Coverage Guidelines

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Coverage Guidelines

Utilization Management Program

Health care management decisions

Health care treatments, drugs and supplies that are not part of the member’s benefit plan or are not medically necessary are not covered. We determine if a treatment, drug or supply is medically necessary and, therefore, covered. Additionally, if health services can be provided in more than one medically appropriate setting, ConnectiCare may determine which setting is eligible for benefit coverage and the health services must be provided in that setting in order for the member to be eligible for benefit coverage. These benefit determinations are made through various health care management procedures, including pre-service review, concurrent review, inpatient hospital readmission review, post-service review, and a reconsideration process.

Note: ConnectiCare reserves the right to use third-party vendors to administer benefits, including utilization management services.

 

Pre-service review (before services are rendered)

  • Pre-admission certification for elective hospitalization
  • Preauthorization for medical necessity of selected elective surgical procedures inpatient and outpatient
  • Preauthorization for elective care from out-of-network providers (excluding Point-of-Service plans)
  • Preauthorization for non-acute facility admissions (sub-acute, skilled nursing facility, hospice, etc.), home health care, durable medical equipment (DME)
  • Preauthorization for prescriptions and injectable medications

Note: Admission to a skilled nursing facility for rehabilitation, in the absence of a preceding hospitalization or acute episode of illness or injury, requires preauthorization and is subject to medical necessity review.

 

Concurrent review (while services are being rendered)

  • Evaluation of discharge readiness based on utilizing nationally recognized criteria received during an inpatient admission
  • Assessment of appropriateness of site for care, including the medical necessity of emergency/urgent admissions
  • Facilitation of care delivery throughout the continuum of care

 

Inpatient hospital readmission review

 

Post-service review (after services are rendered)

  • Review of clinical information for medical necessity and appropriateness of service

 

Peer-to-peer process (upon an adverse medical determination)

  • Review by the clinical peer reviewer who made the initial adverse determination, only upon request by the physician who originally requested approval of the services

 

Decision-making check financial incentives policy

When health care management decisions are made, they are based on the member’s benefit plan and the appropriateness of the proposed health care treatments, drugs and supplies for that member. We do not reward practitioners or other individuals conducting utilization review for issuing denials of coverage for health care treatments, drugs, and supplies. We offer no incentives to promote decision-making that would result in inappropriate denials of services.

We will make non urgent pre-service determinations within seven calendar days from receipt of the request. ConnectiCare will notify the member and the attending physician of the decision in writing. For questions about preauthorization of procedures, 800-562-6833.

When an adverse determination has been issued, providers have the right to the following:

• Provider Appeals Process

Note: Utilization managers are also available for other Utilization Management questions from 8 a.m. to 5 p.m., Monday to Friday at 800-562-6833. After hours, please leave a voicemail message.

 

JP 64217 9/24

Preauthorization Requirements

ConnectiCare directs its authorization efforts to selected services and procedures where medical necessity determination has the potential to make a discernable difference in utilization. The applicable services and procedures are reviewed by ConnectiCare to determine eligibility, level of benefits, and medical necessity. Preauthorization of these services is required even when ConnectiCare is the secondary payer. For a listing of services and procedures that require preauthorization, refer to this preauthorization list.

Physicians requesting preauthorization must make their requests in writing and include all supporting clinical information. The preauthorization requests must be provided to ConnectiCare at least:

  • Five (5) business days in advance of all elective inpatient admissions and any services requiring preauthorization (even when ConnectiCare is secondary payer)
     

Send requests and supporting records to ConnectiCare using the provider portal.

Other providers who are required to seek preauthorization are asked to submit their preauthorization at least five (5) business days in advance to allow time for a response by the scheduled procedure date.

If requesting preauthorization for services from a non-participating (out-of-network) provider:

  • Services provided by a non-participating provider are not covered unless specifically authorized in writing, in advance by ConnectiCare, or if the member has a point-of-service.
  • ConnectiCare will give authorization only for services that are not available within ConnectiCare's participating provider network unless the member has a Point-Of-Service Plan.

PPO plans do not require any preauthorization.

Note: Participating providers may not bill patients for denied claims due to the provider’s failure to obtain preauthorization. Not knowing that a patient has benefit coverage through ConnectiCare is not considered a valid reason for lack of preauthorization.

What happens next?

  • ConnectiCare’s medical director will review the request for authorization and make the determination on a non-urgent request within seven calendar days. For urgent requests, ConnectiCare’s medical director will make a determination as soon as possible, taking into account the covered person’s medical condition, but no later than twenty-four hours after the Plan receives such a request.
  • If the presented clinical information does not meet the authorization criteria, additional information may be requested from the practitioner.
  • If the medical director does not approve the procedure or service, you, the member and if applicable, their authorized representative, will be notified in writing. The provider may utilize ConnectiCare’s peer-to-peer process and/or choose to appeal the decision. See peer-to-peer process and/or Provider Appeals for additional information.
  • The written notification will include: the reason for the determination and clinical rationale, if any; instructions on how to initiate an appeal of the decision; general information on external appeal rights, if applicable, including how to initiate an external appeal; notice of the availability of clinical review criteria referenced in the decision; and the name and phone number of the physician reviewer who made the decision. Note: External appeal may only be available after the internal appeal process has been exhausted. Refer to the state-specific appendices within this manual for detailed information regarding appeals.
  • Procedures not approved through this process or decisions not overturned on appeal will not be covered by the health plan. The member should not be billed, unless he/she agrees in advance, in writing to pay for non-approved procedures.
     

Reversal of a preauthorization upon post-service review

ConnectiCare may reverse a preauthorized treatment, service, or procedure on post-service review when:

  • Relevant medical information presented to ConnectiCare, or its designated vendor, upon concurrent or post-service review is materially different from the information that was presented during the preauthorization review; and
  • The information existed at the time of the preauthorization review, but was withheld or not made available to ConnectiCare or its designated vendor; and
  • ConnectiCare, or its designated vendor, was not aware of the existence of the information at the time of the preauthorization review; and
  • Had the withheld information been made available to ConnectiCare or its designated vendor, the treatment, service, or procedure would not have been authorized. This determination will be made using the same specific standards, criteria or procedures as used during the preauthorization review.

JP 64217 9/24

Preauthorizations for Elective Inpatient admissions

The following information pertains to admitting members to both participating (in-network) and non-participating (out-of-network) inpatient facilities. ConnectiCare’s medical director will review the request for preauthorization and make the determination on a non-urgent request within seven calendar days. For urgent requests, ConnectiCare’s medical director will make a determination as soon as possible, taking into account the covered person’s medical condition, but no later than twenty-four hours after the Plan receives such a request.

If admitting to a PARTICIPATING (in-network) facility:

  • The physician must obtain preauthorization of all elective inpatient admissions at least five (5) business days in advance. (Preauthorization is required even when ConnectiCare is secondary payer.)
  • All elective preauthorizations must be requested using the provider portal.
  • The hospital should verify that the preauthorization has been obtained by using the provider portal or calling Provider Services at 800-828-3407.

Note: Failure to obtain preauthorization for elective admissions or elective procedures may result in a denial of payment to the participating practitioner and/or provider. The member may not be billed for a claim denied for failure to obtain preauthorization.
 

If admitting to a NON-PARTICIPATING (out-of-network) facility:

  • Elective admissions to non-participating hospitals are not covered, unless specifically authorized in writing, in advance by ConnectiCare, or, if the member has a Point-of-Service or PPO Plan. You must submit your request for an out-of-network authorization at least five (5) business days in advance of the anticipated admission date.
  • ConnectiCare will give authorization only for services that are not available within ConnectiCare’s participating provider network unless the member has a Point-of-Service or PPO Plan.

Exception: If they choose, members with a Point-of-Service, PPO, or FlexPOS benefit design may exercise their option to access out-of-plan hospitals without preauthorization. This subjects the member to both out-of-network benefit levels and additional benefit reduction. In addition, the member is responsible for obtaining any necessary preauthorization approvals. Member ID cards clearly identify the Point-of-Service product. Ask members to call Member Services at 860-674-5757 or 800-251-7722 if they have any questions about their benefits.
 

Required information for elective inpatient preauthorization

  • Member’s name and date of birth
  • Member’s address and telephone number
  • Member ID number
  • Scheduled admission date or estimated date of delivery if obstetrical patient
  • Name of hospital/facility
  • Admitting provider’s name and ConnectiCare provider ID number
  • Primary and secondary diagnoses, using ICD-10 codes
  • Reason for hospitalization, using CPT-4 codes, if applicable

Skilled nursing facility admissions

  • If you admit a member to a skilled nursing facility (SNF) on a weekend or holiday, ConnectiCare will automatically authorize payment from the day of admission through the next business day. However, ConnectiCare will not automatically pay for admission to a SNF for rehabilitation in the absence of a hospitalization or acute episode of illness or injury. These admissions require preauthorization using the provider portal and are subject to medical necessity review.
  • You must use the provider portal or call ConnectiCare’s Notification Line at 800-562-6833 to advise us of the admission. This line is available 24 hours/day, seven (7) days/week. If you do not inform ConnectiCare according to these guidelines, the SNF may not receive payment for any additional days of the member’s stay.
  • In addition, ConnectiCare will deny admissions to a SNF that is under Denial for Payment of New Admissions (DPNA) status by CMS or the State of Connecticut. If a member is already in a facility when it goes on a DPNA status, then we will offer the member the option to transfer to a different SNF.
  • Providers:
    • Must obtain preauthorization for admission to a SNF for rehabilitation in the absence of a hospitalization or acute episode of illness or injury. This admission is subject to medical necessity review. 
    • Do not have to obtain preauthorization for land ambulance/medical transport from an in-network hospital to an in-network SNF.

What happens next?

  • As appropriate, ConnectiCare’s medical director may review the proposed admission preauthorization request and make the determination make the determination on a non-urgent request within seven calendar days. For urgent requests, ConnectiCare’s medical director will make a determination as soon as possible, taking into account the covered person’s medical condition, but no later than twenty-four hours after the Plan receives such a request.
  • If the admission meets accepted criteria for medical necessity and place of service, and the request is approved, a case number is assigned.
  • If the admission does not meet established criteria, you may be asked to advise ConnectiCare of additional indications in support of the admission.
  • When a request for authorization is denied, ConnectiCare will notify the member and if applicable, their authorized representative, and physician in writing, including: the reason for the determination and clinical rationale, if any; instructions on how to initiate an appeal of the decision; notice of the availability of clinical review criteria referenced in the decision; general information on external appeal rights, including how to initiate an external appeal, if applicable; notification of the appeals process if the provider and/or member choose to appeal the decision, and the name and phone number of the physician reviewer who made the decision. Refer to the Provider Appeals process for detailed information regarding appeals.

Note: External appeal may only be available only after the internal appeal process has been exhausted.

  • If health services can be provided in more than one medically appropriate setting, it is within ConnectiCare’s discretion to choose the setting for the provision of those services for benefit purposes. In addition, the services must be provided in that setting in order for the member to be eligible for benefit coverage.
  • The hospital or other health delivery organization (HDO) must notify ConnectiCare to confirm that a patient who has been preauthorized for an elective inpatient stay has been admitted. Call ConnectiCare’s Notification Line at 800-562-6833 to leave applicable information.
  • The hospital or other HDO must notify ConnectiCare in the event of a member signing out against medical advice.

Note: Providers are expected to provide inpatient reviews upon request, even when ConnectiCare is the secondary carrier for the member.

 

JP 65073 9/24

Elective Inpatient Admission Notification

Physicians, hospitals, or other Health Delivery Organizations (HDOs) should notify ConnectiCare within twenty-four (24) hours for any emergency or urgent admission. Use the provider portal or call ConnectiCare’s Notification Line at 800-562-6833.

JP 64217 9/2024

Concurrent Review

ConnectiCare approves a length of stay based upon medical necessity on a concurrent review basis. Inpatient care and home care services are subject to concurrent review, which is conducted by a ConnectiCare case manager or designee over the telephone or through direct medical chart review. ConnectiCare uses nationally recognized medical necessity criteria for medical surgical/acute care admissions, skilled nursing/sub-acute admissions, home health care services, and observation level of care.

If you have any questions or would like a copy of the criteria specific to a member’s condition, please contact the utilization manager with whom you are working, or call 800-562-6833.

Although concurrent review activity involves the facility or agency utilization review departments, physicians are frequently contacted for information and assistance in developing a discharge plan that facilitates the delivery of services in the most appropriate setting. The attending physician is contacted for more information when it appears that the member’s condition does not meet continued stay criteria. If the intensity of services or severity of illness of the member does not support a continued stay at the current level of care, a ConnectiCare medical director will review the case. If the authorized length of stay has expired before a continuance is approved, the member may not be held responsible for the fees associated with such services, unless the member was otherwise notified in writing by ConnectiCare in advance.

Note: Practitioners and other providers are expected to comply with inpatient reviews upon request, even when ConnectiCare is the secondary carrier for the member.

Per federal Department of Labor and NCQA timeliness standards, ConnectiCare will issue a decision for a concurrent review within twenty-four (24) hours of the request. If ConnectiCare makes an attempt to obtain the needed clinical information in this twenty-four (24) hour period and the information is not provided, ConnectiCare is still required to issue a determination. In this case, ConnectiCare will issue a determination based on the information already made available. If clinical information is requested by ConnectiCare and it is not provided within one business day of request, ConnectiCare may issue an administrative denial due to lack of information for date of service requested.

In addition, circumstances may occur during a hospital/facility admission in which the patient’s care or treatment is delayed by scheduling problems, delays in getting needed evaluations or consultations, delays in discharge planning, the unavailability of hospital/facility services over the weekend or on holidays, or other administrative delays. These cases will also be reviewed by a ConnectiCare medical director for determination of authorization of payment.

If the delay in discharge results from a facility’s delay in providing needed services, attending physicians will be compensated for their services during this time.

However, if the delay in discharge is due to a decision or lack of action by the attending physician, that physician will not be compensated for days not authorized.

 

What happens next?

  • ConnectiCare’s medical director will review the request for continued stay and make the determination.
  • If the decision results in extending coverage, the notification will include the number of extended services approved, the new total of approved services, the date of onset of the services, and the next review date.
  • If health services can be provided in more than one medically appropriate setting, it is within ConnectiCare’s discretion to choose the setting for the provision of those services. In addition, the services must be provided in that setting in order for the member to be eligible for benefit coverage.
  • If the medical director determines that continued payment for the facility stay cannot be authorized, the attending physician will be notified by phone or fax and will also receive written confirmation. If upon review of clinical documentation the medical director does not approve the day(s), you may utilize their peer-to-peer process and/or appeal the decision. See "Provider Appeals process" for additional information attached with the letter for additional information.
  • The written notification will include: the reason for the determination and clinical rationale, if any, instructions on how to initiate an appeal of the decision; general information on external appeal rights, if applicable; including how to initiate an external appeal; notice of the availability of clinical review criteria referenced in the decision; and the name and phone number of the physician reviewer who made the decision.

 

Medicare PPM/10.16

Post-Service Review

ConnectiCare’s Medical Operations Department conducts post-service reviews on unauthorized elective admissions and emergency admissions of which ConnectiCare was not notified or services that required preauthorization where none was obtained. If a claim is submitted without preauthorization or deemed not to be a true emergency, ConnectiCare may issue an administrative denial for failure to meet the plan’s administrative requirements related to notification.

 

PPM/10.16

Dispute Resolution

ConnectiCare Dispute Resolution for Commercial Plans

Overview

ConnectiCare provides processes for members and practitioners to dispute a determination that results in a denial of payment and/or covered services. Process, terminology, filing instructions and applicable time frames and additional and/or external review rights vary based on the type of plan in which the member is enrolled. The processes in this section apply to commercial and Medicare plans.

We do not discriminate against practitioners or members or attempt to terminate a practitioner's agreement or disenroll a member, for filing a request for dispute resolution.

We have interpreter services available to assist members with language and hearing/vision impairments.

Payments for Services in Dispute

ConnectiCare network practitioners may not seek payment from members for either covered services or services determined by ConnectiCare’s Care Management program not to be medically necessary unless the member agrees, in writing and in advance of the service, to such payment as a private patient and the written agreement is placed in the member's medical record. Any practitioner attempting to collect such payment from the member in the absence of such a written agreement does so in breach of the contractual provisions with ConnectiCare. Such breach may be grounds for termination of the practitioner's contract.

Key Terminology

The following descriptions provide a general overview of the terminology used with commercial and Medicare plans.

Adverse Determination
A notification sent when a health care service, procedure, or treatment is denied.

Appeal
A request to review any aspect of an adverse claim, medical, or benefit determination.

Complaint
A request to review an administrative process, service, or quality-of-care issue that does not pertain to a determination based on claims, benefits, or medical necessity.

Grievance
A request to review any aspect of an adverse benefit or claim determination that is not based on medical necessity.

Certain disputes — whether they are appeals, complaints or grievances — may be filed as expedited or standard depending on the urgency of the patient's condition.

Certain disputes may also be filed as pre-service or post-service depending on the timing of the determination in question.

Managing Entities

ConnectiCare contracts with separate managing entities to provide care for certain types of medical conditions. In these cases, the designated managing entity will determine the applicable process for filing a dispute. Any aspect of service rendered by ConnectiCare or any entity designated to perform administrative functions on our behalf is hereafter jointly referred to as “ConnectiCare."

Initial Adverse Determinations

ConnectiCare will send a written notice on the date when a health care service, procedure, or treatment is given an adverse determination (denial) on the following grounds:

  • Service does not meet or no longer meets the criteria for medical necessity, based on the information provided to us.
  • Service is considered to be experimental or investigational (rare disease, clinical trial, and out-of-network services).
  • Service is approved, but the amount, scope, or duration is less than requested.
  • Service is not a covered benefit under the member's benefit plan.
  • Service is a covered benefit under the member's benefit plan, but the member has exhausted the benefit for that service.

The written notice will be sent to the member and provider if there is member liability and will include:

  • The reasons for the determination, including the clinical rationale, if any.
  • Instructions on how to initiate internal appeals (standard and expedited appeals) and eligibility for external appeals.
  • Notice of the availability, upon request of the member or the member's designee of the clinical review criteria relied upon to make such determination.
  • A description of what additional information, if any, must be provided to, or obtained by, ConnectiCare in order for ConnectiCare to make an appeal determination.
  • The description of the action to be taken.
  • A statement that ConnectiCare will not retaliate or take any discriminatory action against the member if an appeal is filed.
  • The process and time frame for filing/reviewing an appeal with ConnectiCare, including the member's right to file an expedited review.
  • The member's right to contact the Connecticut Insurance Department at 800‑203‑3447 regarding their complaint.

The failure of ConnectiCare to make a utilization review (UR) determination within the prescribed time periods is deemed to be an adverse determination subject to appeal for Medicare only (excludes retrospective and concurrent case types). ConnectiCare must send notice of denial on the date that the utilization review's time frames expire.

Reconsideration/Peer-to-Peer

For all ConnectiCare plans in Connecticut (including plans sold through Access Health CT, the state insurance marketplace):

ConnectiCare offers participating practitioners a peer-to-peer process when an adverse medical determination has been issued. Providers may request a peer-to-peer conference within a two-week period following the date of the notice of adverse determination provided that an appeal has not been initiated. The peer-to-peer shall occur between the practitioner requesting approval of the service and the clinical peer reviewer who made the initial adverse determination. If the adverse determination is not reversed after the peer-to-peer process, providers or members may pursue the provider appeals process. Please note, the peer-to-peer process is not a prerequisite to the appeals process. Requests for peer-to-peer that are initiated more than two weeks after the initial notification of adverse determination will be processed as appeals.

For all ConnectiCare plans in Massachusetts:

ConnectiCare offers providers a reconsideration process when an adverse determination has been issued during a clinical peer review, whether such adverse determination was given during an initial or a concurrent review. That reconsideration process shall take place within one (1) working day after ConnectiCare receives the provider’s request. The reconsideration process shall involve the provider rendering the service and the clinical peer reviewer who made the initial adverse determination or, if the reviewer is not available, the reviewer’s clinical peer designee. If the adverse determination is upheld, the member, or the provider on behalf of the member, may then follow the grievance process through the formal provider appeals process. Please note, the reconsideration process is not a prerequisite to the formal internal grievance process or expedited appeal.

What happens next after the peer-to-peer process or the reconsideration process?

  • ConnectiCare’s medical director will review the request and make the determination.
  • If ConnectiCare upholds the initial adverse determination, providers will be notified verbally. Providers may then use the appeals process as outlined in the provider appeals process. However, members may not be billed for services denied under this process.
  • For determinations that were upheld, the initial adverse determination letter to the provider serves as notification and will include: the reason for the determination and clinical rationale, if any; instructions on how to initiate an appeal of the decision; general information on external appeal rights, if applicable, including how to initiate an external appeal; notice of the availability of clinical review criteria referenced in the decision, and the name and phone number of the physician reviewer who made the decision.

Retrospective Review Requests

For retrospective review requests, ConnectiCare must make a decision and provide written notification of the determination. The decision must be made within 30 days of receipt of the necessary information.

Final Adverse Determinations

For decisions that uphold or partially uphold a determination made regarding a clinical issue for which no additional internal appeal options are available, ConnectiCare will issue a final adverse determination in writing to the member and provider.

The final adverse determination contains the following information:

  • The basis and clinical rationale for the determination.
  • The words "final adverse determination."
  • ConnectiCare contact person and phone number.
  • The member's coverage type.
  • ConnectiCare's contact person or UR agent, address, and phone number.
  • A summary of the appeal.
  • The date the appeal was filed.
  • The date the appeal process was completed.
  • The health service that was denied, including the name of the facility/provider and developer/manufacturer of the health care service as available.
  • A statement that the member may be eligible for external appeal and time frames for appeal.
  • A standard description of external appeals process, including a clear statement in bold that the member/designee has four months from the final adverse determination to request an external appeal.
  • Standard description of external appeals process attached.
  • The terms "medical necessity," "experimental/investigational," "out-of-network," "clinical trial" or "rare disease treatment."
  • Information on available alternative and/or external dispute resolution options.

Notice of Final Appeal Determination

ConnectiCare will notify the member or member's designee in writing of the final appeal determination within 30 calendar days for preservice and 60 calendar days for postservice from the date the appeal is received. However, written notice of final adverse determination concerning an expedited utilization review appeal shall be transmitted to the member by the compliance due date, (48 or 72 hours for commercial or 72 hours for Medicare).

Practitioner Dispute Resolution Procedures: Complaints and Grievances

View TABLE 21-1, PRACTITIONER COMPLAINT/GRIEVANCE PROCEDURES

Practitioner Complaint Process

If a practitioner is dissatisfied with an administrative process, quality of care issue and/or any aspect of service rendered by ConnectiCare that does not pertain to a benefit or claim determination, the practitioner may file a complaint on their own behalf. Examples of such dissatisfaction include:

  • Long wait times on ConnectiCare's authorization phone lines.
  • Difficulty accessing ConnectiCare's systems.
  • Quality-of-care issues.

Once a decision is made on a practitioner's complaint, it is considered final and there are no additional internal review rights.

Complaints must be submitted in writing to ConnectiCare's Grievance and Appeals Department. A complaint should include a detailed explanation of the clinician's request and any documentation to support the practitioner's position.

ConnectiCare will acknowledge receipt of the practitioner's complaint in writing no later than 15 days after its receipt. Practitioner complaints will be reviewed, and a written response will be issued directly to the practitioner no later than 30 days after receipt.

Practitioner Grievance Process

If a practitioner is not satisfied with any aspect of a claim determination rendered by ConnectiCare (or any entity designated to perform administrative functions on our behalf) which does not pertain to a medical necessity determination, that practitioner may file a claim inquiry with ConnectiCare. If the inquiry does not resolve the issue, the practitioner may then file a grievance.

The practitioner should use the secure provider portal to submit a claim inquiry along with supporting documentation. To initiate an inquiry, sign in to connecticare.com/providers and follow these steps:

  1. Select the Claims tab and click Search Claims to locate your claim.
  2. On the Claims Detail page, click Ask a Question.
  3. On the Message Details page, select Claims and Payments category (and a subcategory) to file a claim inquiry
  4. Enter Message Content and upload Attachments (if necessary) and click Submit.

If the practitioner is not satisfied with the outcome of the inquiry, they have the option of filing a grievance via the secure provider portal. To submit a grievance, sign in to connecticare.com/providers and follow these steps:

  1. Click the User Profile icon and select My Messages.
  2. On the My Messages page, search and locate the message you submitted for the initial claim inquiry.
  3. Click Follow-up to create a linked message.
  4. On the Message Details page, select Grievances & Appeals category (and a subcategory) to file a grievance.
  5. Enter Message Content and upload Attachments (if necessary) and click Submit.

See the provider portal training guides and videos for step-by-step instructions on using the Message Center and Claims – Search, View, and Export.

The Grievance and Appeals Department is not involved in determining claim payment or authorizing services, but independently investigates all grievances.

Examples of reasons for filing grievances include dissatisfaction with a decision resulting from a failure to follow a plan policy or procedure, or failure to obtain prior approval for an inpatient admission. A practitioner may also file a grievance regarding how a claim was processed, including issues such as computational errors, interpretation of contract reimbursement terms, or timeliness of payment.

In addition, providers who wish to challenge the recovery of an overpayment or request a reconsideration for commercial claims denied exclusively for untimely filing may follow the grievance procedures in this sub-section.

If a claim was submitted after the time frame outlined in the Filing Limits section of Billing and Claims, ConnectiCare may deny the claim in full or in the alternative may agree to reduce payments by up to 25% of the amount that would have been paid had the claim been submitted in a timely manner. For grievances related to untimely filing, the provider must demonstrate that the late submission was an unusual occurrence and that they have a pattern of submitting claims in a timely manner. Examples of an unusual occurrence include:

  • Member submitted the wrong insurance information to the provider.
  • Coordination of Benefits related issues.
  • Member retroactively reinstated.

The grievance should be accompanied by a copy of the notice of the standard denial or other documentation of the denial, an explanation outlining the details of the request for a review and all documentation to support a reversal of the decision.

ConnectiCare will review the grievance and a written response will be issued for grievances with a final disposition of partial overturn or upheld, no later than 30 days for Medicare and 90 days for commercial after receipt. The determination included in the response will be final. 

Grievances with a favorable disposition will receive a claims remittance advice in lieu of a written response no later than 30 days for Medicare and 90 days for commercial after receipt.

Member Dispute Resolution Procedures: Complaints and Grievances for ConnectiCare Commercial and ConnectiCare of Massachusetts Plans

Member Complaint – First-Level Process

View Member Complaint – First-Level Process Tables

A member or designee may file a first-level complaint when the member is dissatisfied with any aspect of an ConnectiCare-rendered service that does not pertain to a benefit or claim determination. Examples of such dissatisfaction include:

  • Dissatisfaction with treatment received from ConnectiCare, its practitioners or benefit administrators.
  • Quality-of-care complaints.
  • Privacy complaints regarding ConnectiCare's practices in using or disclosing protected health information.
  • Alleged violation of ConnectiCare's privacy practices and/or state and federal law regarding the privacy of protected health information.
  • Fraud and abuse.

Complaints should include a detailed description of the circumstances surrounding the occurrence. ConnectiCare will acknowledge receipt of the complaint and request any necessary information in writing. Complaints will be reviewed, and a response will be issued in writing according to the time frames applicable to the member's benefit plan and detailed in the table linked above.

Member Grievance – First-Level Process

View Member Grievance – First-Level Process Table

If a member or designee is not satisfied with any aspect of a benefit or claim determination rendered by ConnectiCare that does not pertain to a medical necessity, experimental determination, or investigational determination, they may file a first-level grievance.

Grievances should be accompanied by a copy of the adverse determination, an explanation outlining the details of the request for a review and all documentation to support a reversal of the decision. We will acknowledge receipt of the grievance and request any necessary information in writing. Grievances will be reviewed, and a response will be issued according to the time frames detailed in the tables linked above.

Provider and Member Clinical Appeal Processes

ConnectiCare may reverse a prior approval decision for a treatment, service, or procedure on retrospective review when all the following criteria are met:

  • Relevant medical information presented to ConnectiCare or the utilization review agent upon retrospective review is materially different from the information that was presented during the prior approval.
  • The information existed at the time of the prior approval review but was withheld or not made available.
  • ConnectiCare or the utilization review agent was not aware of the existence of the information at the time of the prior approval review.
  • Had they been aware of the information, the treatment, service, or procedure being requested would not have been authorized.

Clinical Appeal - Expedited Process

View Table 21-10, Clinical Appeal - Expedited

If a member or designee is not satisfied with a service or a determination that was rendered based on issues of medical necessity, an experimental or investigational use, a rare disease or (in certain instances) out-of-network services, an expedited appeal may be filed if we determine or the provider indicates that a delay would seriously jeopardize the member’s life, health, or ability to attain, maintain, or regain maximum function. The member or designee may request expedited review of a prior approval request or concurrent review request.

An expedited appeal may be filed:

  • For continued or extended health care services, procedures, or treatments.
  • For additional services for members undergoing a course of continued treatment.
  • When the health care provider believes an immediate appeal is warranted.
  • When ConnectiCare honors the member’s request for an expedited review.

Expedited appeals should be accompanied by a copy of the denial letter, an explanation outlining the details of the request for a review and all documentation to support a reversal of the decision. The expedited utilization review appeal may be filed in writing or by telephone.

Missing Information

If ConnectiCare required information necessary to conduct an expedited appeal, ConnectiCare shall immediately notify the member and the member's health care provider by phone or fax and to identify and request the necessary information followed by written notification.

Reviewer of Expedited Appeal Requests

The review will be conducted by a qualified ConnectiCare medical director who was neither involved in prior determinations nor the subordinate of any person involved in the initial adverse determination. A clinical peer reviewer will be available to discuss the appeal within one business day.

Denial of Expedited Appeal Process

If we deny the request for expedited review because it does not meet the criteria for an expedited appeal, we will process the request through the standard appeal review time frames and will notify the appellant of this verbally and in writing.

Failure to Render a Decision

If we do not render a decision on the appeal within the applicable timelines, the adverse determination will be reversed automatically, and the requested services or benefits will be approved.

Expedited Appeal Not Resolved to Member's Satisfaction

Expedited appeals not resolved to the satisfaction of the member or designee may be reappealed through an external appeal process.

We will review the request and respond within the time frames noted in the table linked above.

Clinical Appeal - Standard Process

Procedures for initiating a standard appeal are outlined TABLE 21-11, APPEAL - STANDARD.

If a member or designee or provider is not satisfied with a service or a determination that was rendered based on issues of medical necessity, an experimental or investigational use, a clinical trial, a rare disease, or (in certain instances) out-of-network services, an appeal may be filed. The standard Clinical Appeal may be filed in writing or by telephone.

Missing Information

If we require information necessary to conduct a standard internal appeal, we will notify the member and the member's health care provider, in writing, within 15 calendar days of receipt of the appeal (as noted in the tables linked above), to identify and request the necessary information. If only a portion of such necessary information is received, we shall request the missing information, in writing, within five business days of receipt of the partial information.

Reviewer of Standard Appeal Requests

The review will be conducted by a qualified ConnectiCare medical director who was neither involved in prior determinations nor the subordinate of any person involved in the initial adverse determination. A clinical peer reviewer will be available to discuss the appeal within one business day.

Failure to Render a Decision (ConnectiCare of Massachusetts Plan only)

If we do not render a decision on the appeal within the applicable timelines, the adverse determination will be reversed automatically, and the requested services or benefits will be approved.

Standard Appeal Not Resolved to Member’s Satisfaction

Member or designee may request an External Appeal as described in this chapter.

State of Connecticut External Appeals

State of Connecticut External Appeals

A member or their authorized representative may submit a request for an external review or an expedited external review to the office of the insurance commissioner if our decision involved making a judgment as to the medical necessity, appropriateness, health care setting, level of care, or effectiveness of the health care service or treatment you requested or was related to experimental or investigational issues.

An external review or expedited external review request must be submitted in writing to the Insurance Commissioner for the State of Connecticut Insurance Department, Attn. External Review, P.O. Box 816, Hartford, CT 06142‑0816 or at 860‑297‑3900.

The external review request must be made within 120 calendar days of your receipt of this final denial letter. If you request an external review or expedited external review, the Commissioner will send a copy of such request to us. We will complete a preliminary review of the request and notify you and the Commissioner in writing whether the request is complete and eligible for such review.

The Circumstances When an External Appeal May Be Filed

  1. When the member has had coverage of a health care service, which would otherwise be a covered benefit under a subscriber contract or governmental health benefit program, denied on appeal, in whole or in part, on the grounds that such health care service is not medically necessary.
  2. ConnectiCare has rendered a final adverse determination with respect to such health care service.

An External Appeal May Also Be Filed

  1. When the member has had coverage of a health care service denied on the basis that such service is experimental or investigational.
  2. The denial has been upheld on appeal. 
  3. The member's attending physician has certified that the member has a life-threatening or disabling condition or disease for which any of the following apply:
    • Standard health services or procedures have been ineffective or would be medically inappropriate.
    • There does not exist a more beneficial standard health service or procedure covered by the health care plan.
    • There exists a clinical trial or rare disease treatment.
  4. The member's attending physician, who must be a licensed, board-certified, or board-eligible physician qualified to practice in the area of practice appropriate to treat the member's life-threatening or disabling condition or disease, must have recommended a clinical trial for which the member is eligible. Any physician certification provided under this section shall include a statement of the evidence relied upon by the physician in certifying their recommendation.
  5. The specific health service or procedure recommended by the attending physician would otherwise be covered under the policy except for the health care plan's determination that the health service or procedure is experimental or investigational.

External Appeal for Denial of Out-of-Network Service

The member has had coverage of the health service, which would otherwise be a covered benefit under the member's benefit plan which is denied on appeal, in whole or in part, on the grounds that such health service is out-of-network and an alternate recommended health service is available in-network, and ConnectiCare has rendered a final adverse determination with respect to an out-of-network denial or both ConnectiCare and the member have jointly agreed to waive any internal appeal; and the member's attending doctor, who shall be a licensed, board-certified or eligible physician qualified to practice in the specialty area of practice appropriate to treat the member for the health service sought, certifies that the out-of-network health service is materially different from the alternate recommended in-network service, and recommends a health care service that, based on two documents from the available medical and scientific evidence, is likely to be more clinically beneficial than the alternate recommended in-network treatment and the adverse risk of the requested health service would likely not be substantially increased over the alternate recommended in-network health service.

ConnectiCare has only one level of internal appeal.

How to File an External Clinical Appeal

The member and member's designee (including the provider in the capacity of the member's designee) may submit the same form within four months of the final adverse determination.

An external appeal must be submitted within the applicable time frame upon receipt of the final adverse determination of the first level appeal.

ConnectiCare will provide medical and treatment records and an itemization of the clinical standards used to determine medical necessity within three business days of receiving the agent's information and completed release forms. For an expedited appeal, this information will be provided within 24 hours of receipt.

For urgent medical circumstances, an expedited review may be requested which will render a decision within three days.

For standard cases, a determination will be made within 30 days from receipt of the member's request, in accordance with the commissioner's instructions. The external appeal agent shall have the opportunity to request additional information from the member, practitioner and ConnectiCare within the 30-day period, in which case the agent shall have up to five additional business days to make a determination.

The decision of the external appeal agent is final and binding on both the member and ConnectiCare.

To obtain an application or to inquire about external appeals, please contact the Connecticut Insurance Department:

Note: Practitioners appealing concurrent review determinations cannot pursue reimbursement from members other than copayments from a member for services deemed not medically necessary by the external appeal agent.

Facility Dispute Resolution Procedures

Retrospective Utilization Review Requests

View TABLE 21-12, FACILITY RETROSPECTIVE REVIEW REQUEST

If a ConnectiCare-contracted facility fails to follow prior approval and/or emergency admittance procedures, payments for such services may be denied and the facility, ConnectiCare or its managing entity may initiate a retrospective utilization review (RUR).

For Denials Based on "No Prior Approval"

If the facility fails to obtain prior approval, payment will be denied for "no prior approval." The remittance statement will include information regarding the facility's right to request a retrospective utilization review for medical necessity.

If the facility fails to request a retrospective utilization review and submit the medical record within 45 days of receipt of the remittance statement, the claim denial will be upheld, and the facility will have no further appeal rights.

Facility Clinical Appeals

View TABLE 21-13, FACILITY CLINICAL APPEAL

If an ConnectiCare-contracted facility is not satisfied with a claim determination regarding denial of payment for inpatient services based on medical necessity, the facility may file a facility clinical appeal.

ConnectiCare provides one internal level of appeal for facilities.

ConnectiCare handles all facility clinical appeals.

ConnectiCare will render a decision within 30 days of receipt of the appeal request.

  • For members already discharged
    If the facility provides additional information after the denial is issued and after the member is already discharged, no reconsideration review will be performed. However, the facility may exercise its right to a clinical appeal.

    The appeal request must be filed within 60 days for Medicare and 180 days for commercial of the initial adverse determination or as stated in the facility contract. If the appeal request is received outside of this time frame, the original denial will be upheld and there will be no further appeal rights. Facilities are not permitted to balance bill members for such denials.
  • For denials based on "No Information"
    If the facility fails to provide any clinical information to establish medical necessity for an admission or procedure, the claim will be denied based on "no information" and the facility may file a clinical appeal.

New: Submitting Clinical Information

Learn More

Medical Management Program

Health care management decisions

Health care treatments, drugs and supplies that are not part of the member’s benefit plan or are not reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve function are not covered. We determine if a treatment, drug or supply is medically necessary and, therefore, covered. Additionally, if health services can be provided in more than one medically appropriate setting, ConnectiCare may determine which setting is eligible for benefit coverage and the health services must be provided in that setting in order for the member to be eligible for benefit coverage. These benefit determinations are made through various health care management procedures, including pre-service review, concurrent review, inpatient hospital readmission review, and post-service review.

All providers must cooperate with the decisions, rules and regulations established by ConnectiCare's Quality Improvement and Utilization Management Programs. ConnectiCare works with an independent quality improvement organization to develop quality improvement and utilization management programs to ensure compliance with federal standards.

Note: ConnectiCare reserves the right to use third-party vendors to administer benefits, including utilization management services.

Pre-service review (before services are rendered)

  • Pre-admission certification for elective hospitalization
  • Preauthorization for medical necessity of select elective surgical procedures
  • Preauthorization for elective care from out-of-plan providers
  • Preauthorization for non-acute facility admissions (sub-acute, skilled nursing facility, hospice, etc.), home health care, Durable Medical Equipment (DME)

Note: Admission to a skilled nursing facility (SNF) for rehabilitation, in the absence of a preceding hospitalization or acute episode of illness or injury, requires preauthorization and is subject to medical necessity review.
 

Concurrent review (while services are being rendered)

  • Evaluation of discharge readiness based on severity of illness and intensity of services received during an inpatient admission.
  • Assessment of appropriateness of site for care, including the medical necessity of emergency/urgent admissions.
  • Facilitation of care delivery throughout the continuum.

Inpatient hospital readmission review

When a member who is discharged from a hospital is readmitted to the same hospital or same hospital network within thirty (30) days, a ConnectiCare utilization manager will review the case to determine if the readmission is related to the original inpatient stay.

View our complete Hospital Readmission Policy

Post-service review (after services are rendered)

  • Review of clinical information for medical necessity and appropriateness of service
     

Decision-making
When health care management decisions are made, they are based on the member’s benefit plan and the appropriateness of the proposed health care treatments, drugs and supplies for that member. We do not reward practitioners or other individuals conducting utilization review for issuing denials of coverage for health care treatments, drugs, and supplies. We offer no incentives to promote decision making that would result in inappropriate denials of services.

We will make a preauthorization  determination on a non-urgent request within seven calendar days. For urgent requests, ConnectiCare’s medical director will make a determination as soon as possible, taking into account the covered person’s medical condition, but no later than twenty-four hours after the Plan receives such a request. ConnectiCare will notify the member and if applicable, their authorized representative, and the attending physician of the decision in writing. For questions about preauthorization of procedures, call 800-508-6157.

When an adverse determination has been issued, providers have the right to the following:

Note: Case managers are also available for other Utilization Management questions from 8 a.m. to 5 p.m., Monday through Friday at 800-508-6157. After hours, please leave a voicemail message.

 

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Preauthorization Requirements

ConnectiCare directs its authorization efforts to selected services and procedures where medical necessity determination has the potential to make a discernable difference in utilization. The applicable services and procedures are reviewed by ConnectiCare to determine eligibility, level of benefits, and medical necessity. Preauthorization of these services is required even when ConnectiCare is the secondary payer. Here’s a listing services and procedures that require preauthorization.

Note: These preauthorization requirements apply to ConnectiCare Medicare Advantage plans only.  

Physicians requesting preauthorization must submit their requests in writing and include all supporting clinical information. The preauthorization requests must be provided to ConnectiCare at least:

  • Five (5) business days in advance of all elective inpatient admissions (even when ConnectiCare is secondary payer), or
  • Five (5) business days in advance of any other services requiring preauthorization.

    Send requests and supporting records to ConnectiCare using the provider portal.

Other providers who are required to seek preauthorization are asked to call at least five (5) business days in advance to allow time for a response by the scheduled procedure date.

 

If requesting preauthorization for services from a non-participating (out-of-plan) provider:

  • ConnectiCare will give authorization only for services that are not available within ConnectiCare's Medicare Advantage participating provider network.
  • You must request preauthorization – in advance and in writing – to obtain services from a non-participating provider. Such referrals should be made according to the plan and requested by the ConnectiCare referring physician of the like specialty. Send requests using the provider portal.

Note: Participating providers may not bill patients for denied claims due to the provider’s failure to obtain preauthorization. Not knowing that a patient has benefit coverage through ConnectiCare is not considered a valid reason for lack of preauthorization.

 

What happens next?

  • ConnectiCare’s medical director will review the request for authorization and make the determination. on a non-urgent request within seven calendar days. For urgent requests, ConnectiCare’s medical director will make a determination as soon as possible, taking into account the covered person’s medical condition, but no later than twenty-four hours after the Plan receives such a request.
  • If the presented clinical information does not meet the authorization criteria, additional information may be requested from the practitioner.
  • If the medical director does not approve the procedure or service, you will be notified in writing. You may choose to appeal the decision. See "Provider Appeals" for additional information.
  • ConnectiCare will notify the member and if applicable, their authorized representative, and physician in writing which will include: the reason for the determination and clinical rationale, if any; instructions on how to initiate an appeal of the decision; general information on appeal rights, if applicable, notice of the availability of the Medicare guideline referenced in the decision; and the name and phone number of the physician reviewer who made the decision.
  • Procedures not approved through this process or decisions not overturned on appeal will not be covered by the health plan. The member should not be billed.

Reversal of a preauthorization upon post-service review
ConnectiCare may reverse a preauthorized treatment, service, or procedure on post-service review when:

  • Relevant medical information presented to ConnectiCare, or its designated vendor, upon concurrent or post-service review is different from the information that was presented during the preauthorization review; and
  • The information existed at the time of the preauthorization review, but was withheld or not made available to ConnectiCare or its designated vendor; and
  • ConnectiCare, or its designated vendor, was not aware of the existence of the information at the time of the preauthorization review; and
  • Had ConnectiCare or its designated vendor had been aware of the information, the treatment, service, or procedure would not have been authorized. This determination will be made using the same specific standards, guidelines or procedures as used during the preauthorization review.

 

Services and procedures requiring preauthorization

Admission to any facility, including:

  • Hospital admissions that are elective or not the result of an emergency, including behavioral health services (mental health and alcohol or substance abuse services)
  • Rehabilitation facility admissions
  • Skilled nursing facility admissions
  • Sub-acute care admissions

 

Non-emergency ambulance/medical transportation

Behavioral health program services (mental health and alcohol or substance abuse services)
For preauthorization of all behavioral health services call 800-349-5365.

Drugs, physician administered
Drugs administered by a health care professional outside of the hospital setting.

Drugs, prescription
Preauthorization reviews of prescription drugs are handled through the Pharmacy Program. For information call 877-224-8168.

Durable medical equipment (DME):

  • Power mobility devices and scooters
  • Oral appliance for the treatment of sleep apnea
  • Osteogenic bone growth stimulators (including spinal, non-spinal and ultrasound)
  • Ventricular Assist Device

Elective services & procedures:

  • Clinical trials (to validate that trial qualifies under Medicare Guidelines)
  • Mammoplasty (breast augmentation or reduction)
  • Mobile Outpatient Cardiac Telemetry or Ambulatory ECG Monitoring
  • Transplants (organ, stem cell or bone marrow)
     

Genetic testing
With the exception of the list below, all genetic tests require preauthorization.

Preauthorization is not required for:

  • Genetic counseling
  • FISH testing for lymphoma or leukemia
  • Chromosomal Microarray except for prenatal/fetal diagnosis
  • Screening for Cystic Fibrosis, Prothrombin, Factor V Leiden, Fragile X and Hereditary hemochromatosis

 

Home health care

Out-of-plan services:

  • All out-of-plan services (non-emergency)

Pulmonary rehabilitation

Use the provider portal to submit clinical information.

 

Radiological services (except for inpatient or emergency services, or when such radiological services are done in conjunction with a biopsy or other surgical procedure):

  • Bone mineral density exams ordered more frequently than every 23 months
  • CT scans (all diagnostic exams)
  • MRI/MRA (all examinations)
  • Nuclear cardiology
  • PET scans
  • Radiation Therapy for the following cancer diagnoses: breast, prostate, lung, colon and rectal cancer
  • Stress Echocardiograms (CPT code 93350)
  • Stereotactic Radiosurgery

For preauthorization of these radiological services only, call 877-607-2363 or visit www.radmd.com. If authorization is not obtained, payment for the service may be denied.

Note: Services, supplies or drugs that are considered to be experimental or investigational will not be considered a covered benefit.

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Preauthorization of Elective Inpatient Aadmissions

The following information pertains to admitting members to both participating (in-plan) and non-participating (out-of-plan) inpatient facilities.


If admitting to a PARTICIPATING (in-plan) facility:

  • The physician must obtain preauthorization of all elective inpatient admissions at least five (5) business days in advance. (Preauthorization is required even when ConnectiCare is secondary payer.)
  • All elective preauthorizations must be requested using the provider portal.
  • The hospital should verify that the preauthorization has been obtained by using the provider portal or calling Provider Services at 877-224-8230.

Note: Failure to obtain preauthorization for elective admissions or elective procedures may result in a denial of payment to the participating practitioner and/or provider. The member may not be billed for a claim denied for failure to obtain prior authorization.


If admitting to a NON-PARTICIPATING (out-of-plan) facility:

  • Elective admissions to non-participating hospitals are not covered, unless specifically authorized in writing, in advance by ConnectiCare. You must submit your request for an out-of-plan authorization at least five (5) business days in advance of the anticipated admission date.
  • ConnectiCare will give authorization only for services that are not available within ConnectiCare’s participating provider network.

 

Required information for elective inpatient preauthorization

  • Member’s name and date of birth
  • Member’s address and telephone number
  • Member ID number
  • Scheduled admission date or estimated date of delivery if obstetrical patient
  • Name of hospital/facility
  • Admitting provider’s name and ConnectiCare provider ID number
  • Primary and secondary diagnoses, using ICD-10 codes
  • Reason for hospitalization, using CPT-4 codes, if applicable

Skilled nursing facility admissions

All skilled nursing facility (SNF) admissions for skilled care require preauthorization. You must call 860-409-8951 or 800-451-7784 extension 8951 to request preauthorization. If you are admitting a member for custodial care only, you must still notify ConnectiCare prior to admission. ConnectiCare is required to provide the member with proper notification under the requirements of the Centers for Medicare & Medicaid Services (CMS).

In addition, ConnectiCare will deny admissions to a SNF that is under Denial of Payment of New Admissions (DOPNA) status by CMS or the State of Connecticut. If a member is already in a facility when it goes on a DOPNA status, then we will offer the member the option to transfer to a different SNF.

Providers:

  • Must obtain preauthorization for admission to a SNF for rehabilitation in the absence of a hospitalization or acute episode of illness or injury. This admission is subject to medical necessity review.
  • Do not have to obtain preauthorization for land ambulance/medical transport from an in-network hospital to an in-network SNF.

What happens next?

  • ConnectiCare’s medical director will review the proposed admission and make the determination.
  • If the admission meets Medicare guidelines and the request is approved, an authorization number is assigned, and the provider receives a phone call with the authorization number.
  • If the admission does not meet Medicare guidelines, you may be asked to advise ConnectiCare of additional indications in support of the admission.
  • When a request for authorization is denied, ConnectiCare will notify the member and physician in writing, including: the reason for the determination and clinical rationale, if any; notice of the availability of Medicare guidelines referenced in the decision; information about appeal rights, including how to initiate an appeal, if applicable; notification of the appeals process if the provider and/or member choose to appeal the decision, and the name and phone number of the physician reviewer who made the decision.
  • If health services can be provided in more than one medically appropriate setting, it is within ConnectiCare’s discretion to choose the setting for the provision of those services for benefit purposes. In addition, the services must be provided in that setting in order for the member to be eligible for benefit coverage.
  • The hospital or other Health Delivery Organization (HDO) must notify ConnectiCare to confirm that a patient who has been preauthorized for an elective inpatient stay has been admitted. Call 800-508-6157 to leave applicable information.
  • The hospital or other HDO must notify ConnectiCare in the event of a member signing out against medical advice.

 

Notice of Medicare Non-Coverage with Appeal Rights
Skilled nursing facilities: Once the last date of covered services is determined, ConnectiCare will fax you the Notice of Medicare Non-Coverage with Appeal Rights at least two days prior to the services not being covered. You are responsible for providing the Notice with Appeal Rights to the member (or legal representative) and obtaining a signature with the date signed. A copy of the signed and dated notice must be faxed to ConnectiCare at 860-674-2831. If you are unable to deliver the notice at least two days prior to the last date of covered services – you must contact ConnectiCare at 800-451-7784.

 

Home care agencies and comprehensive outpatient rehabilitation facilities: The Notice of Medicare Non-Coverage with Appeal Rights must be provided to the member (or legal representative) at least two days prior to the discontinuation of services. If there is more than a two-day span between services, the notice should be issued the next to last time the services are provided. A copy of the signed and dated notice must be faxed to ConnectiCare at 860-674–5893. If you are unable to provide the notice at least two days prior to the discontinuation of services – you must contact ConnectiCare at 800-451-7784.

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Elective Inpatient Admission Notification

Physicians, hospitals, or other Health Delivery Organizations (HDOs) should notify ConnectiCare within twenty-four (24) hours for any emergency or urgent admission. Use the provider portal or call ConnectiCare’s Notification Line at 800-562-6833.

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Concurrent Review

Concurrent review

ConnectiCare approves a length of stay based upon medical necessity on a concurrent review basis. Inpatient care and home care services are subject to concurrent review, which is conducted by a ConnectiCare case manager or designee over the telephone or through direct medical chart review. ConnectiCare uses Medicare guidelines for medical surgical/acute care admissions, skilled nursing/sub-acute admissions, home health care services, and observation level of care.

If you have any questions or would like a copy of the guideline specific to a member’s condition, please contact the case manager with whom you are working, or call 800-508-6157.

Although concurrent review activity involves the facility or agency utilization review departments, physicians are frequently contacted for information and assistance in developing a discharge plan that facilitates the delivery of services in the most appropriate setting. The attending physician is contacted for more information when it appears that the member’s condition does not meet continued stay criteria. If the intensity of services or severity of illness of the member does not support a continued stay at the current level of care, the applicable physician organization’s medical director or a ConnectiCare medical director will review the case. If the authorized length of stay has expired before a continuance is approved, the member may not be held responsible for the fees associated with such services, unless the member was otherwise notified in writing by ConnectiCare in advance.

Note: Practitioners and other providers are expected to comply with inpatient reviews upon request, even when ConnectiCare is the secondary carrier for the member.

ConnectiCare will issue a decision in a timeframe consistent with federal regulation for a concurrent review. If ConnectiCare makes an attempt to obtain the needed clinical information in this timeframe and the information is not provided, ConnectiCare is still required to issue a determination. In this case, ConnectiCare will issue a determination based on the information already made available. An administrative denial may be issued if information was requested but not submitted within this twenty-four (24) hour period.

In addition, circumstances may occur during a hospital/facility admission in which the patient’s care or treatment is delayed by scheduling problems, delays in getting needed evaluations or consultations, delays in discharge planning, the unavailability of hospital/facility services over the weekend or on holidays, or other administrative delays. These cases will also be reviewed by the applicable physician organization medical director or a ConnectiCare medical director for determination of authorization of payment to the hospital/facility and physician.

If the delay in discharge results from a facility’s delay in providing needed services, attending physicians will be compensated for their services during this time.

However, if the delay in discharge is due to a decision or lack of action by the attending physician, that physician will not be compensated for days not authorized.

 

What happens next?

  • ConnectiCare’s medical director will review the request for continued stay and make the determination.
  • If the decision results in extending coverage, the notification will include the number of extended services approved, the new total of approved services, the date of onset of the services, and the next review date.
  • If health services can be provided in more than one medically appropriate setting, it is within ConnectiCare’s discretion to choose the setting for the provision of those services. In addition, the services must be provided in that setting in order for the member to be eligible for benefit coverage.
  • If the medical director determines that continued payment for the facility stay cannot be authorized, the attending physician will be notified by phone or fax and will also receive written confirmation. If upon review of clinical documentation the medical director does not approve the day(s), you may utilize the reconsideration process and/or appeal the decision. See "Provider Appeals" for additional information.
  • The written notification will include: the reason for the determination and clinical rationale, if any; instructions on how to initiate an appeal of the decision; general information on external appeal rights, if applicable; notice of the availability of clinical review criteria referenced in the decision, and the name and phone number of the physician reviewer who made the decision.

 

Medicare PPM/1.12

Inpatient Hospital Readmission Review

Inpatient hospital readmission review

When a member who is discharged from a hospital is readmitted to the same hospital or same hospital network within thirty (30) days, a ConnectiCare utilization manager will review the case to determine if the readmission is related to the original inpatient stay.

View our complete Hospital Readmission Policy

 

Medicare PPM/10.18

Post-Service Review

Post-service review

ConnectiCare's Medical Operations Department conducts post-service reviews on unauthorized elective admissions and emergency admissions of which ConnectiCare was not notified or services that required preauthorization where none was obtained. If a claim is submitted without preauthorization, ConnectiCare may issue an administrative denial for failure to meet the plan’s administrative requirements related to prior approval or notification.

 

Medicare PPM/2.10

Dispute Resolution

ConnectiCare Dispute Resolution for Medicare Plans

Overview

ConnectiCare provides processes for members and practitioners to dispute a determination that results in a denial of payment and/or covered services. Process, terminology, filing instructions and applicable time frames and additional and/or external review rights vary based on the type of plan in which the member is enrolled. The processes in this section apply to commercial and Medicare plans.

We do not discriminate against practitioners or members or attempt to terminate a practitioner's agreement or disenroll a member, for filing a request for dispute resolution.

We have interpreter services available to assist members with language and hearing/vision impairments.

Payments for Services in Dispute

ConnectiCare network practitioners may not seek payment from members for either covered services or services determined by ConnectiCare’s Care Management program not to be medically necessary unless the member agrees, in writing and in advance of the service, to such payment as a private patient and the written agreement is placed in the member's medical record. Any practitioner attempting to collect such payment from the member in the absence of such a written agreement does so in breach of the contractual provisions with ConnectiCare. Such breach may be grounds for termination of the practitioner's contract.

Key Terminology

The following descriptions provide a general overview of the terminology used with commercial and Medicare plans.

Adverse Determination
A notification sent when a health care service, procedure, or treatment is denied.

Appeal
A request to review any aspect of an adverse claim, medical, or benefit determination.

Complaint
A request to review an administrative process, service, or quality-of-care issue that does not pertain to a determination based on claims, benefits, or medical necessity.

Grievance
A request to review any aspect of an adverse benefit or claim determination that is not based on medical necessity.

Certain disputes — whether they are appeals, complaints or grievances — may be filed as expedited or standard depending on the urgency of the patient's condition.

Certain disputes may also be filed as pre-service or post-service depending on the timing of the determination in question.

Managing Entities

ConnectiCare contracts with separate managing entities to provide care for certain types of medical conditions. In these cases, the designated managing entity will determine the applicable process for filing a dispute. Any aspect of service rendered by ConnectiCare or any entity designated to perform administrative functions on our behalf is hereafter jointly referred to as “ConnectiCare."

Initial Adverse Determinations

ConnectiCare will send a written notice on the date when a health care service, procedure, or treatment is given an adverse determination (denial) on the following grounds:

  • Service does not meet or no longer meets the criteria for medical necessity, based on the information provided to us.
  • Service is considered to be experimental or investigational (rare disease, clinical trial, and out-of-network services).
  • Service is approved, but the amount, scope, or duration is less than requested.
  • Service is not a covered benefit under the member's benefit plan.
  • Service is a covered benefit under the member's benefit plan, but the member has exhausted the benefit for that service.

The written notice will be sent to the member and provider if there is member liability and will include:

  • The reasons for the determination, including the clinical rationale, if any.
  • Instructions on how to initiate internal appeals (standard and expedited appeals) and eligibility for external appeals.
  • Notice of the availability, upon request of the member or the member's designee of the clinical review criteria relied upon to make such determination.
  • A description of what additional information, if any, must be provided to, or obtained by, ConnectiCare in order for ConnectiCare to make an appeal determination.
  • The description of the action to be taken.
  • A statement that ConnectiCare will not retaliate or take any discriminatory action against the member if an appeal is filed.
  • The process and time frame for filing/reviewing an appeal with ConnectiCare, including the member's right to file an expedited review.
  • The member's right to contact the Connecticut Insurance Department at 800‑203‑3447 regarding their complaint.

The failure of ConnectiCare to make a utilization review (UR) determination within the prescribed time periods is deemed to be an adverse determination subject to appeal for Medicare only (excludes retrospective and concurrent case types). ConnectiCare must send notice of denial on the date that the utilization review's time frames expire.

Reconsideration/Peer-to-Peer

For all ConnectiCare plans in Connecticut (including plans sold through Access Health CT, the state insurance marketplace):

ConnectiCare offers participating practitioners a peer-to-peer process when an adverse medical determination has been issued. Providers may request a peer-to-peer conference within a two-week period following the date of the notice of adverse determination provided that an appeal has not been initiated. The peer-to-peer shall occur between the practitioner requesting approval of the service and the clinical peer reviewer who made the initial adverse determination. If the adverse determination is not reversed after the peer-to-peer process, providers or members may pursue the provider appeals process. Please note, the peer-to-peer process is not a prerequisite to the appeals process. Requests for peer-to-peer that are initiated more than two weeks after the initial notification of adverse determination will be processed as appeals.

For all ConnectiCare plans in Massachusetts:

ConnectiCare offers providers a reconsideration process when an adverse determination has been issued during a clinical peer review, whether such adverse determination was given during an initial or a concurrent review. That reconsideration process shall take place within one (1) working day after ConnectiCare receives the provider’s request. The reconsideration process shall involve the provider rendering the service and the clinical peer reviewer who made the initial adverse determination or, if the reviewer is not available, the reviewer’s clinical peer designee. If the adverse determination is upheld, the member, or the provider on behalf of the member, may then follow the grievance process through the formal provider appeals process. Please note, the reconsideration process is not a prerequisite to the formal internal grievance process or expedited appeal.

What happens next after the peer-to-peer process or the reconsideration process?

  • ConnectiCare’s medical director will review the request and make the determination.
  • If ConnectiCare upholds the initial adverse determination, providers will be notified verbally. Providers may then use the appeals process as outlined in the provider appeals process. However, members may not be billed for services denied under this process.
  • For determinations that were upheld, the initial adverse determination letter to the provider serves as notification and will include: the reason for the determination and clinical rationale, if any; instructions on how to initiate an appeal of the decision; general information on external appeal rights, if applicable, including how to initiate an external appeal; notice of the availability of clinical review criteria referenced in the decision, and the name and phone number of the physician reviewer who made the decision.

Retrospective Review Requests

For retrospective review requests, ConnectiCare must make a decision and provide written notification of the determination. The decision must be made within 30 days of receipt of the necessary information.

Practitioner Dispute Resolution Procedures: Complaints and Grievances

View TABLE 21-1, PRACTITIONER COMPLAINT/GRIEVANCE PROCEDURES

Practitioner Complaint Process

If a practitioner is dissatisfied with an administrative process, quality of care issue and/or any aspect of service rendered by ConnectiCare that does not pertain to a benefit or claim determination, the practitioner may file a complaint on their own behalf. Examples of such dissatisfaction include:

  • Long wait times on ConnectiCare's authorization phone lines.
  • Difficulty accessing ConnectiCare's systems.
  • Quality-of-care issues.

Once a decision is made on a practitioner's complaint, it is considered final and there are no additional internal review rights.

Complaints must be submitted in writing to ConnectiCare's Grievance and Appeals Department. A complaint should include a detailed explanation of the clinician's request and any documentation to support the practitioner's position.

ConnectiCare will acknowledge receipt of the practitioner's complaint in writing no later than 15 days after its receipt. Practitioner complaints will be reviewed, and a written response will be issued directly to the practitioner no later than 30 days after receipt.

Practitioner Grievance Process

If a practitioner is not satisfied with any aspect of a claim determination rendered by ConnectiCare (or any entity designated to perform administrative functions on our behalf) which does not pertain to a medical necessity determination, that practitioner may file a claim inquiry with ConnectiCare. If the inquiry does not resolve the issue, the practitioner may then file a grievance.

The practitioner should use the secure provider portal to submit a claim inquiry along with supporting documentation. To initiate an inquiry, sign in to connecticare.com/providers and follow these steps:

  1. Select the Claims tab and click Search Claims to locate your claim.
  2. On the Claims Detail page, click Ask a Question.
  3. On the Message Details page, select Claims and Payments category (and a subcategory) to file a claim inquiry
  4. Enter Message Content and upload Attachments (if necessary) and click Submit.

If the practitioner is not satisfied with the outcome of the inquiry, they have the option of filing a grievance via the secure provider portal. To submit a grievance, sign in to connecticare.com/providers and follow these steps:

  1. Click the User Profile icon and select My Messages.
  2. On the My Messages page, search and locate the message you submitted for the initial claim inquiry.
  3. Click Follow-up to create a linked message.
  4. On the Message Details page, select Grievances & Appeals category (and a subcategory) to file a grievance.
  5. Enter Message Content and upload Attachments (if necessary) and click Submit.

See the provider portal training guides and videos for step-by-step instructions on using the Message Center and Claims – Search, View, and Export.

The Grievance and Appeals Department is not involved in determining claim payment or authorizing services, but independently investigates all grievances.

Examples of reasons for filing grievances include dissatisfaction with a decision resulting from a failure to follow a plan policy or procedure, or failure to obtain prior approval for an inpatient admission. A practitioner may also file a grievance regarding how a claim was processed, including issues such as computational errors, interpretation of contract reimbursement terms, or timeliness of payment.

In addition, providers who wish to challenge the recovery of an overpayment or request a reconsideration for commercial claims denied exclusively for untimely filing may follow the grievance procedures in this sub-section.

If a claim was submitted after the time frame outlined in the Filing Limits section of Billing and Claims, ConnectiCare may deny the claim in full or in the alternative may agree to reduce payments by up to 25% of the amount that would have been paid had the claim been submitted in a timely manner. For grievances related to untimely filing, the provider must demonstrate that the late submission was an unusual occurrence and that they have a pattern of submitting claims in a timely manner. Examples of an unusual occurrence include:

  • Member submitted the wrong insurance information to the provider.
  • Coordination of Benefits related issues.
  • Member retroactively reinstated.

The grievance should be accompanied by a copy of the notice of the standard denial or other documentation of the denial, an explanation outlining the details of the request for a review and all documentation to support a reversal of the decision.

ConnectiCare will review the grievance and a written response will be issued for grievances with a final disposition of partial overturn or upheld, no later than 30 days for Medicare and 90 days for commercial after receipt. The determination included in the response will be final. 

Grievances with a favorable disposition will receive a claims remittance advice in lieu of a written response no later than 30 days for Medicare and 90 days for commercial after receipt.

Member Dispute Resolution Procedures: Complaints and Grievances for ConnectiCare Commercial and ConnectiCare of Massachusetts Plans

Member Complaint – First-Level Process

View Member Complaint – First-Level Process Tables

A member or designee may file a first-level complaint when the member is dissatisfied with any aspect of an ConnectiCare-rendered service that does not pertain to a benefit or claim determination. Examples of such dissatisfaction include:

  • Dissatisfaction with treatment received from ConnectiCare, its practitioners or benefit administrators.
  • Quality-of-care complaints.
  • Privacy complaints regarding ConnectiCare's practices in using or disclosing protected health information.
  • Alleged violation of ConnectiCare's privacy practices and/or state and federal law regarding the privacy of protected health information.
  • Fraud and abuse.

Complaints should include a detailed description of the circumstances surrounding the occurrence. ConnectiCare will acknowledge receipt of the complaint and request any necessary information in writing. Complaints will be reviewed, and a response will be issued in writing according to the time frames applicable to the member's benefit plan and detailed in the table linked above.

Member Grievance – First-Level Process

View Member Grievance – First-Level Process Table

If a member or designee is not satisfied with any aspect of a benefit or claim determination rendered by ConnectiCare that does not pertain to a medical necessity, experimental determination, or investigational determination, they may file a first-level grievance.

Grievances should be accompanied by a copy of the adverse determination, an explanation outlining the details of the request for a review and all documentation to support a reversal of the decision. We will acknowledge receipt of the grievance and request any necessary information in writing. Grievances will be reviewed, and a response will be issued according to the time frames detailed in the tables linked above.

Provider and Member Clinical Appeal Processes

ConnectiCare may reverse a prior approval decision for a treatment, service, or procedure on retrospective review when all the following criteria are met:

  • Relevant medical information presented to ConnectiCare or the utilization review agent upon retrospective review is materially different from the information that was presented during the prior approval.
  • The information existed at the time of the prior approval review but was withheld or not made available.
  • ConnectiCare or the utilization review agent was not aware of the existence of the information at the time of the prior approval review.
  • Had they been aware of the information, the treatment, service, or procedure being requested would not have been authorized.

Clinical Appeal - Expedited Process

View Table 21-10, Clinical Appeal - Expedited

If a member or designee is not satisfied with a service or a determination that was rendered based on issues of medical necessity, an experimental or investigational use, a rare disease or (in certain instances) out-of-network services, an expedited appeal may be filed if we determine or the provider indicates that a delay would seriously jeopardize the member’s life, health, or ability to attain, maintain, or regain maximum function. The member or designee may request expedited review of a prior approval request or concurrent review request.

An expedited appeal may be filed:

  • For continued or extended health care services, procedures, or treatments.
  • For additional services for members undergoing a course of continued treatment.
  • When the health care provider believes an immediate appeal is warranted.
  • When ConnectiCare honors the member’s request for an expedited review.

Expedited appeals should be accompanied by a copy of the denial letter, an explanation outlining the details of the request for a review and all documentation to support a reversal of the decision. The expedited utilization review appeal may be filed in writing or by telephone.

Missing Information

If ConnectiCare requires information necessary to conduct an expedited appeal, ConnectiCare shall immediately notify the member and the member's health care provider by phone or fax to identify and request the necessary information followed by written notification.

Reviewer of Expedited Appeal Requests

The review will be conducted by a qualified ConnectiCare medical director who was neither involved in prior determinations nor the subordinate of any person involved in the initial adverse determination. A clinical peer reviewer will be available to discuss the appeal within one business day.

Denial of Expedited Appeal Process

If we deny the request for expedited review because it does not meet the criteria for an expedited appeal, we will process the request through the standard appeal review time frames and will notify the appellant of this verbally and in writing.

Clinical Appeal - Standard Process

Procedures for initiating a standard appeal are outlined TABLE 21-11, APPEAL - STANDARD.

If a member or designee or provider is not satisfied with a service or a determination that was rendered based on issues of medical necessity, an experimental or investigational use, a clinical trial, a rare disease, or (in certain instances) out-of-network services, an appeal may be filed. The standard Clinical Appeal may be filed in writing or by telephone.

Missing Information

If we require information necessary to conduct a standard internal appeal, we will notify the member and the member's health care provider, in writing, within 15 calendar days of receipt of the appeal (as noted in the tables linked above), to identify and request the necessary information. If only a portion of such necessary information is received, we shall request the missing information, in writing, within five business days of receipt of the partial information.

Reviewer of Standard Appeal Requests

The review will be conducted by a qualified ConnectiCare medical director who was neither involved in prior determinations nor the subordinate of any person involved in the initial adverse determination. A clinical peer reviewer will be available to discuss the appeal within one business day.

Facility Dispute Resolution Procedures

Retrospective Utilization Review Requests

View TABLE 21-12, FACILITY RETROSPECTIVE REVIEW REQUEST

If a ConnectiCare-contracted facility fails to follow prior approval and/or emergency admittance procedures, payments for such services may be denied and the facility, ConnectiCare or its managing entity may initiate a retrospective utilization review (RUR).

For Denials Based on "No Prior Approval"

If the facility fails to obtain prior approval, payment will be denied for "no prior approval." The remittance statement will include information regarding the facility's right to request a retrospective utilization review for medical necessity.

If the facility fails to request a retrospective utilization review and submit the medical record within 45 days of receipt of the remittance statement, the claim denial will be upheld, and the facility will have no further appeal rights.

Facility Clinical Appeals

View TABLE 21-13, FACILITY CLINICAL APPEAL

If an ConnectiCare-contracted facility is not satisfied with a claim determination regarding denial of payment for inpatient services based on medical necessity, the facility may file a facility clinical appeal.

ConnectiCare provides one internal level of appeal for facilities.

ConnectiCare handles all facility clinical appeals.

ConnectiCare will render a decision within 30 days of receipt of the appeal request.

  • For members already discharged
    If the facility provides additional information after the denial is issued and after the member is already discharged, no reconsideration review will be performed. However, the facility may exercise its right to a clinical appeal.

    The appeal request must be filed within 60 days for Medicare and 180 days for commercial of the initial adverse determination or as stated in the facility contract. If the appeal request is received outside of this time frame, the original denial will be upheld and there will be no further appeal rights. Facilities are not permitted to balance bill members for such denials.
  • For denials based on "No Information"
    If the facility fails to provide any clinical information to establish medical necessity for an admission or procedure, the claim will be denied based on "no information" and the facility may file a clinical appeal.
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Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your  plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.