Senate Bill 180 (SB180 File No. 18) proposes amendments to the healthcare system's adverse determination and utilization review processes, with an effective date of January 1, 2025. The bill specifies that clinical peers conducting reviews must hold a nonrestricted license in the same specialty as the treating professional for general reviews, and for substance use or mental health disorders, they must have specific qualifications such as board certification in psychiatry or a doctoral-level psychology degree. It requires health carriers to use clinical review criteria based on sound clinical evidence, periodically evaluate their effectiveness, and make them available online. A key insertion in the bill is the rebuttable presumption that healthcare services ordered by a professional within their scope of practice are medically necessary, shifting the burden of proof to the health carrier to prove otherwise.

The bill also outlines the responsibilities of health carriers in notifying covered persons or their representatives about utilization review and benefit determinations, including expedited reviews for urgent care requests. It introduces a requirement for health carriers to inform the covered person's health care professional of the opportunity for a conference with a clinical peer in the event of an initial adverse determination. The clinical peer is granted the authority to reverse the initial adverse determination. The bill amends sections 38a-591a(7), 38a-591c(a), 38a-591d(a), and 38a-591e(c) of the general statutes and includes a fiscal impact statement indicating potential costs and revenue impacts for state and municipal entities.