Connecticut General Statutes 38a-472g – Restrictions applicable to prior authorization or precertification
(a)(1) No insurer, health care center, fraternal benefit society, hospital service corporation or medical service corporation or other entity, delivering, issuing for delivery, renewing, amending or continuing an individual or group health insurance policy in this state providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of § 38a-469 or utilization review company performing utilization review for such insurer, center, society, corporation or entity, that issues prior authorization for or precertifies, on or after January 1, 2012, an admission, service, procedure or extension of stay shall reverse or rescind such prior authorization or precertification or refuse to pay for such admission, service, procedure or extension of stay if:
Terms Used In Connecticut General Statutes 38a-472g
- Contract: A legal written agreement that becomes binding when signed.
- Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
- Fraud: Intentional deception resulting in injury to another.
- Insurance: means any agreement to pay a sum of money, provide services or any other thing of value on the happening of a particular event or contingency or to provide indemnity for loss in respect to a specified subject by specified perils in return for a consideration. See Connecticut General Statutes 38a-1
- Insured: means a person to whom or for whose benefit an insurer makes a promise in an insurance policy. See Connecticut General Statutes 38a-1
- Policy: means any document, including attached endorsements and riders, purporting to be an enforceable contract, which memorializes in writing some or all of the terms of an insurance contract. See Connecticut General Statutes 38a-1
- State: means any state, district, or territory of the United States. See Connecticut General Statutes 38a-1
(A) Such insurer, center, society, corporation, entity or company failed to notify the insured‘s or enrollee’s health care provider at least three business days prior to the scheduled date of such admission, service, procedure or extension of stay that such prior authorization or precertification has been reversed or rescinded on the basis of medical necessity, fraud or lack of coverage; and
(B) Such admission, service, procedure or extension of stay has taken place in reliance on such prior authorization or precertification.
(2) The provisions of this subsection shall apply regardless of whether such prior authorization or precertification is required or is requested by an insured’s or enrollee’s health care provider. Unless reversed or rescinded as set forth in subparagraph (A) of subdivision (1) of this subsection, such prior authorization or precertification shall be effective for not less than sixty days from the date of issuance.
(b) Nothing in subsection (a) of this section shall be construed to authorize benefits or services in excess of those that are provided for in the insured’s or enrollee’s policy or contract.
(c) Nothing in subsection (a) of this section shall affect the provisions of subsection (b) of § 38a-479b.