements. Report to commissioner upon request.
Section 38a-591i. - Regulations.
Section 38a-591k. - Violations. Notice and hearing. Penalties. Appeal.