Connecticut Prior Authorization Rules

Overview

Connecticut Public Act 21-103 (2021) establishes prior authorization response timelines: standard PA requests must be decided within 5 business days and urgent requests within 72 hours of receiving complete clinical information. Connecticut Public Act 23-197 (effective January 1, 2024) adds a critical requirement: all adverse determinations (denials) of prior authorization must include human clinical review and cannot be based on artificial intelligence analysis alone.

Key Requirements

1. Standard PA Timeline: Five business days from receipt of complete clinical information to approve, deny, or request additional information.
2. Urgent PA Timeline: 72 hours for urgent or expedited requests where standard timeline could adversely affect patient care.
3. No AI-Only Denials: Connecticut PA 23-197 mandates that all adverse PA determinations require human clinical review. AI-only decisions are prohibited.
4. Denial Notice Requirements: Denial notices must include the specific clinical criteria, reviewer credentials, and evidence-based clinical rationale for the denial.
5. Emergency Exception: Prior authorization is not required for emergency services.

Penalties and Enforcement

The Connecticut Insurance Department enforces prior authorization requirements under PA 21-103 and PA 23-197. Violations include missing response deadlines, issuing denials without human clinical review, and using AI-only determinations. Insurers in violation are subject to complaints, investigations, and enforcement action. Connecticut PA 23-197 violations specifically can result in citations for AI-only determinations and require corrective action.

Appeals and Exceptions

All patients and providers have the right to appeal any PA denial. Internal appeals must be submitted within 45 days and are decided within 30 days. External review through the Connecticut Insurance Department is available for adverse internal appeal determinations. No exceptions exist to the human review requirement—all denials must include human clinical evaluation regardless of claim complexity.

Interaction with Federal Law

Connecticut's PA timelines and AI prohibition are more protective than federal requirements. Self-funded ERISA plans follow federal requirements, but Connecticut PA 23-197 may apply depending on plan administration. Connecticut state law governs all state-regulated plans and applies the strongest protections available.

Common Questions