|
Home
|
|
Symptoms
|
|
Live Discussion
|
|
Diagnosis
|
|
Treatment
|
|
Area Support
|
|
Library
|
|
Research
|
|
Lymelinks
|
|
Contact
|
|
Pets & Lyme
|
|
DONATIONS
|
|
Drug Info
|
|
Medical Dictionary
|
|
Board of Directors
|
|
|
No Warranties or Representations
Lyme Disease symptoms vary from person to person. (lymes disease lyme's disease lime disease limes disease)
The data and information presented in this web site are presented in good faith and believed to be accurate regarding Lyme disease (commonly misspelled lymes disease lyme's disease lime disease limes disease) and other related diseases. Any and all liability for the content or any omissions including any inaccuracies, errors, or misstatements in such data or information is expressly disclaimed. The web site is compiled for the sole purpose of informing community members of resources and information pertaining to Lyme Borreliosis Disease and its coinfections. Lyme disease symptoms may vary from person to person.
The Canadian Lyme Disease Foundation, Directors and members are not liable for any direct or indirect damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action arising out of or in connection with the use or performance of information available from this website.
Consult a qualified Lyme ( Borreliosis ) Disease literate doctor for medical advice if Lyme Disease is suspect to discuss your Lyme Disease Symptoms.
|
Connecticut Proposes Bill Providing Better Respect for Doctors Opinion --
Regaining Control from the Insurers and HMO's
This bill will benefit anyone on a managed care plan, not just Lyme patients.
It basically requires the health care provider to prove that a requested
treatment is not necessary, rather then the current laws requiring patients and
physicians to prove medical necessity.
Please take a few minutes to fax your thoughts 860-240-0020, or call the
committee number 860-240-0510. This bill has been given very little time (and
publicity). If this bill is not referred by Thursday March 24th, it will be
discarded. If it is referred, then please contact your state legislators to share
your thoughts about it as they will be voting to make it a law.
I've enclosed Tom's letter as well as the member list for the Insurance and
Real Estate Committee.
Thanks,
Debbie Siciliano
Co-President
Time for Lyme
Please Note: The correct fax number for the committee is (860) 240-0027
Time for Lyme, an affiliate of the Lyme Disease Association, and CT Attorney
General Blumenthal's office and the Lyme Disease Association are asking for
your support of this important insurance bill (below).
If you are a CT resident
or physician, please read and take appropriate action. Time is of the
essence.
Pat Smith
President
Lyme Disease Association
Here is the Bill
General Assembly Raised Bill No. 6914
January Session, 2005 LCO No. 4456
*04456_______INS*
Referred to Committee on Insurance and Real Estate
AN ACT CONCERNING UTILIZATION REVIEW DETERMINATIONS AND APPEALS UNDER HEALTH
INSURANCE PLANS.
Be it enacted by the Senate and House of Representatives in General Assembly
convened:
Section 1. Subsection (a) of section 38a-226c of the general statutes is
repealed and the following is substituted in lieu thereof (Effective July 1, 2005):
(a) All utilization review companies shall meet the following minimum
standards:
(1) Each utilization review company shall maintain and make available
procedures for providing notification of its determinations regarding certification
in accordance with the following:
(A) Notification of any prospective determination by the utilization review
company shall be mailed or otherwise communicated to the provider of record or
the enrollee or other appropriate individual within two business days of the
receipt of all information necessary to complete the review, provided any
determination not to certify an admission, service, procedure or extension of stay
shall be in writing. After a prospective determination that authorizes an
admission, service, procedure or extension of stay has been communicated to the
appropriate individual, based on accurate information from the provider, the
utilization review company may not reverse such determination if such admission,
service, procedure or extension of stay has taken place in reliance on such
determination.
(B) Notification of a concurrent determination shall be mailed or otherwise
communicated to the provider of record within two business days of receipt of
all information necessary to complete the review or, provided all information
necessary to perform the review has been received, prior to the end of the
current certified period and provided any determination not to certify an
admission, service, procedure or extension of stay shall be in writing.
(C) The utilization review company shall not make a determination not to
certify based on incomplete information unless it has clearly indicated, in
writing, to the provider of record or the enrollee all the information that is
needed to make such determination.
(D) Notwithstanding subparagraphs (A) to (C), inclusive, of this subdivision,
the utilization review company may give authorization orally, electronically
or communicated other than in writing. If the determination is an approval for
a request, the company shall provide a confirmation number corresponding to
the authorization.
(E) Any notice of a determination not to certify an admission, service,
procedure or extension of stay shall include in writing (i) the principal reasons
for the determination and, if the reason not to certify is based on medical
necessity, the notice shall include an explanation of why the admission, service,
procedure or extension of stay is not medically necessary, (ii) the
procedures to initiate an appeal of the determination or the name and telephone number
of the person to contact with regard to an appeal pursuant to the provisions
of this section, and (iii) the procedure to appeal to the commissioner pursuant
to section 38a-478n.
(F) For all determinations, there shall be a presumption that an admission,
service, procedure or extension of stay is medically necessary if it is ordered
by a licensed participating provider and is within the provider's scope of
practice. The utilization review company shall have the burden of proving that
the admission, service, procedure or extension of stay is not medically
necessary.
(2) Each utilization review company shall maintain and make available a
written description of the appeal procedure by which either the enrollee or the
provider of record may seek review of determinations not to certify an admission,
service, procedure or extension of stay. The procedures for appeals shall
include the following:
(A) Each utilization review company shall notify in writing the enrollee and
provider of record of its determination on the appeal as soon as practical,
but in no case later than thirty days after receiving the required documentation
on the appeal.
(B) On appeal, all determinations not to certify an admission, service,
procedure or extension of stay shall be made by a licensed practitioner of the
medical arts.
(3) The process established by each utilization review company may include a
reasonable period within which an appeal must be filed to be considered.
(4) Each utilization review company shall also provide for an expedited
appeals process for emergency or life threatening situations. Each utilization
review company shall complete the adjudication of such expedited appeals within
two business days of the date the appeal is filed and all information necessary
to complete the appeal is received by the utilization review company.
(5) Each utilization review company shall utilize written clinical criteria
and review procedures which are established and periodically evaluated and
updated with appropriate involvement from practitioners.
(6) Physicians, nurses and other licensed health professionals making
utilization review decisions shall have current licenses from a state licensing
agency in the United States or appropriate certification from a recognized
accreditation agency in the United States, provided, any final determination not to
certify an admission, service, procedure or extension of stay for an enrollee
within this state, except for a claim brought pursuant to chapter 568, shall be
made by a physician, nurse or other licensed health professional under the
authority of a physician, nurse or other licensed health professional who has a
current Connecticut license from the Department of Public Health.
(7) In cases where an appeal to reverse a determination not to certify is
unsuccessful, each utilization review company shall
(A) assure that a
practitioner in a specialty related to the condition is reasonably available to review
the case, and
(B) prior to making a final determination, provide the enrollee an
opportunity to request a hearing which shall be conducted in person, by
telephone or by other means at the enrollee's discretion. At the hearing, the
utilization review company shall make available the practitioner responsible for
reviewing the case.
When the reason for the determination not to certify is
based on medical necessity, including whether a treatment is experimental or
investigational, each utilization review company shall have the case reviewed by a
physician who is a specialist in the field related to the condition that is
the subject of the appeal.
Any such review, except for a claim brought pursuant
to chapter 568, that upholds a final determination not to certify in the case
of an enrollee within this state shall be conducted by such practitioner or
physician under the authority of a practitioner or physician who has a current
Connecticut license from the Department of Public Health. The review shall be
completed within thirty days of the request for review. The utilization review
company shall be financially responsible for the review and shall maintain,
for the commissioner's verification, documentation of the review, including the
name of the reviewing physician.
(8) Except as provided in subsection (e) of this section, each utilization
review company shall make review staff available by toll-free telephone, at
least forty hours per week during normal business hours.
(9) Each utilization review company shall comply with all applicable federal
and state laws to protect the confidentiality of individual medical records.
Summary and aggregate data shall not be considered confidential if it does not
provide sufficient information to allow identification of individual patients.
(10) Each utilization review company shall allow a minimum of twenty-four
hours following an emergency admission, service or procedure for an enrollee or
[his] the enrollee's representative to notify the utilization review company
and request certification or continuing treatment for that condition.
(11) No utilization review company may give an employee any financial
incentive based on the number of denials of certification such employee makes.
(12) Each utilization review company shall annually file with the
commissioner (A) the names of all managed care organizations, as defined in section
38a-478, that the utilization review company services in Connecticut, (B) any
utilization review services for which the utilization review company has contracted
out for services and the name of such company providing the services, and (C)
the number of utilization review determinations not to certify an admission,
service, procedure or extension of stay and the outcome of such determination
upon appeal within the utilization review company. Determinations related to
mental or nervous conditions, as defined in section 38a-514, shall be reported
separately from all other determinations reported under this subdivision.
(13) Any utilization review decision to initially deny services shall be made
by a licensed health professional.
Sec. 2. Section 38a-478m of the general statutes is repealed and the
following is substituted in lieu thereof (Effective July 1, 2005):
(a) Each managed care organization shall establish and maintain an internal
grievance procedure to assure that enrollees may seek a review of any grievance
that may arise from a managed care organization's action or inaction, other
than action or inaction based on utilization review, and obtain a timely
resolution of any such grievance. Such grievance procedure shall comply with the
following requirements:
(1) Enrollees shall be informed of the grievance procedure at the time of
initial enrollment and at not less than annual intervals thereafter, which
notification may be met by inclusion in an enrollment agreement or update. Enrollees
shall also be informed of the grievance procedure when a decision has been
made not to certify an admission, service or extension of stay.
(2) Notices to enrollees describing the grievance procedure shall explain:
(A) The process for filing a grievance with the managed care organization, which
may be communicated orally, electronically or in writing;
(B) that the
enrollee, or a person acting on behalf of an enrollee, including the enrollee's
health care provider, may make a request for review of a grievance; and
(C) the
time periods within which the managed care organization must resolve the
grievance.
(b) With respect to a final review for which no appeal is provided under the
internal grievance procedure, the managed care organization shall provide the
enrollee an opportunity to request a hearing which shall be conducted in
person, by telephone or by other means at the enrollee's discretion.
[(b)] (c) All reviews conducted under this section shall be resolved not
later than sixty days from the date the enrollee commences the complaint, unless
an extension is requested by the enrollee.
This act shall take effect as follows and shall amend the following sections:
Section 1July 1, 200538a-226c(a)
Sec. 2July 1, 200538a-478m
Statement of Purpose:
To revise the process for determining medical necessity in health insurance
determinations.
[Proposed deletions are enclosed in brackets. Proposed additions are
indicated by underline, except that when the entire text of a bill or resolution or a
section of a bill or resolution is new, it is not underlined.]
TO THE TOP
|
| | |
