SB 1158 Summary

• Establishes comprehensive utilization review and grievance procedures for health carriers, including definitions of adverse determinations, medical necessity standards, and clinical peer review requirements that take effect July 1, 2011.

• Creates internal grievance processes requiring health carriers to review adverse determinations within 30-60 days for non-urgent cases and expedited reviews within 72 hours for urgent care requests, with specific notice requirements and clinical peer involvement.

• Implements independent external review process allowing covered persons to appeal final adverse determinations to the Insurance Commissioner within 120 days, with expedited reviews available for urgent medical conditions or experimental treatments.

• Requires health carriers to maintain detailed records of utilization review determinations and grievances for at least six years, file annual compliance reports with the Insurance Commissioner, and establish clear written procedures for benefit requests and determinations.

• Sets filing fee of $25 for external review requests (waivable for indigent persons) and holds health carriers responsible for paying independent review organization costs; repeals prior external appeal procedures in sections 38a-478m, 38a-478n, and 38a-478p.