CT SB00372

Health carriers must use documented clinical review criteria based on sound clinical evidence for utilization review programs, which shall be periodically evaluated for effectiveness.

Health carriers may develop their own clinical review criteria or purchase criteria from qualified vendors approved by the commissioner, and must post all criteria on their website and make them available to government agencies upon request.

For substance use disorder treatment, health carriers must use the American Society of Addiction Medicine Treatment Criteria or criteria consistent with it, with allowance for developing additional criteria for new technologies or care types not covered in the ASAM criteria.

For child/adolescent and adult mental disorder treatment, health carriers must use guidelines from the American Academy of Child and Adolescent Psychiatry or American Psychiatric Association respectively, or criteria consistent with those guidelines, with similar allowances for advancements in technology or care.

Adverse determination notices must include the specific rule, guideline, protocol, or criterion relied upon (or a statement that a copy will be provided free upon request), along with links to the criteria on the health carrier's website and, when applicable, links to comparison documents for substance use disorder and mental disorder treatment criteria.