AN ACT CONCERNING CLINICAL REVIEW CRITERIA FOR UTILIZATION REVIEW AND ADVERSE DETERMINATION NOTICES

AN ACT CONCERNING CLINICAL REVIEW CRITERIA FOR UTILIZATION REVIEW AND ADVERSE DETERMINATION NOTICES

SUMMARY: This act allows insurers, HMOs, and other types of health carriers to develop, purchase, or license clinical review criteria that address technological or treatment advances for substance use, child or adolescent mental, or adult mental disorders not covered in the most recent edition of the professional medical society publications for these disorders (see BACKGROUND). Under prior law, carriers could not use such criteria until after they were included in these publications. (Carriers use clinical review criteria to determine the appropriate covered care for these and other disorders. )

Under prior law, health carriers had to post on their websites certain information about the clinical review criteria they used for the disorders listed above. The act (1) requires health carriers to post information about the clinical review criteria they use for all disorders and (2) changes the information that must be posted.

The act allows health carriers to develop, purchase, or license clinical review criteria for substance use, child or adolescent mental, or adult mental disorders that address advancements in technology or the type of care for treating these disorders not covered in the most recent edition of the professional medical society publications for these disorders. Prior law required health carriers, for these disorders, to either adopt the criteria published in, or develop criteria demonstrably consistent with, specified professional medical society publications. Because of this requirement, health carriers could not, under prior law, update their criteria to address advances in technology or treatment until the respective societies updated their publications.

Under the act, any criteria developed, purchased, or licensed to treat these disorders must be based on sound clinical evidence and evaluated periodically. These standards already apply to the clinical review criteria existing law allows carriers to develop, purchase, or license for other disorders.

Instead of developing, purchasing, or licensing review criteria, health carriers may still choose to adopt criteria in, or demonstrably consistent with, the medical societies' publications. If they choose the latter, the act specifies they must demonstrate the criteria's consistency to the insurance commissioner.

The act requires health carriers to post on their websites any clinical review criteria they use and links to any rule, guidelines, protocol, or other similar criteria they rely on to make an adverse determination decision.

Prior law required internet posting for clinical review criteria that addressed the specific mental health disorders. It required health carriers to maintain, in an easily accessible location on their websites, a document that (1) compared their clinical review criteria for substance use, child or adolescent mental, or adult mental disorders with the respective medical society's published review criteria and (2) provided citations to peer-reviewed medical literature generally recognized by the relevant medical community or professional society guidelines that justify any difference between the two review criteria. As under existing law, health carriers must still make clinical review criteria available upon request to authorized government agencies.

Notwithstanding the exception created by the act, the law generally requires health carriers to adopt the criteria published in, or develop criteria demonstrably consistent with, the following publications:

1. American Society of Addiction Medicine Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, for substance use disorders;

2. American Academy of Child and Adolescent Psychiatry's Child and Adolescent Service Intensity Instrument guidelines, for child or adolescent mental disorders; or

3. American Psychiatric Association guidelines or the Standards and Guidelines of the Association for Ambulatory Behavioral Healthcare, for adult mental disorders.