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Internal grievance procedure. Notice re procedure and final resolution. Penalties. Fines allocated to Office of the Healthcare Advocate - Conn. Gen. Stat. § 38a-478m

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Managed Care Organizations and Health Insurers (“Insurer”) must maintain an internal grievance procedure that allows enrollees to obtain a timely review of the Insurer’s action or inaction. Enrollees may not challenge utilization review decisions through this process.

Insurer’s must give enrollees notice of the grievance procedure upon enrollment and at least annually thereafter. Upon the Insurer’s decision “not [to] certify an admission, service or extension ordered by [a] provider,” the Insurer must give the enrollee and their provider notice of the grievance procedures. Grievance notices must explain (1) the grievance filing process; (2) that the enrollee, their representative or their provider may file a grievance; and (3) the time periods for resolving the grievance. Managed Care Organizations that do not provide proper notice are subject to $25 fines for each violation.

An Insurer must give an enrollee written notice if an enrollee appeals a claim denial on the basis that the service is medically necessary and their claim is unsuccessful. The notice must state that the enrollee has exhausted their internal appeal procedures and include instructions for appealing to the Insurance Commissioner.

Insurers must complete a grievance review within 60 days of receiving the complaint unless the complaining party requests and extension. 

Current as of June 2015