§ 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 section 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: (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service, procedure or extension of stay that such prior authorization or precertification has been reversed or rescinded on the basis of medical necessity, fraud or lack of coverage; and (B) Such admission, service, procedure or extension of stay has taken place in reliance on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 Unless reversed or rescinded as set forth in subparagraph (A) of subdivision (1) of this subsection, such prior authorization or precertification shall be effective for not less than sixty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 section 38a-479b .

Legislative History

(P.A. 11-58, S. 18; P.A. 17-15, S. 37.) History: P.A. 11-58 effective January 1, 2012; P.A. 17-15 made technical changes in Subsec. (a).