CT SB00335

Redefines "clinical peer" for adverse determination and utilization reviews, requiring peers to hold a nonrestricted license in the same or similar specialty as the treating physician, a doctoral or medical degree, and either appropriate national board certification or active practice experience with the condition or procedure under review.

Establishes separate qualification standards for clinical peers reviewing child/adolescent substance use or mental health disorders (requiring national board certification in child and adolescent psychiatry or doctoral psychology degree with relevant training) and adult substance use or mental health disorders (requiring national board certification in psychiatry or doctoral psychology degree with relevant training).

Requires health carriers to notify covered persons' health care professionals of initial adverse determinations based on medical necessity and offer the opportunity to confer with a clinical peer before any grievance is filed.

Grants clinical peers authority to reverse initial adverse determinations made by health carriers, with such conferences not considered formal grievances if no grievance has been filed prior to the conference.

Effective date: January 1, 2021 for all provisions.