"Utilization Review License Application Form" - Connecticut

Utilization Review License Application Form is a legal document that was released by the Connecticut Insurance Department - a government authority operating within Connecticut.

Form Details:

  • Released on August 1, 2018;
  • The latest edition currently provided by the Connecticut Insurance Department;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut Insurance Department.

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UTILIZATION REVIEW LICENSE APPLICATION
The format below must be followed in preparing an application for a license to conduct utilization review.
Applications should be completed as directed, signed and acknowledged by the applicant’s president or
other duly authorized representative. Applications will not be considered complete until all required
information is submitted. Completed applications must be returned to:
Regular mail: Connecticut Insurance Department, Life & Health Division, PO Box 816, Hartford, CT
06142-0816
th
Overnight mail or hand delivery: 153 Market St., 7
Floor, Hartford, CT 06103
ALL UTILIZATION REVIEW LICENSES EXPIRE ANNUALLY ON DECEMBER 31ST.
Name of Company: _________________________________________________
Address:
_______________________________________________________
_______________________________________________________
Telephone:
________________________ Toll Free: ______________________
Business Hours (eastern time) ________________________________________
Contact Person:
_______________________ Direct #: __________________
e-mail address: _____________________________________________________
The following information is submitted as evidence of compliance with the requirements found in the
most recently amended versions of Section §§38a-591a et seq. of the Connecticut General Statutes
(C.G.S.) in support of the application for licensing of the above named company. Please note that any
material change in the information in a request for licensure or renewal must be filed with the Insurance
Commissioner within 30 calendar days after the change. Please note that all responses, letters and data
provided should be Connecticut specific. Applications that include processes, letters or data for
jurisdictions other than Connecticut will be rejected.
THE APPLICATION AND ALL SUPPORTING MATERIALS MUST BE
CONNECTICUT SPECIFIC FOR FULLY INSURED PLANS. ANY APPLICATION
THAT CONTAINS PROVISIONS REGARDING JURISDICTIONS OUTSIDE OF
CONNECTICUT OR FOR SELF-FUNDED PLANS WILL BE REJECTED.
IF YOUR COMPANY PROVIDES UTILIZATION REVIEW SERVICES FOR BOTH
MEDICAL/SURGICAL SERVICES AND MENTAL HEALTH/ SUBSTANCE ABUSE
DISORDERS, YOU MUST SEPARATELY NOTE PROCEDURES FOR EACH
CATEGORY OF SERVICES IN ALL RESPONSES AS THE REQUIREMENTS HAVE
BEEN EXPANDED OR MODIFIED FOR MENTAL HEALTH/SUBSTANCE ABUSE
SERVICES.
Rev. 8/18
UTILIZATION REVIEW LICENSE APPLICATION
The format below must be followed in preparing an application for a license to conduct utilization review.
Applications should be completed as directed, signed and acknowledged by the applicant’s president or
other duly authorized representative. Applications will not be considered complete until all required
information is submitted. Completed applications must be returned to:
Regular mail: Connecticut Insurance Department, Life & Health Division, PO Box 816, Hartford, CT
06142-0816
th
Overnight mail or hand delivery: 153 Market St., 7
Floor, Hartford, CT 06103
ALL UTILIZATION REVIEW LICENSES EXPIRE ANNUALLY ON DECEMBER 31ST.
Name of Company: _________________________________________________
Address:
_______________________________________________________
_______________________________________________________
Telephone:
________________________ Toll Free: ______________________
Business Hours (eastern time) ________________________________________
Contact Person:
_______________________ Direct #: __________________
e-mail address: _____________________________________________________
The following information is submitted as evidence of compliance with the requirements found in the
most recently amended versions of Section §§38a-591a et seq. of the Connecticut General Statutes
(C.G.S.) in support of the application for licensing of the above named company. Please note that any
material change in the information in a request for licensure or renewal must be filed with the Insurance
Commissioner within 30 calendar days after the change. Please note that all responses, letters and data
provided should be Connecticut specific. Applications that include processes, letters or data for
jurisdictions other than Connecticut will be rejected.
THE APPLICATION AND ALL SUPPORTING MATERIALS MUST BE
CONNECTICUT SPECIFIC FOR FULLY INSURED PLANS. ANY APPLICATION
THAT CONTAINS PROVISIONS REGARDING JURISDICTIONS OUTSIDE OF
CONNECTICUT OR FOR SELF-FUNDED PLANS WILL BE REJECTED.
IF YOUR COMPANY PROVIDES UTILIZATION REVIEW SERVICES FOR BOTH
MEDICAL/SURGICAL SERVICES AND MENTAL HEALTH/ SUBSTANCE ABUSE
DISORDERS, YOU MUST SEPARATELY NOTE PROCEDURES FOR EACH
CATEGORY OF SERVICES IN ALL RESPONSES AS THE REQUIREMENTS HAVE
BEEN EXPANDED OR MODIFIED FOR MENTAL HEALTH/SUBSTANCE ABUSE
SERVICES.
Rev. 8/18
Provide the information required for each of the following items:
1.
Verify that the utilization review program uses documented clinical review criteria that are based
on sound clinical evidence and are evaluated periodically. Indicate whether the company has
developed its own clinical criteria or if purchased, provide the name of the vendor(s).
2.
Verify that clinical review criteria and links to any rule, guideline, protocol or other similar
criterion relied upon to make an adverse determination are posted on the company’s web site.
3.
Verify that clinical review criteria will be made available upon request to authorized government
agencies.
A. Describe the company’s procedures for standard and expedited/urgent care requests for
4.
providing notification for each of the following:
1) Prospective Determinations
2) Concurrent Determinations
3) Retrospective Determinations
B. Verify that in accordance with C.G.S. Section §38a-591c and §38a-591d that the health plan or
its designated utilization review agent shall:
1) Contract with health care professionals to administer the utilization review
program. Describe procedures to ensure the appropriate professionals are being
designated to conduct the review and are applying the clinical review criteria
consistently.
2) Contract with clinical peers to evaluate the clinical appropriateness of an adverse
determination. Include a description of how the company assures that an
appropriate clinical peer is available to conduct such evaluations.
3) Collect only information necessary, including pertinent clinical data, to make the
utilization review or benefit determination.
4) Ensure that such review is conducted in a manner to ensure the independence and
impartiality of the individual or individuals involved in making the utilization
review or benefit determination.
5) Have all appeals conducted and evaluated by a clinical peer that was not involved
in the initial or previous adverse determination.
6) Make no decisions regarding the hiring, compensation, termination, promotion or
other similar matters of such clinical peers based on the likelihood that such peers
will support the denial of benefits.
7) Have data systems sufficient to support the utilization review program activities
and to generate management reports.
8) Provide covered persons and participating providers with access to its utilization
review staff through a toll-free number or by electronic means.
9) Coordinate the utilization review program with other medical management activity
such as quality assurance, credentialing, contracting with health care professionals,
data reporting, grievance procedures and process for assessing member satisfaction
and risk management.
10) Routinely assess the effectiveness and efficiency of the utilization review program.
C. Verify that the company is in compliance with timeframes and notification processes for initial
reviews (standard and expedited/urgent).
Please note that C.G.S. §38a-591defines an urgent request as a request: For which the time
period for a non-urgent care request could seriously jeopardize the life or health of covered
person or the ability to regain maximum function, or
Rev. 8/18
1) That in the opinion of a health care professional with knowledge of the covered
persons medical condition, the time period for non-urgent requests would subject the
covered person to severe pain that cannot be managed without the service or treatment
being requested, or
2) For a Substance Use Disorder, as described in section §17a-458, C.G.S., or for co-
occurring Mental Disorder, or
3) For a Mental Disorder requiring (i) inpatient services, (ii) partial hospitalization, as
defined in section §38a-496, (iii) residential treatment, or (iv) intensive outpatient
services necessary to keep a covered person from requiring an inpatient setting.
5.
Attach sample copies of approval notices sent to covered persons and, if applicable, the covered
person’s authorized representative/provider of record.
6.
Attach sample copies of all adverse determination notices (initial denial through final appeal) sent
to covered persons and, if applicable, the covered person’s authorized representative/provider of
record. The notices must be Connecticut-specific and include a brief description of all appeal
rights including the timeframes for filing, the next steps to initiate the appeal and the name and
toll-free number of the department responsible for administering the appeal.
All determination notices must be clear as to who the Utilization review entity and the carrier is
within the notice.
All adverse determination notices must include a statement that such appeals are sometimes
successful and that the covered person or authorized representative may benefit from free
assistance the Office of the Healthcare Advocate in filing a grievance. In accordance with Bulletin
HC-98, the Department requests that the notice also include contact information for the Consumer
Affairs Division of the Connecticut Insurance Department. The notice must also state that the
covered person or authorized representative has the right to ask their health care professional for
narratives, letters and treatment notes and is encouraged to submit such documentation for the
health carrier’s consideration during the review of an adverse determination.
The contact information is shown below:
State of Connecticut Insurance Department
Consumer Affairs Unit
PO Box 816
Hartford, CT 06142-0816
Tel: 860-297-3900 or 1-800-203-3447
cid.ca@ct.gov
State of Connecticut
Office of the Healthcare Advocate
PO Box 1543
Hartford, CT 06144
1-866-466-4446
Healthcare.advocate@ct.gov
In addition, the final denial letter must include:
Rev. 8/18
1) a statement that all internal appeals have been exhausted;
2) the CPT/ICD-9 diagnostic code(s) relating to the denial; and
3) a copy of the consumer guide and external review application published by the Insurance
Department regarding the external review process. To download a copy of the external
review consumer guide and application for reproducing and distribution, please access the
Department web site at:
http://www.ct.gov/cid/lib/cid/External_Appeal_Consumer_Guide.pdf
(guide) and
http://www.ct.gov/cid/lib/cid/External_Review_Application.pdf
(application).
All notices of adverse determination must include a copy of the specific rule, guideline, protocol,
or other similar criterion relied upon to make the determination or include a statement that a
specific rule, guideline, protocol or other similar criterion was relied upon and will be provided
free of charge upon request.
All notices of adverse determination shall provide a link to such rule,
guideline, protocol or other similar criterion on the health carrier’s website.
Include a copy of the company’s grievance procedures, broken down by type of grievance:
7.
prospective, concurrent, retrospective and expedited/urgent, including timelines for reviews and
notifications.
8.
Describe the procedure by which the company assures that the appropriate clinical peer takes into
account all comments, documents, records and other information relevant to the review of the
adverse determination .
9.
Confirm that all concurrent determinations (both standard & urgent) shall have their treatment
continued without liability to the covered person until the covered person has been notified of the
review decision.
Describe any peer to peer consultation offered to the covered person’s health care professional
10.
following an initial adverse determination, including time frames for initiating such consultations.
Confirm that if such consultation occurs prior to the initiation of any grievance by the covered
person or his authorized representative or health care professional, it shall not be considered a
grievance of the initial adverse determination.
11.
Describe the process for disclosing new or additional information. Confirm that prior to issuing a
decision, the covered person or the covered person’s representative/provider of record, if
applicable, is provided, free of charge, any new or additional evidence relied upon and any new or
additional scientific or clinical rationale used. Confirm that such information is provided
sufficiently in advance of the date a decision is required to permit the covered person or authorized
representative a reasonable opportunity to respond.
Describe the process by which the company’s written clinical review criteria and review
12.
procedures are developed, evaluated and revised, including how practitioners are involved in this
process. Identify the source of the clinical review criteria if purchased or licensed from a vendor.
If doing utilization review for mental health and substance abuse services, indicate whether the
clinical review criteria used is that required in Conn. Gen. Statute §§38a-591c, separately for
substance abuse and mental health indicating for adults as well as for children and adolescents.
Describe any additional clinical review criteria developed or purchased to address advancements
in technology or types of treatment not covered in the required criteria. Confirm that any such
criteria is based on sound clinical evidence and evaluated periodically.
Rev. 8/18
State the hours (in eastern time) during which the company’s review staff is available by toll-
13.
free telephone.
14.
State the number of nurses, practitioners and other licensed health professionals making
utilization review decisions for the company and describe their professional qualifications.
Supporting material may be attached.
Describe the company’s procedures to ensure compliance with applicable state and federal
15.
laws protecting the confidentiality of medical records. Supporting material may be attached.
16.
Confirm that no person engaged in utilization review receives any compensation based on the
number of denials.
17.
Attach the completed certification (Attachment 1) and survey (Attachment 2) that follow.
Rev. 8/18