PA 10-19—sHB 5303

Insurance and Real Estate Committee

AN ACT REQUIRING REPORTING OF CERTAIN HEALTH INSURANCE CLAIMS DENIAL DATA

SUMMARY: This act adds claims denial data for the prior calendar year to the information that managed care organizations (MCOs) must report to the insurance commissioner annually by May 1. (MCOs include insurers, HMOs, hospital or medical service corporations, or other organizations issuing managed care plans in Connecticut. ) By law, an MCO that fails to file data on time must pay a late fee of $100 per day for each day late (CGS 38a-478b).

The act requires the commissioner to post the claims denial information on the Insurance Department's website and include it in the Consumer Report Card on Health Insurance Carriers in Connecticut, which the department publishes annually by October 15.

The act also makes technical and conforming changes.

EFFECTIVE DATE: July 1, 2010, except the consumer report card provision is effective January 1, 2011.

CLAIMS DENIAL DATA REPORTING

The act requires MCOs to report claims denial data to the insurance commissioner annually by May 1, in a format the commissioner prescribes. The data is for the prior calendar year and must relate to Connecticut residents covered by managed care plans.

The data must include the number of (1) claims received, (2) claims denied, (3) denials that were appealed, and (4) denials that were reversed on appeal. The data must also include (1) the reasons for the denials, including “not a covered benefit,” “not medically necessary,” and “not an eligible enrollee”; (2) the number and percentage of times each reason was used; and (3) other information the commissioner deems necessary.

OLR Tracking: JLK: KM: pf: ts