PA 15-139—SB 417

Insurance and Real Estate Committee

AN ACT CONCERNING CONFERENCES BETWEEN HEALTH CARRIERS' CLINICAL PEERS AND HEALTH CARE PROFESSIONALS

SUMMARY: Prior law allowed health carriers (e. g. , insurers or HMOs) to offer to a covered person's health care professional a conference with the health carrier's clinical peer (see BACKGROUND) following certain initial adverse determinations (i. e. , a denial or reduction of coverage for a specific service). The act instead requires them to do so at the health care professional's request.

Under the act, health carriers must notify the health care professional of the conference opportunity when they notify the covered person or his or her authorized representative or health care professional of the adverse determination. By law, a covered person may challenge an adverse determination by filing a grievance. A conference is not considered a grievance unless a grievance has been previously filed. The notice must include this information.

The conference requirement applies only:

1. to an initial adverse determination based at least in part on medical necessity, of a concurrent or prospective utilization review, or of a benefit request and

2. when the covered person, representative, or health care professional does not file a grievance of the adverse determination before the conference.

EFFECTIVE DATE: October 1, 2015

BACKGROUND

Clinical Peer

A “clinical peer” is generally a physician or other health care professional who holds a nonrestricted license in (1) a U. S. state and (2) the same or similar specialty as someone who typically manages the medical service under review. Clinical peers reviewing adverse determinations relating to substance use or certain mental disorders must meet additional qualifications.

OLR Tracking: AR: ND: PF: cmg