State Codes and Statutes
Statutes > Connecticut > Title38a > Chap700c > Sec38a-478nSec. 38a-478n. Exhaustion of internal appeal mechanisms. External appeal to commissioner. Applicability to health insurers, managed care organizations and utilization review companies. Fees. Waiver and refund of fees. Request for information. Public education outreach program. (a) Any enrollee, or any provider acting on behalf of an enrollee with the enrollee's consent, who has exhausted the internal mechanisms provided by a managed care organization, health insurer or utilization review company to appeal the denial of a claim based on medical necessity or a determination not to certify an admission, service, procedure or extension of stay, regardless of whether such determination was made before, during or after the admission, service, procedure or extension of stay, may appeal such denial or determination to the commissioner. As used in this section and section 38a-478m, "health insurer" means any entity, other than a managed care organization, which delivers, issues for delivery, renews or amends an individual or group health plan in this state, "health plan" means a plan of health insurance providing coverage of the type specified in subdivision (1), (2), (4), (10), (11), (12) and (13) of section 38a-469, but does not include a managed care plan offered by a managed care organization, and "enrollee" means a person who has contracted for or who participates in a managed care plan or health plan for himself or his eligible dependents.
(b) (1) To appeal a denial or determination pursuant to this section an enrollee or any provider acting on behalf of an enrollee shall, not later than sixty days after receiving final written notice of the denial or determination from the enrollee's managed care organization, health insurer or utilization review company, file a written request with the commissioner. The appeal shall be on forms prescribed by the commissioner and shall include the filing fee set forth in subdivision (2) of this subsection and a general release executed by the enrollee for all medical records pertinent to the appeal. The managed care organization, health insurer or utilization review company named in the appeal shall also pay to the commissioner the filing fee set forth in subdivision (2) of this subsection. If the Insurance Commissioner receives three or more appeals of denials or determinations by the same managed care organization or utilization review company with respect to the same procedural or diagnostic coding, the Insurance Commissioner may, on said commissioner's own motion, issue an order specifying how such managed care organization or utilization review company shall make determinations about such procedural or diagnostic coding.
(2) The filing fee shall be twenty-five dollars and shall be deposited in the Insurance Fund established in section 38a-52a. If the commissioner finds that an enrollee is indigent or unable to pay the fee, the commissioner shall waive the enrollee's fee. The commissioner shall refund any paid filing fee to (A) the managed care organization, health insurer or utilization review company if the appeal is not accepted for full review, or (B) the prevailing party upon completion of a full review pursuant to this section.
(3) Upon receipt of the appeal together with the executed release and appropriate fee, the commissioner shall assign the appeal for review to an entity as defined in subsection (c) of this section.
(4) Upon receipt of the request for appeal from the commissioner, the entity conducting the appeal shall conduct a preliminary review of the appeal and accept the appeal if such entity determines: (A) The individual was or is an enrollee of the managed care organization or health insurer; (B) the benefit or service that is the subject of the complaint or appeal reasonably appears to be a covered service, benefit or service under the agreement provided by contract to the enrollee; (C) the enrollee has exhausted all internal appeal mechanisms provided; (D) the enrollee has provided all information required by the commissioner to make a preliminary determination including the appeal form, a copy of the final decision of denial and a fully-executed release to obtain any necessary medical records from the managed care organization or health insurer and any other relevant provider.
(5) Upon completion of the preliminary review, the entity conducting such review shall immediately notify the member or provider, as applicable, in writing as to whether the appeal has been accepted for full review and, if not so accepted, the reasons why the appeal was not accepted for full review.
(6) If accepted for full review, the entity shall conduct such review in accordance with the regulations adopted by the commissioner, after consultation with the Commissioner of Public Health, in accordance with the provisions of chapter 54.
(c) To provide for such appeal the Insurance Commissioner, after consultation with the Commissioner of Public Health, shall engage impartial health entities to provide for medical review under the provisions of this section. Such review entities shall include (1) medical peer review organizations, (2) independent utilization review companies, provided any such organizations or companies are not related to or associated with any managed care organization or health insurer, and (3) nationally recognized health experts or institutions approved by the commissioner.
(d) (1) Not later than five business days after receiving a written request from the commissioner, enrollee or any provider acting on behalf of an enrollee with the enrollee's consent, a managed care organization or health insurer whose enrollee is the subject of an appeal shall provide to the commissioner, enrollee or any provider acting on behalf of an enrollee with the enrollee's consent, written verification of whether the enrollee's plan is fully insured, self-funded, or otherwise funded. If the plan is a fully insured plan or a self-insured governmental plan, the managed care organization or health insurer shall send: (A) Written certification to the commissioner or reviewing entity, as determined by the commissioner, that the benefit or service subject to the appeal is a covered benefit or service; (B) a copy of the entire policy or contract between the enrollee and the managed care organization or health insurer, except that with respect to a self-insured governmental plan, (i) the managed care organization or health insurer shall notify the plan sponsor, and (ii) the plan sponsor shall send, or require the managed care organization or health insurer to send, such copy; or (C) written certification that the policy or contract is accessible to the review entity electronically and clear and simple instructions on how to electronically access the policy or contract.
(2) Failure of the managed care organization or health insurer to provide information or notify the plan sponsor in accordance with subdivision (1) of this subsection within said five-business-day period shall (A) create a presumption on the review entity, solely for purposes of accepting an appeal and conducting the review pursuant to subdivision (4) of subsection (b) of this section, that the benefit or service is a covered benefit under the applicable policy or contract, except that such presumption shall not be construed as creating or authorizing benefits or services in excess of those that are provided for in the enrollee's policy or contract, and (B) entitle the commissioner to require the managed care organization or health insurer from whom the enrollee is appealing a medical necessity determination to reimburse the department for the expenses related to the appeal, including, but not limited to, expenses incurred by the review entity.
(e) The commissioner shall accept the decision of the review entity and the decision of the commissioner shall be binding.
(f) Not later than January 1, 2000, the Insurance Commissioner shall develop a comprehensive public education outreach program to educate health insurance consumers of the existence of the appeals procedure established in this section. The program shall maximize public information concerning the appeals procedure and shall include, but not be limited to: (1) The dissemination of information through mass media, interactive approaches and written materials; (2) involvement of community-based organizations in developing messages and in devising and implementing education strategies; and (3) periodic evaluations of the effectiveness of educational efforts. The Healthcare Advocate shall coordinate the outreach program and oversee the education process.
(P.A. 97-99, S. 20; June 18 Sp. Sess. P.A. 97-8, S. 60, 88; P.A. 99-284, S. 14, 60; P.A. 03-278, S. 94; P.A. 04-157, S. 1; P.A. 05-29, S. 1; 05-94, S. 3; 05-102, S. 1, 5; P.A. 06-54, S. 4; P.A. 07-75, S. 3; P.A. 08-147, S. 7.)
History: June 18 Sp. Sess. P.A. 97-8 amended Subsec. (b)(2) to require that the fee be deposited in the Insurance Fund, effective July 1, 1997; P.A. 99-284, which was added editorially by the Revisors as Subsec. (e), required the commissioner to develop a public education outreach program and required the ombudsman to coordinate the program and oversee the education process, effective July 7, 1999; P.A. 03-278 made a technical change in Subsec. (b)(2), effective July 9, 2003; P.A. 04-157 amended Subsec. (a) to include appeals for "the denial of a claim based on medical necessity" and add "regardless of whether such determination was made before, during or after the admission, service, procedure or extension of stay", amended Subsec. (b)(1) to require managed care organization or utilization review company named in the appeal to pay filing fee, amended Subsec. (b)(2) to require commissioner to refund any paid filing fee if the appeal is not accepted or upon completion of full review, inserted new Subsec. (d) re written request for information and failure to provide information or notify the plan sponsor, redesignated existing Subsecs. (d) and (e) as new Subsecs. (e) and (f), respectively, and made conforming and technical changes; P.A. 05-29 amended Subsec. (d)(1)(C)to add "or contract"; P.A. 05-94 amended Subsec. (a) to define "health insurer", "health plan" and "enrollee", referenced health insurers throughout, and amended Subsec. (d) to change "managed care plan" to "plan", reference "or contract" and delete references to "self-insured governmental plan" and notice to and from "plan sponsor", effective July 1, 2005; P.A. 05-102 amended Subsec. (b)(1) by authorizing commissioner to issue order with respect to multiple appeals of same procedural or diagnostic coding and amended Subsec. (f) by renaming the Managed Care Ombudsman the Healthcare Advocate; P.A. 06-54 amended Subsec. (d)(1) to require managed care organization or health insurer to send commissioner written certifications and a copy of entire policy or contract between enrollee and such organization or insurer if plan is a self-insured governmental plan, but with respect to sending such copy, organization or insurer shall notify plan sponsor who shall send or require such organization or insurer to send such copy, and amended Subsec. (d)(2) to provide that failure of managed care organization or health insurer to notify plan sponsor within five-business-day period or before thirty-day appeal period ends, whichever is later as determined by commissioner, shall have consequences specified in Subparas. (A) and (B) of said Subdiv., effective May 8, 2006; P.A. 07-75 amended Subsecs. (b)(1) and (d)(2) to extend the time to file an appeal with commissioner from 30 to 60 days, effective May 30, 2007; P.A. 08-147 amended Subsec. (d)(2) by deleting provision re 60-day period for insurers to provide information or notify plan sponsor of evidence of coverage.
