(a)(1) Each health carrier shall establish and maintain written procedures for (A) the review of grievances of adverse determinations that were based, in whole or in part, on medical necessity, (B) the expedited review of grievances of adverse determinations of urgent care requests, including concurrent review urgent care requests involving an admission, availability of care, continued stay or health care service for a covered person who has received emergency services but has not been discharged from a facility, and (C) notifying covered persons or covered persons' authorized representatives of such adverse determinations.
(2) Each health carrier shall file with the commissioner a copy of such procedures, including all forms used to process requests, and any subsequent material modifications to such procedures.
(3) In addition to a copy of such procedures, each health carrier shall file annually with the commissioner, in a form prescribed by the commissioner, a certificate of compliance stating that the health carrier has established and maintains grievance procedures for each of its health benefit plans that are fully compliant with the provisions of sections 38a-591a to 38a-591n, inclusive.
(b) (1) A covered person or a covered person's authorized representative may file a grievance of an adverse determination that was based, in whole or in part, on medical necessity with the health carrier not later than one hundred eighty calendar days after the covered person or the covered person's authorized representative, as applicable, receives the notice of an adverse determination.
(2) For prospective or concurrent urgent care requests, a covered person or a covered person's authorized representative may make a request for an expedited review orally or in writing.
(c) (1) (A) When conducting a review of an adverse determination under this section, the health carrier shall ensure that such review is conducted in a manner to ensure the independence and impartiality of the clinical peer or peers involved in making the review decision.
(B) If the adverse determination involves utilization review, the health carrier shall designate an appropriate clinical peer or peers to review such adverse determination. Such clinical peer or peers shall not have been involved in the initial adverse determination.
(C) The clinical peer or peers conducting a review under this section shall take into consideration all comments, documents, records and other information relevant to the covered person's benefit request that is the subject of the adverse determination under review, that are submitted by the covered person or the covered person's authorized representative, regardless of whether such information was submitted or considered in making the initial adverse determination.
(D) Prior to issuing a decision, the health carrier shall provide free of charge, by facsimile, electronic means or any other expeditious method available, to the covered person or the covered person's authorized representative, as applicable, any new or additional documents, communications, information and evidence relied upon and any new or additional scientific or clinical rationale used by the health carrier in connection with the grievance. Such documents, communications, information, evidence and rationale shall be provided sufficiently in advance of the date the health carrier is required to issue a decision to permit the covered person or the covered person's authorized representative, as applicable, a reasonable opportunity to respond prior to such date.
(2) If the review under subdivision (1) of this subsection is an expedited review, all necessary information, including the health carrier's decision, shall be transmitted between the health carrier and the covered person or the covered person's authorized representative, as applicable, by telephone, facsimile, electronic means or any other expeditious method available.
(3) If the review under subdivision (1) of this subsection is an expedited review of a grievance involving an adverse determination of a concurrent review request, pursuant to 45 CFR 147.136, as amended from time to time, the treatment shall be continued without liability to the covered person until the covered person has been notified of the review decision.
(d) (1) The health carrier shall notify the covered person and, if applicable, the covered person's authorized representative, in writing or by electronic means, of its decision within a reasonable period of time appropriate to the covered person's medical condition, but not later than:
(A) For prospective review and concurrent review requests, thirty calendar days after the health carrier receives the grievance;
(B) For retrospective review requests, sixty calendar days after the health carrier receives the grievance;
(C) For expedited review requests, except as specified under subparagraph (D) of this subdivision, forty-eight hours after the health carrier receives the grievance or seventy-two hours after such health carrier receives such grievance if any portion of such forty-eight-hour period falls on a weekend; and
(D) For expedited review requests of a health care service or course of treatment specified under subparagraph (B) or (C) of subdivision (38) of section 38a-591a, twenty-four hours after the health carrier receives the grievance.
(2) The time periods set forth in subdivision (1) of this subsection shall apply regardless of whether all of the information necessary to make a decision accompanies the filing.
(e) (1) The notice required under subsection (d) of this section shall set forth, in a manner calculated to be understood by the covered person or the covered person's authorized representative:
(A) The titles and qualifying credentials of the clinical peer or peers participating in the review process;
(B) Information sufficient to identify the claim involved with respect to the grievance, including the date of service, if applicable, the health care professional and the claim amount;
(C) A statement of such clinical peer's or peers' understanding of the covered person's grievance;
(D) The clinical peer's or peers' decision in clear terms and the health benefit plan contract basis or scientific or clinical rationale for such decision in sufficient detail for the covered person to respond further to the health carrier's position;
(E) Reference to the evidence or documentation used as the basis for the decision;
(F) For a decision that upholds the adverse determination:
(i) The specific reason or reasons for the final adverse determination, including the denial code and its corresponding meaning, as well as a description of the health carrier's standard, if any, that was used in reaching the denial;
(ii) Reference to the specific health benefit plan provisions on which the decision is based;
(iii) A statement that the covered person may receive from the health carrier, free of charge and upon request, reasonable access to and copies of, all documents, records, communications and other information and evidence not previously provided regarding the adverse determination under review;
(iv) If the final adverse determination is based on a health carrier's internal rule, guideline, protocol or other similar criterion, (I) the specific rule, guideline, protocol or other similar criterion, or (II) a statement that a specific rule, guideline, protocol or other similar criterion of the health carrier was relied upon to make the final adverse determination and that a copy of such rule, guideline, protocol or other similar criterion will be provided to the covered person free of charge upon request and instructions for requesting such copy;
(v) If the final adverse determination is based on medical necessity or an experimental or investigational treatment or similar exclusion or limit, the written statement of the scientific or clinical rationale for the final adverse determination and (I) an explanation of the scientific or clinical rationale used to make the determination that applies the terms of the health benefit plan to the covered person's medical circumstances, or (II) a statement that an explanation will be provided to the covered person free of charge upon request and instructions for requesting a copy of such explanation;
(vi) A statement describing the procedures for obtaining an external review of the final adverse determination;
(G) If applicable, the following statement: “You and your plan may have other voluntary alternative dispute resolution options such as mediation. One way to find out what may be available is to contact your state Insurance Commissioner.”; and
(H) A statement disclosing the covered person's right to contact the commissioner's office or the Office of the Healthcare Advocate at any time. Such disclosure shall include the contact information for said offices.
(2) Upon request pursuant to subparagraph (F)(iii) of subdivision (1) of this subsection, the health carrier shall provide such copies in accordance with subsection (b) of section 38a-591n.
(f) (1) Whenever a health carrier fails to strictly adhere to the requirements of this section with respect to receiving and resolving grievances involving an adverse determination, the covered person shall be deemed to have exhausted the internal grievance process of such health carrier and may file a request for an external review, regardless of whether the health carrier asserts that it substantially complied with the requirements of this section, or that any error it committed was de minimis.
(2) A covered person who has exhausted the internal grievance process of a health carrier may, in addition to filing a request for an external review, pursue any available remedies under state or federal law on the basis that the health carrier failed to provide a reasonable internal grievance process that would yield a decision on the merits of the claim.
(P.A. 11-58, S. 58; P.A. 12-102, S. 2; P.A. 13-3, S. 74; P.A. 16-213, S. 18; P.A. 19-117, S. 242.)
History: P.A. 11-58 effective July 1, 2011; P.A. 12-102 amended Subsec. (a)(3) to replace reference to Sec. 38a-591m with reference to Sec. 38a-591n, amended Subsec. (c)(1)(D) to add provision re methods by which health carrier is to provide copies and add “documents, communications, information” re materials health carrier is required to provide, amended Subsec. (e) to redesignate existing provisions as new Subdiv. (1), redesignate existing Subdivs. (1) to (8) as Subparas. (A) to (H) and make conforming changes, add “communications” and “evidence not previously provided regarding” and delete “relevant to” re adverse determination in redesignated Subdiv. (1)(F)(iii), and add new Subdiv. (2) re health carrier obligation to provide copies in accordance with Sec. 38a-591n(b); P.A. 13-3 amended Subsec. (c) by replacing “individual or individuals” with “clinical peer or peers” in Subdiv. (1)(A) and (C), adding reference to 45 CFR 147.136 in Subdiv. (3) and making same applicable to all concurrent review requests, rather than concurrent review urgent care requests, amended Subsec. (d)(1) by adding Subpara. (D) re 24-hour notification period for expedited review requests for substance use or mental disorder treatment, amended Subsec. (e)(1) by replacing references to individual or individuals with references to clinical peer or peers in Subparas. (A), (C) and (D), and made technical and conforming changes; P.A. 16-213 amended Subsec. (a)(3) by replacing “as part of its annual report required under subsection (e) of section 38a-591b” with “in a form prescribed by the commissioner”, effective July 1, 2016; P.A. 19-117 amended Subsec. (d)(1)(C) by substituting “forty-eight hours” for “seventy-two hours” and adding “or seventy-two hours after such health carrier receives such grievance if any portion of such forty-eight-hour period falls on a weekend”, effective January 1, 2020.