Qualified Vendors For Utilization Review Of Behavioral Health (This bulletin repeals and replaces bulletin HC-93 )

STATE OF CONNECTICUT INSURANCE DEPARTMENT BULLETIN NUMBER HC-I 05 SEPTEMBER 23, 2015 TO: ALL INSURANCE COMPANIES, FRATERNAL BENEFIT SOCIETIES, HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE CORPORATIONS AND HEALTH CARE CENTERS THAT ARE LICENSED IN CONNECTICUT TO WRITE HEALTH INSURANCE; ALL UTILIZATION REVIEW ENTITIES LICENSED IN CONNECTICUT SUBJECT: QUALIFIED VENDORS FOR UTILIZATION REVIEW OF BEHA VIORAL HEALTH This Bulletin repeals and replaces Bulletin HC-93 dated September 3, 2013. Connecticut General Statutes §38a-59Ic requires that each utilization review program use documented clinical review criteria that are based on sound clinical evidence and are evaluated periodically by the health carrier to assure its program's ongoing effectiveness. A health carrier may develop its own clinical review criteria or it may purchase or license clinical review criteria from qualified vendors approved by the Insurance Commissioner. The purpose of this bulletin is to provide guidance relating to how a vendor will be deemed qualified by the Commissioner. Vendor Qualification Requirements To be considered a qualified vendor of behavioral health clinical review criteria pursuant to Conn. Gen. Stat. §38a-591c, the company must certify to the Commissioner that they meet the following minimum requirements: 1. The vendor must have a process in place to develop criteria based on the following requirements: • The guidelines and clinical criteria are clearly defined. • Target users and how they will use guidelines are clearly defined. • Strengths and limitations of the body of evidence used have been identified and disclosed to users. • Systematic methods were used to search for evidence. • Health benefits, side effects and risks were considered in formulating the guidelines. • There is an explicit link between the guideline and the supporting criteria. • Independent and appropriate clinical staff was involved in the development process. • The development group includes experts from all relevant professional groups. www.ct.gov/cid P.O. Box 816 • Hartford. CT06142-0816 An Equal Opportunity Employer • Proposed criteria is reviewed and tested by independent experts and the process requires that a consensus be reached. • Discussions of guidelines are documented and conflicting or competing interests are recorded and addressed. • Guidelines are reviewed and updated at a minimum annually. • The funding body should not have undue influence over the content of the guidelines. 2. Current criteria guidelines must meet the following requirements: • The overall objectives of the guidelines are specifically described. • The health questions covered by the guidelines are specifically described. • The population to whom the guideline applies is specifically described. • The criteria are specific and unambiguous. • All options for management of a condition or health issue are clearl y presented. • The guidelines provide advice or tools on how the recommendations can be put into practice. • The guidelines describe any facilitators and barriers to the application of the specific guidelines. • Any potential resource implications of applying the recommendation are noted and considered in the guidelines. • The guidelines are based on independently monitored and audited criteria. • The criteria span all aspects of the continuum of care from acute to residential and community setting. • The criteria incorporate a safety risk assessment. • The criteria address dual diagnosis, co-morbidity or non-specific diagnosis as appropriate. • For treatment of a substance use disorder, as described in section 17a-458, the clinical review criteria used shall be: (i) The most recent edition of the American Society of Addiction Medicine's Patient Placement Criteria; or (ii) clinical review criteria demonstrated to be consistent with the most recent edition of the American Society of Addiction Medicine's Patient Placement Criteria. • For treatment of a child or adolescent mental disorder, the clinical review criteria used shall be: (i) The most recent guidelines of the American Academy of Child and Adolescent Psychiatry's Child and Adolescent Service Intensity Instrument; or (ii) clinical review criteria demonstrated to be consistent with the most recent guidelines of the American Academy of Child and Adolescent Psychiatry's Child and Adolescent Service Intensity Instrument. • For treatment of an adult mental disorder, the clinical review criteria used shall be: (i) The most recent guidelines of the American Psychiatric Association or the most recent Standards and Guidelines of the Association for Ambulatory Behavioral Healthcare; or (ii) clinical review criteria demonstrated to be consistent with the most recent guidelines of the American Psychiatric Association or the most recent Standards and Guidelines of the Association for Ambulatory Behavioral Healthcare. 3. The applicant agrees to cooperate with companies using the applicant's criteria and assist them in developing links to criterion that must be provided in the case of an adverse determination in accordance with Conn. Gen. Stat. §38a-591d(e)(1)(F). 4. The applicant agrees to provide a copy of the company's clinical review criteria upon request by the Commissioner. The Insurance Department will consider the clinical review criteria to be a confidential trade secret and exempt from the Connecticut Freedom of Information Act. Any submission must be marked as Confidential and Proprietary and exempt from disclosure pursuant to Conn. Gen. Stat. §1-21O(b)(5)(A). Filing Requirements The applicant shall submit the application and certification that are available on the Insurance Department website under the FORMS tab. The certification that all vendor qualifications are met must be signed by an officer of the company. Any qualified statements should be noted if a specific requirement cannot be met. If approved, the Commissioner will post on the Department website that the vendor is qualified for a period of one year. Companies will need to reapply annually to maintain qualified status. Questions Please contact the Insurance Department Life and Health Division at cid.lh uv.ct.gov with any ques IOns. tharine L. Wade Insurance Commissioner