Process and Time line Requirements for Revised Internal and External Review Processes

Connecticut State Seal STATE OF CONNECTICUT INSURANCE DEPARTMENT BULLETIN HC-83 MAY 20, 201] TO: ALL INSURANCE COMPANIES, FRATERNAL BENEFIT SOCIETIES, HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE CORPORATIONS AND HEALTH CARE CENTERS THAT DELNER OR ISSUE INDNIDUAL AND GROUP HEALTH INSURANCE POLICIES IN CONNECTICUT SUBJECT: PROCESS AND TThlIELTI\JE REQUIREMENTS FOR REVISED INTERNAL AND EXTERNAL REVIEW PROCESSES The Patient Protection and Affordable Care Act, Pub.L.111-48, as amended by the Health Care and Education Reconciliation Act of 20 I0, Pub.L.111-152 (collectively "PPACA") requires that a health insurance issuer offering group or individual health insurance coverage comply with the applicable state process that at a minimum includes the consumer protections set forth in the Uniform External Review Model Act promulgated by the National Association of Insurance Commissioners (NAIC) and is binding on such plans. The Connecticut Insurance Department is seeking legislative changes to bring the state internal and external review process into compliance with the requirements set forth in PPACA. The proposed legislation also modifies the requirements for internal appeals and utilization review to conform to PPACA requirements that health insurance issuers must follow. This bulletin provides information on the new notification requirements for health insurance carriers and other entities listed above in relation to internal benefit determinations and internal claims appeal processes under the proposed legislation. This high level information is being offered in recognition ofthe operational changes that will be needed to comply with the July I, 2011 enforcement date. A chait titled "Health CaITier Notification Time Tables - July 2011" is attached detailing these timeframes. The Department offers further guidance on the proposed changes to the External Review process including new responsibilities for health insurance carriers under this revised workflow. A chart titled "State of Connecticut­ External Review - July 2011" is attached that provides details on timeframes and workflow processes. In the event that the proposed legislation is not enacted, carriers will still be required to comply with the federal requirements for internal and external appeals processes as outlined in these charts. Both charts have been reviewed by the US Department of Health and Human Services and have been approved for content. In addition, insurers should be aware that consistent with the NAIC Model, payment for external reviews will be the direct responsibility ofthe carriers effective July 1,20 II. For guidance on form filings related to these changes, please refer to Department Bulletin HC-82 dated May 11, 2011. You may also contact the Insurance Department External Review Department at cid.ea(a)ct.frov with questions regarding the revised External Review processes. Insurance Commissioner's signature Thomas B. Leonardi Insurance Commissioner www.ct.gov/cid P.O. Box 816 • Hartford, CT 06142-0816 An Equal Opportunity Employer State of Connecticut - External Review July 2011 El' 'bTt I tty D t Igl e ermlllatlOlls . , Filing Deadline Standard Review: 120 Days Expedited: 120 Days after any adverse determination Determination By: Notification of Ineligibility to Covered Person By: Health Carrier Health Cainer Contract Ineligible (Dental, vision, self-insured non-governmental plans, out-of-state, Worker's Compensation, MedicarelMedicaid) Commissioner Commissioner • Coverage is Not In Force • Not a Covered Benefit • Has not exhausted internal grievance process • Missing information or required forms • Not a medical necessity denial (rescissions and eliRibility issues allowed) Health Carrier Health Carrier Process Workflow Task Completed By: Standard Review Expedited Review Notification to Covered Person By: External Review Received Commissioner (1) Business Day (1) Day Send to health carrier Preliminary Review Health Carrier (5) Business Days + (1) Business Day to Notify of Results (1) Day Health Carrier Request is eligible and complete. -or- Notifies that appeal is incomplete or ineligible. if ineligible, covered person may appeal to Commissione.r· Individual is a covered person, health care service is a covered service, Internal Appeals have been exhausted or it is expedited, all required forms and releases have been signed. Accepted for Full Review Commissioner (1) Business Day (1) Day Commissioner Assign lRO & notify covered person of right to submit new information. Documents to lRO Health Carrier (5) Business Days (1) Day DocumentslInfo considered in making an adverse determination sent to IRQ. Full Review Process lRO (45) Days or (20) Days (Experimental) (72) Hours or (5) Days (Experimental) lRO CT Insurance Department May 20, 20ll Health Carrier Notification Time Tables - July 2011 Initial Initial Determination Missing Information Failure to Grievance Appeal Grievance Appeal Notices Determination Extension* . - Meet Filing Procedures Determination , , Medical Necessity Reviews ~ Prospective 15 Days 15 Days* Notification prior to the end of the initial benefit determination period. - Notification prior to the end of the initial benefit determination period. - Must allow 45 days for receipt of missing information. 5 Days 30 Days All Notices of Adverse Determination: Notification of right to submit written material to be considered by ~ Concurrent 15 Days None - Notification prior to the end of the initial benefit determination 5 Days 30 Days health carrier dUring grievance. period. Right to receive free of charge . Must allow 45 days for receipt access to documents related to of missinQ information. request for benefits. ~ Retrospective 30 Days 15 Days* - Notification prior to the end of the initial benefit determination 5 Days 60 Days Grievance procedures for standard Notification prior to the end of the initial benefit determination period. period. - Must allow 45 days for receipt of missing information. and expedited grievance. Right to contact the Connecticut Insurance Department and the ~ Expedited Urgent 72 Hours None 24 Hours 24 Hours 72 Hours Office of the Healthcare Advocate. Care Plan years 1-1-12 and after Must allow 48 hours for receipt of missing infonmation. .................................... Full compliance requirements provided in US DOL Technical Release 2011-01 dated 3-18-11 Non-Medical Necessity Reviews 30 Days 15 Days* Notification prior to the end of the initial benefit determination period. 20 Business Days + Extension* of 10 Business Days 3 Business Days Notification of right to submit written material to be considered by health carrier. *Extension only allowed due to circumstances beyond the health carrier's control and with prior notification. CT Insurance Department May 20, 2011