(a) Each health carrier shall establish and maintain written procedures for (1) the review of grievances of adverse determinations that were not based on medical necessity, and (2) notifying covered persons or covered persons' authorized representatives of such adverse determinations.

(b) (1) A covered person or the covered person's authorized representative may file a grievance of an adverse determination that was not based on medical necessity with the health carrier not later than one hundred eighty calendar days after the covered person or the covered person's representative, as applicable, receives the notice of an adverse determination.

(2) The health carrier shall notify the covered person and, if applicable, the covered person's authorized representative not later than three business days after the health carrier receives a grievance the covered person or the covered person's authorized representative, as applicable, is entitled to submit written material to the health carrier to be considered when conducting a review of the grievance.

(3) (A) Upon receipt of a grievance, a health carrier shall designate an individual or individuals to conduct a review of the grievance.

(B) The health carrier shall not designate the same individual or individuals who denied the claim or handled the matter that is the subject of the grievance to conduct the review of the grievance.

(C) The health carrier shall provide the covered person and, if applicable, the covered person's authorized representative with the name, address and telephone number of the individual or the organizational unit designated to coordinate the review on behalf of the health carrier.

(c) (1) The health carrier shall notify the covered person and, if applicable, the covered person's authorized representative in writing, of its decision not later than twenty business days after the health carrier received the grievance.

(2) If the health carrier is unable to comply with the time period specified in subdivision (1) of this subsection due to circumstances beyond the health carrier's control, the time period may be extended by the health carrier for up to ten business days, provided on or before the twentieth business day after the health carrier received the grievance, the health carrier provides written notice to the covered person and, if applicable, the covered person's authorized representative of the extension and the reasons for the delay.

(d) (1) The written decision issued pursuant to subsection (c) of this section shall contain:

(A) The titles and qualifying credentials of the individual or individuals participating in the review process;

(B) A statement of such individual's or individuals' understanding of the covered person's grievance;

(C) The individual's or individuals' decision in clear terms and the health benefit plan contract basis for such decision in sufficient detail for the covered person to respond further to the health carrier's position;

(D) Reference to the documents, communications, information and evidence used as the basis for the decision; and

(E) For a decision that upholds the adverse determination, a statement (i) that the covered person may receive from the health carrier, free of charge and upon request, reasonable access to and copies of, all documents, communications, information and evidence regarding the adverse determination that is the subject of the final adverse determination, and (ii) disclosing the covered person's right to contact the Office of the Healthcare Advocate at any time, and that such covered person may benefit from free assistance from the Office of the Healthcare Advocate, which can assist such covered person with the filing of a grievance pursuant to 42 USC 300gg-93, as amended from time to time. Such disclosure shall include the contact information for said office.

(2) Upon request pursuant to subparagraph (E) of subdivision (1) of this subsection, the health carrier shall provide such copies in accordance with subsection (b) of section 38a-591n.

(P.A. 11-58, S. 59; P.A. 12-102, S. 3; P.A. 13-3, S. 75; 13-134, S. 23; P.A. 14-40, S. 4; P.A. 18-68, S. 20.)

History: P.A. 11-58 effective July 1, 2011; P.A. 12-102 amended Subsec. (d) to redesignate existing provisions as new Subdiv. (1), redesignate existing Subdivs. (1) to (4) as Subparas. (A) to (D), add “documents, communications, information” and delete “or documentation” re basis for decision in redesignated Subdiv. (1)(D), add Subdiv. (1)(E) re statement for decision that upholds an adverse determination, and add new Subdiv. (2) re health carrier obligation to provide copies in accordance with Sec. 38a-591n(b); P.A. 13-3 amended Subsec. (d)(1)(E) by designating existing provision re reasonable access to information as clause (i) and adding clause (ii) re disclosure of additional assistance information to be provided to a covered person with an adverse determination notice; P.A. 13-134 made a technical change in Subsec. (a); P.A. 14-40 amended Subsec. (d)(1)(E) to delete references to commissioner's office and Division of Consumer Affairs within Insurance Department, and to make a conforming change, effective May 28, 2014; P.A. 18-68 made a technical change in Subsec. (c)(2).