Managed Care

For assistance on specific managed care problems we recommend contacting the Office of Managed Care Ombudsman, State of Connecticut, P.O. Box 1543, Hartford, CT 06144-1543. You may call the Ombudsman Toll Free at (866) HMO-4446 or in the Hartford phone exchange at (860) 297-3956. You may also email the Ombudsman atmanagedcare.ombudsman@po.state.ct.us

The laws listed here, and the Ombudsman Office is the product of successful legislative lobbying by health reform advocates,of which NASW/CT has played a major role.

The information below is in two sections. The first deals with utilization review organizations and the second with managed care organizations.

UTILIZATION REVIEW LAW

A utilization review company must meet the following requirements:

Certification:

• ·        Must provide notification of any prospective determination by mail or otherwise communicate to the provider of record or the enrollee of receipt of all information to complete the review, within two business days.
• ·        Must provide an authorization number if the determination is approved.
• ·        If a prospective determination has been authorized and communicated a retrospective denial may not be made when an admission, service, procedure or extension of stay has already taken place.
• ·        Any determination to not certify an admission, service, procedure or extension of stay must be made in writing.
• ·        In the case of emergency service, admission or procedure the enrollee or their representative must have at least 24 hours to notify the utilization review company and to request certification or continuance of treatment for that condition.

Denials of Certification:

• ·        Where certification is denied such decision must be in writing, stating the reason(s) for denial and the process for initiating an appeal or the name and phone number of the person to call regarding an appeal.
• ·        Denials can be made where the provider of record fails to provide all relevant information to make a determination on a request to certify care.

Appeals:

• ·        Notification of decision must be sent in writing to the enrollee and provider of record as soon as practical, but no later than 30 days after receiving the required documentation to make a decision.
• ·        A licensed practitioner of the medical arts must make all decisions denying an appeal.
• ·        When the reason for denying an appeal is based on medical necessity, including cases where the treatment is deemed experimental or investigational, the case is to be reviewed by a physician who is a specialist in the field related to the medical condition. The review must be completed within 30 days of the request for a review.

Expedited Review:

• ·        In the case of emergency or life threatening circumstances an expedited appeal of denial must be completed within two business days of the date of the appeal being filed with all necessary information to complete the appeal. Each utilization company will have staff available from 8:00 a.m. to 9:00 p.m. to process such requests.

FURTHER STATUTES GOVERNING MANAGED CARE ORGANIZATIONS

Decision on Care:

• ·        Managed Care Organizations (MCO) must notify the insured or the insured’s provider of its decision on a request for service no later than 45 days after receipt of the request. If the decision is to deny coverage the reason(s) must be in writing along with how to file an appeal.

Appeals:

• ·        MCO’s must have an internal appeals process that enrollees must be made aware of when the MCO does not certify an admission, service, or extension of stay. Such appeals may be made orally, electronically, or in writingand all appeals must be completed within 60 days unless the enrollee requests an extension. When requesting an appeal it is important to specifically state you are asking for an “appeal”.
• ·        The MCO shall make available, upon request of a participating provider, a copy of the relevant medical protocol to the participating provider, along with an explanation of the denial at the time the denial is made.
• ·        Any enrollee or provider acting on behalf of the enrollee may request an external appeal to the State’s Insurance Commissioner if all internal appeals have been exhausted. There is a fee of $25.00, which may be waived for low-income person’s. The Insurance Commissioner will assign the review to an external organization and the external review decision is binding on all parties.
• ·        Any person who has been diagnosed with a condition that creates a life expectancy in that person of less than two years and who has been denied an otherwise covered procedure, treatment or drug on the grounds that is experimental may request an expedited appeal based on the medical efficacy of such procedure, treatment or drug.

Experimental Coverage:

• Insurance policies must define the extent to which coverage is provided for experimental treatment and cannot deny coverage of treatments that have successfully completed a phase III clinical trial of the Federal Food and Drug Administration.

Timely Payments:

• MCO’s must make timely payments to providers, which shall be no later than 45 days after receipt of a completed request for payment. If a deficiency exists in the request for payment the insurer has 30 days to notify the provider in writing of all missing information or other deficiencies and than has 30 days for payment once the claim is received with correction of deficiencies. Insurers may not return the claim to the provider for a second time seeking information not requested by the insurer in its first request.

Drug Formulary:

• Patient’s using a drug on an outpatient basis cannot be denied coverage for any drug that the insurer removes from the covered list, or otherwise ceases to provide coverage for, if the person was covered and using the drug for treatment of a chronic illness prior to its removal and the person’s attending health care provider states in writing that the drug is medically necessary and lists the reasons why it is more medically beneficial than drugs on the covered list.

Provider Profiles:

• MCO’s, in developing provider profiles or otherwise measuring health care provider performance, shall: 1.) make allowances for severity of illness or condition of the patient mix; 2.) make allowances for patients with multiple illnesses or conditions; 3.) make available to the Insurance Commissioner documentation of how the MCO makes such allowances; and 4.) inform enrollees and participating providers, upon request, how the managed care organization considers patient mix when profiling or evaluating providers.

Contract Termination:

• Each MCO that has contracts with participating providers must give said provider’s at least 60 days advance written notice of plans to withdraw or terminate such contract. Participating provider’s must also give at least 60 days advance notice of plans to withdraw or terminate from the provider contract. This does not apply in cases where the health and safety of enrollees are at risk or when a provider has entered into a contract based on fraud, misrepresentation, or if the provider has engaged in fraudulent activity.

Open Communication With Patients

• MCO’s cannot prohibit a provider from discussing with an enrollee any treatment options and services available in or out of network, including experimental treatments.
• MCO’s cannot prohibit a provider from disclosing, to an enrollee who inquires, the method the MCO uses to compensate the provider.

This information has been posted in July 2002. Statutes are subject to change.