OLR Bill Analysis

sSB 861

AN ACT CONCERNING THE MODERNIZATION OF CERTAIN MEDICAL FORMS.

SUMMARY:

This bill requires the insurance commissioner to develop, by January 1, 2014, uniform prior authorization forms for health care services. The forms must at least cover professional office visits, prescription drug benefits, imaging, and other diagnostic or laboratory testing.

Under the bill, all health care professionals must use the forms. All insurers, other health carriers, or utilization review companies that require prior authorization for health care services must accept and use them. Prior authorization is considered to have been granted if a carrier or company fails to (1) accept a fully completed form or (2) grant or deny prior authorization within 24 hours of receiving the prior authorization request.

The bill requires managed care organizations (MCOs) to get input from physicians when altering or replacing utilization review criteria. It expands access to medical protocols, including utilization review criteria, drug formularies, and lists of covered drugs.

EFFECTIVE DATE: October 1, 2013

PRIOR AUTHORIZATION FORMS

Under the bill, when developing the forms, the commissioner must seek input from health carriers, utilization review companies, health care professionals, and other stakeholders. He may develop different forms for different services as he considers necessary or appropriate.

The forms must:

1. not exceed two pages,

2. be available in paper and electronic formats,

3. be capable of being completed and submitted electronically, and

4. be consistent with existing prior authorization forms established by the federal Centers for Medicare and Medicaid Services and any national standards on electronic prior authorization procedures.

After developing the forms, the commissioner must notify health carriers of their availability. Health carriers must notify and make the forms available to (1) utilization review companies they use and (2) health care professionals they contract with to provide health care services to their insureds. Within 180 days after the commissioner provides his notice, health care professionals must use the forms, and health carriers or utilization review companies that require prior authorization for health care services must use and accept them.

A carrier or utilization review company may use a prior authorization system that uses an Internet web site, an Internet-based portal, or other electronic systems to access or submit the prior authorization form, instead of a paper form.

MEDICAL PROTOCOLS

The bill requires MCOs to treat utilization review criteria as medical protocols when making substantive changes to these criteria. By law, MCOs must obtain input from physicians actively practicing in Connecticut in relevant specialty areas before establishing new protocols or substantially modifying existing protocols. Utilization review (1) evaluates the medical necessity, appropriateness, efficacy, or efficiency of health care services, procedures, or settings or (2) monitors the use of such services, procedures, or settings.

Under current law, MCOs must make their medical protocols available to their participating providers, upon request, to examine at their principal Connecticut headquarters during regular business hours. The bill instead requires MCOs to make protocols available to their participating providers on their Internet web sites. The bill also specifies that these must be the current protocols.

UTILIZATION REVIEW CRITERIA

By law, each utilization review program must use documented clinical review criteria that are based on sound clinical evidence and are evaluated periodically. The bill specifies that these criteria must be current.

By law, carriers must make their criteria available, upon request, to authorized government agencies. The bill additionally requires them to make the criteria available electronically to health care professionals with whom they contract to provide health care services.

COMMITTEE ACTION

Insurance and Real Estate Committee

Joint Favorable Substitute

Yea

17

Nay

2

(02/26/2013)