Senate Bill No. 180 (SB180), also referred to as File No. 18, is a legislative proposal aimed at amending the general statutes concerning health insurance, specifically in the areas of adverse determination and utilization reviews. The bill introduces a rebuttable presumption that health care services ordered by a health care professional within their scope of practice are medically necessary, thus placing the burden of proof on health carriers to prove otherwise. It also enhances the qualifications for clinical peers involved in reviews, requiring them to have a nonrestricted license in the same specialty as the treating health care professional, with additional qualifications for reviews related to substance use disorders and mental disorders. The bill removes the term "similar" from the specialty requirement and mandates that health carriers post their clinical review criteria online and make them available upon request. The bill is set to take effect on January 1, 2025.

Additionally, SB180 requires health carriers to maintain written procedures for utilization review and benefit determinations, including expedited reviews for urgent care requests. It defines an urgent care request based on the judgment of a prudent layperson or a health care professional familiar with the patient's condition. The bill also ensures that health carriers notify the covered person's health care professional of the opportunity for a conference in the case of an initial adverse determination and that such a conference is not considered a grievance unless a grievance has been filed. Health carriers are required to ensure the independence and impartiality of clinical peers reviewing adverse determinations and to continue treatment without liability to the covered person until the review decision is communicated if the review is expedited. The fiscal impact statement notes potential increased administrative costs and medical service utilization for the State Comptroller's state employee health plan and possible cost impacts on municipalities. The bill has been favorably passed by the Public Health Committee.