CT SB00211

Establishes a rebuttable presumption that health care services ordered by a licensed health care professional are medically necessary, effective January 1, 2019.

Shifts the burden of proof to health carriers to demonstrate that a service is not medically necessary during utilization reviews and adverse determinations.

Requires clinical peers conducting adverse determination reviews to consider all comments, documents, records, and information submitted by the covered person or authorized representative, regardless of whether it was considered in the initial determination.

Mandates that health carriers provide new or additional documents, communications, information, evidence, and clinical rationale to the covered person or representative sufficiently in advance to allow reasonable opportunity for response before issuing a review decision.

Continues treatment without liability to the covered person during expedited reviews of concurrent review requests until the covered person is notified of the review decision.