State Codes and Statutes
Statutes > Connecticut > Title38a > Chap698a > Sec38a-226cSec. 38a-226c. Utilization review company minimum standards: Determinations, notification, appeals and expedited review. Reports to commissioner. Penalties. Regulations. (a) All utilization review companies shall meet the following minimum standards:
(1) Each utilization review company shall maintain and make available procedures for providing notification of its determinations regarding certification in accordance with the following:
(A) Notification of any prospective determination by the utilization review company shall be mailed or otherwise communicated to the provider of record or the enrollee or other appropriate individual within two business days of the receipt of all information necessary to complete the review, provided any determination not to certify an admission, service, procedure or extension of stay shall be in writing. After a prospective determination that authorizes an admission, service, procedure or extension of stay has been communicated to the appropriate individual, based on accurate information from the provider, the utilization review company may not reverse such determination if such admission, service, procedure or extension of stay has taken place in reliance on such determination.
(B) Notification of a concurrent determination shall be mailed or otherwise communicated to the provider of record within two business days of receipt of all information necessary to complete the review or, provided all information necessary to perform the review has been received, prior to the end of the current certified period and provided any determination not to certify an admission, service, procedure or extension of stay shall be in writing.
(C) The utilization review company shall not make a determination not to certify based on incomplete information unless it has clearly indicated, in writing, to the provider of record or the enrollee all the information that is needed to make such determination.
(D) Notwithstanding subparagraphs (A) to (C), inclusive, of this subdivision, the utilization review company may give authorization orally, electronically or communicated other than in writing. If the determination is an approval for a request, the company shall provide a confirmation number corresponding to the authorization.
(E) Except as provided in subparagraph (F) of this subdivision with respect to a final notice, each notice of a determination not to certify an admission, service, procedure or extension of stay shall include in writing (i) the principal reasons for the determination, (ii) the procedures to initiate an appeal of the determination or the name and telephone number of the person to contact with regard to an appeal pursuant to the provisions of this section, and (iii) the procedure to appeal to the commissioner pursuant to section 38a-478n.
(F) Each notice of a final determination not to certify an admission, service, procedure or extension of stay shall include in writing (i) the principal reasons for the determination, (ii) a statement that all internal appeal mechanisms have been exhausted, and (iii) a copy of the application and procedures prescribed by the commissioner for filing an appeal to the commissioner pursuant to section 38a-478n.
(2) Each utilization review company shall maintain and make available a written description of the appeal procedure by which either the enrollee or the provider of record may seek review of determinations not to certify an admission, service, procedure or extension of stay. The procedures for appeals shall include the following:
(A) Each utilization review company shall notify in writing the enrollee and provider of record of its determination on the appeal as soon as practical, but in no case later than thirty days after receiving the required documentation on the appeal.
(B) On appeal, all determinations not to certify an admission, service, procedure or extension of stay shall be made by a licensed practitioner of the healing arts.
(3) The process established by each utilization review company may include a reasonable period within which an appeal must be filed to be considered.
(4) Each utilization review company shall also provide for an expedited appeals process for emergency or life threatening situations. Each utilization review company shall complete the adjudication of such expedited appeals within two business days of the date the appeal is filed and all information necessary to complete the appeal is received by the utilization review company.
(5) Each utilization review company shall utilize written clinical criteria and review procedures which are established and periodically evaluated and updated with appropriate involvement from practitioners.
(6) Physicians, nurses and other licensed health professionals making utilization review decisions shall have current licenses from a state licensing agency in the United States or appropriate certification from a recognized accreditation agency in the United States, provided, any final determination not to certify an admission, service, procedure or extension of stay for an enrollee within this state, except for a claim brought pursuant to chapter 568, shall be made by a physician, nurse or other licensed health professional under the authority of a physician, nurse or other licensed health professional who has a current Connecticut license from the Department of Public Health.
(7) In cases where an appeal to reverse a determination not to certify is unsuccessful, each utilization review company shall assure that a practitioner in a specialty related to the condition is reasonably available to review the case. When the reason for the determination not to certify is based on medical necessity, including whether a treatment is experimental or investigational, each utilization review company shall have the case reviewed by a physician who is a specialist in the field related to the condition that is the subject of the appeal. Any such review, except for a claim brought pursuant to chapter 568, that upholds a final determination not to certify in the case of an enrollee within this state shall be conducted by such practitioner or physician under the authority of a practitioner or physician who has a current Connecticut license from the Department of Public Health. The review shall be completed within thirty days of the request for review. The utilization review company shall be financially responsible for the review and shall maintain, for the commissioner's verification, documentation of the review, including the name of the reviewing physician.
(8) Except as provided in subsection (e) of this section, each utilization review company shall make review staff available by toll-free telephone, at least forty hours per week during normal business hours.
(9) Each utilization review company shall comply with all applicable federal and state laws to protect the confidentiality of individual medical records. Summary and aggregate data shall not be considered confidential if it does not provide sufficient information to allow identification of individual patients.
(10) Each utilization review company shall allow a minimum of twenty-four hours following an emergency admission, service or procedure for an enrollee or his representative to notify the utilization review company and request certification or continuing treatment for that condition.
(11) No utilization review company may give an employee any financial incentive based on the number of denials of certification such employee makes.
(12) Each utilization review company shall annually file with the commissioner:
(A) The names of all managed care organizations, as defined in section 38a-478, that the utilization review company services in Connecticut;
(B) Any utilization review services for which the utilization review company has contracted out for services and the name of such company providing the services;
(C) The number of utilization review determinations not to certify an admission, service, procedure or extension of stay and the outcome of such determination upon appeal within the utilization review company. Determinations related to mental or nervous conditions, as defined in section 38a-514, shall be reported separately from all other determinations reported under this subdivision; and
(D) The following information relative to requests for utilization review of mental health services for enrollees of fully insured health benefit plans or self-insured or self-funded employee health benefit plans, separately and by category: (i) The reason for the request, including, but not limited to, an inpatient admission, service, procedure or extension of inpatient stay or an outpatient treatment, (ii) the number of requests denied by type of request, and (iii) whether the request was denied or partially denied.
(13) Any utilization review decision to initially deny services shall be made by a licensed health professional.
(b) Unless there is a contrary written agreement between the utilization review company and the hospital, all hospitals in this state shall permit each licensed utilization review company to conduct reviews on the premises. Each utilization review company shall conduct its telephone, on-site information gathering reviews and hospital communications during the hospitals' and practitioners' reasonable and normal business hours, unless other arrangements are mutually agreed upon. Each utilization review company's staff shall identify themselves by name and by the name of their organization and, for on-site reviews, shall carry photographic identification and the utilization review company's company identification card.
(c) The provider of record shall provide to each utilization review company, within a reasonable period of time, all relevant information necessary for the utilization review company to certify the admission, procedure, treatment or length of stay. Failure of the provider to provide such documentation for review shall be grounds for a denial of certification in accordance with the policy of the utilization review company or the health benefit plan.
(d) No provider, enrollee or agent thereof may provide to any utilization review company information which is fraudulent or misleading. If fraudulent or misleading statements have occurred, the commissioner shall provide notice of the alleged violation and opportunity to request a hearing in accordance with chapter 54 to said provider, enrollee or agent thereof. If a hearing is not requested or if after a hearing the commissioner finds that a violation has in fact occurred, the commissioner may impose a civil penalty (1) of not more than seven thousand five hundred dollars, or (2) commensurate with the value of services provided which were certified as a result of said fraudulent or misleading information. In addition, any allegation or denial made without reasonable cause and found untrue shall subject the party pleading the same to the payment of such reasonable expenses as may be necessary to compensate the department for expenses incurred due to such untrue pleading. All such payments to the department shall be dedicated exclusively to the regulation of utilization review.
(e) On or after November 1, 1997, if an enrollee has been admitted to an acute care hospital and the attending physician determines that the enrollee's life will be endangered or other serious injury or illness could occur if the patient is discharged or if treatment is delayed, the attending physician may transmit, pursuant to the standardized process developed pursuant to section 38a-478p, a request for an expedited review to the utilization review company. If such attending physician receives no response, in the standardized process developed pursuant to section 38a-478p, from the utilization review company after three hours have passed since the provider sent the request and all information needed to complete the review, the request shall be deemed approved. Each utilization review company shall make review staff available from 8:00 a.m. to 9:00 p.m. to process requests pursuant to this subsection.
(f) The Insurance Commissioner, after consultation with the Commissioner of Public Health, shall adopt regulations, in accordance with chapter 54, as he deems necessary to clarify or supplement the standards set forth in this section. The regulations shall include standards, which may be based on the national standards of the American Accreditation Health Care Commission, concerning the confidentiality of patient medical records.
(P.A. 91-305, S. 4; P.A. 97-99, S. 18; P.A. 01-124, S. 3; 01-139, S. 7; 01-174, S. 5; 01-195, S. 179, 181; P.A. 05-94, S. 1; P.A. 06-54, S. 3; 06-188, S. 33; P.A. 08-178, S. 9.)
History: (Revisor's note: In 1997 a reference in Subdiv. (15) to "Health Commissioner" was replaced editorially by the Revisors with "Commissioner of Public Health" for consistency with customary statutory usage and the provisions of P.A. 95-257); P.A. 97-99 designated existing provisions as Subsecs. (a), (c), (d) and (f) and amended Subsec. (a) by requiring determinations to be in writing and putting restrictions on reversals in Subdiv. (1)(A), requiring determinations to be in writing in Subdiv. (1)(B), adding new Subdiv. (1)(C) and (D) and redesignating former Subpara. (C) as (E), adding notice-to-appeal requirement to Subdiv. (1)(E), requiring specialist review in Subdiv. (7), adding exception in Subdiv. (8), deleting former Subdiv. (9) and redesignating former Subdivs. (10) and(11) as Subdivs. (9) and (10) and adding new Subdivs. (11), (12) and (13), added new Subsec. (b) re on-site and telephone reviews, deleted former Subdiv. (14), added new Subsec. (e) re expedited review process, added provision in Subsec. (f) requiring regulations re confidentiality of medical records and made technical changes; P.A. 01-124 and P.A. 01-139 both amended Subsec. (a)(12) by adding identical provisions re reporting of determinations related to mental or nervous conditions; P.A. 01-174 amended Subsec. (a)(6) to substitute "physicians" for "practitioners" and amended Subsec. (a)(6) and (7) to add provisions re final determinations not to certify enrollee care; P.A. 01-195 amended Subsec. (a)(6) and (7) to exempt claims brought pursuant to Ch. 568, effective July 11, 2001; P.A. 05-94 amended Subsec. (a)(1)(E) and added Subsec. (a)(1)(F) re notice of final determination, effective July 1, 2005; P.A. 06-54 amended Subsec. (a)(2)(B) to substitute "healing" arts for "medical" arts; P.A. 06-188 amended Subsec. (a)(12) by making technical changes and adding Subpara. (D) re reporting requirement re requests for utilization review of mental health services; P.A. 08-178 increased maximum penalty from $5,000 to $7,500 in Subsec. (d)(1).
See Sec. 38a-478p re standardized form for expedited review.
