Connecticut reviews eligibility denials, not just medical ones

The clinical judgement has to be a peer's

Connecticut requires each health carrier to contract with health care professionals to administer its utilization review programme, and with clinical peers to evaluate the clinical appropriateness of an adverse determination. The judgement behind a denial is to be a peer's rather than an administrator's.

What Connecticut will review

The eligible grounds are wider than the usual medical-necessity-only framing, which matters when the denial has nothing to do with clinical judgement:

• Medical-necessity determinations.
• Continued treatment stays.
• Experimental or investigational denials.
• Eligibility determinations — whether the person was covered at all.
• Rescission of coverage.

120 days, in writing, with $25

The request must be submitted within 120 days of the written notification that internal appeals have been exhausted. It goes in writing to the insurance commissioner, and it must include a copy of the health plan's final denial letter. Connecticut charges a $25 filing fee, waived where the covered person is indigent or unable to pay — so the fee is a formality to handle, not a barrier to plan around.

One business day to assign the reviewer

Connecticut moves quickly at the front. Within one business day after the commissioner receives a complete request, an independent review organization is assigned from the approved list and the health carrier is notified of the assignment. The organizations are under contract with the Department and have no affiliation with the insurer, and each must assign a clinical reviewer licensed in the same or a similar specialty to the one that typically manages the condition under review.

How to file

1. 1

   Exhaust the plan's internal appeals

   The 120 days run from the written notice that the internal appeals are finished.

2. 2

   Complete the External Review Application

   The Insurance Department publishes the form; the request must be in writing to the commissioner.

3. 3

   Attach the final denial letter

   A copy of the plan's final denial is required with the application.

4. 4

   Send it to the Department with the fee

   Connecticut Insurance Department, P.O. Box 816, Hartford, CT, with the $25 fee unless you are indigent or unable to pay.

Free help from the state's own advocate

Connecticut funds an Office of the Healthcare Advocate separate from the Insurance Department, whose job is to help residents with denied claims and appeals. Where the obstacle is the paperwork rather than the medicine, that office exists precisely for it, and using it costs nothing.

Prior authorization: a day to answer, and two hard limits

Connecticut moves fast on the front end too, and it has written two substantive limits into the step-therapy rules rather than leaving them to negotiation:

• A carrier must determine a prior-authorization request and notify you within 24 hours — and if it needs more information, it has to ask for that within 24 hours as well.
• A request counts as urgent where delay could seriously jeopardise life, health or the ability to regain maximum function, or subject the patient to severe pain.
• Requests for substance-use-disorder or mental-health treatment requiring a higher level of care are treated as urgent automatically, without argument.
• Step therapy for a prescribed drug is limited to no longer than 60 days.
• Step therapy is prohibited outright for stage IV metastatic cancer drugs.
• Insurers must establish an override process and disclose it to providers.

For Connecticut practices

The broader grounds are the practical takeaway. A denial recorded internally as an eligibility problem — coverage lapsed, member not enrolled on the date of service — is reviewable here in a way it would not be in a state whose statute reaches only medical judgement. Before writing such a claim off as non-clinical and therefore non-appealable, check it against Connecticut's list.