Connecticut has a law requiring managed care plans to have an internal appeals system available for consumers who disagree with a plan decision (sometimes called an "adverse determination"). Those internal appeals requirements generally include the following features:

• Notice: The consumer must be told in writing that they have the right to appeal the plan’s decision along with information on how to file such an appeal. The patient also must be notified in writing of the reviewer’s decision and given copies of documentation supporting that decision.

• Timeline: Plans must respond to a patient’s appeal in a timely manner – usually within 15 – 30 days. In emergency cases, plans have to respond with 24 – 72 hours.

  • Review by qualified professionals: Plans must have a qualified health care professional (generally a physician trained in the field of care that is involved) review the case. This doctor should not have been involved with the initial decision to deny coverage.

  • Levels of appeal: Typically the health plans provide for two levels of internal appeal. In the first level, another doctor in the plan may review the decision to deny coverage. If that doctor agrees with the denial, the patient can appeal to a higher level – often the plan’s medical director.

  • Care during the review process: Some health plans continue to pay for the care in dispute while the appeal is being considered.

Managed care plan enrollees have the right to question decisions regarding their health care coverage. Connecticut state law requires that each managed care health plan establish and maintain an internal grievance procedure to insure that enrollees may seek a review of any grievance that may arise from the plan’s action or inaction. In February 2001, The Office of the Healthcare Advocate reviewed the policies and procedures of the seven largest managed care health plans in Connecticut and provide them to you for reference.

Appeals Process Summary

Other Related Links:

Determine the Problem

3 Step Complaint Process

How to Write an Appeal Letter

External Appeals Process

Download Consent Statement