(a) The commissioner shall not assign an independent review organization, and no independent review organization shall assign a clinical peer, to conduct an external review or an expedited external review of a specified case if such organization or clinical peer has a material professional, familial or financial conflict of interest with any of the following:

Terms Used In Connecticut General Statutes 38a-591m

  • Commissioner: means the Insurance Commissioner. See Connecticut General Statutes 38a-1
  • Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
  • Person: means an individual, a corporation, a partnership, a limited liability company, an association, a joint stock company, a business trust, an unincorporated organization or other legal entity. See Connecticut General Statutes 38a-1
  • State: means any state, district, or territory of the United States. See Connecticut General Statutes 38a-1

(1) The health carrier that is the subject of such review;

(2) The covered person whose treatment is the subject of such review or the covered person’s authorized representative;

(3) Any officer, director or management employee of the health carrier that is the subject of such review;

(4) The health care provider, the health care provider’s medical group or independent practice association recommending the health care service or treatment that is the subject of such review;

(5) The facility at which the recommended health care service or treatment would be provided; or

(6) The developer or manufacturer of the principal drug, device, procedure or other therapy being recommended for the covered person whose treatment is the subject of such review.

(b) To determine whether an independent review organization or a clinical peer of the independent review organization has a material professional, familial or financial conflict of interest for purposes of subsection (a) of this section, the commissioner shall consider situations in which the independent review organization to be assigned to conduct an external review or an expedited external review of a specified case or a clinical peer to be assigned by the independent review organization to conduct such review of a specified case may have an apparent professional, familial or financial relationship or connection with a person described in subsection (a) of this section, but the characteristics of such relationship or connection are such that they are not a material professional, familial or financial conflict of interest that results in the disapproval of the independent review organization or the clinical peer from conducting such review.

(c) An independent review organization shall be unbiased. In addition to any other written procedures required under § 38a-591l, an independent review organization shall establish and maintain written procedures to ensure that it is unbiased.

(d) No independent review organization or clinical peer working on behalf of an independent review organization or an employee, agent or contractor of an independent review organization shall be liable in damages to any person for any opinions rendered or acts or omissions performed within the scope of the organization’s or person’s duties during or upon completion of an external review or an expedited external review conducted pursuant to § 38a-591g, unless such opinion was rendered or act or omission performed in bad faith or involved gross negligence.

(e) (1) Each independent review organization assigned by the commissioner to conduct a review pursuant to § 38a-591g shall maintain written records of all external reviews, whether standard or expedited external reviews, conducted by such organization in a calendar year. Such organization shall maintain such records in the aggregate by state where the covered person requesting such review resides and by health carrier, and shall submit a report to the commissioner upon request, in a format prescribed by the commissioner.

(2) Such report shall include, in the aggregate by state where the covered person requesting such review resides and by health carrier:

(A) The total number of requests for an external review, whether such requests were for a standard or an expedited external review;

(B) The number of such requests resolved and, of those resolved, the number resolved upholding the adverse determination or final adverse determination and the number resolved reversing the adverse determination or final adverse determination;

(C) The average length of time for resolution;

(D) A summary of the types of coverages or cases for which a review was sought;

(E) The number of such reviews that were terminated as a result of reconsideration by the health carrier of its adverse determination or final adverse determination after the receipt of additional information from the covered person or the covered person’s authorized representative; and

(F) Any other information the commissioner may request or require.

(3) Each independent review organization shall retain the written records required pursuant to subdivision (1) of this subsection for not less than six years after the assignment of an external review or an expedited external review.

(f) The commissioner shall adopt regulations, in accordance with chapter 54, to carry out the provisions of this section and sections 38a-591j to 38a-591l, inclusive.

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