Section 17b-262-825 - Authorization(a) Behavioral health clinic services for clients with psychiatric and substance abuse disorders shall be subject to authorization requirements to the extent required by this section. Where a service is subject to authorization requirements, Medicaid payment for such service shall not be available unless the provider complies with such requirements.(b) Services that require authorization shall be designated as such on the provider's fee schedule published at www.ctdssmap.com.(c) The following requirements shall apply to all services that require authorization under subsection (b) of this subsection:(1) The initial authorization period shall be based on the needs of the client;(2) In order to receive payment from the department, a provider shall comply with all authorization requirements. The department or its agent, in its sole discretion, determines what information is necessary in order to approve an authorization request. Authorization does not, however, guarantee payment unless all other requirements for payment are met;(3) A provider shall present medical or social information adequate for evaluating medical necessity when requesting authorization. The provider shall maintain documentation adequate to support requests for authorization including, but not limited to, medical or social information adequate for evaluating medical necessity;(4) Requests for authorization for the continuation of services shall include the progress made to date with respect to established treatment goals, the future gains expected from additional treatment and medical or social information adequate for evaluating medical necessity;(5) The provider shall maintain documentation adequate to support requests for continued authorization including, but not limited to: Progress made to date with respect to established treatment goals; the future gains expected from additional treatment; and medical or social information adequate for evaluating medical necessity; and(6) The department may require a review of the discharge plan and actions taken to support the successful implementation of the discharge plan as a condition of authorization.(d) The following requirements shall apply to all services that require prior authorization: (1) If prior authorization is needed beyond the initial or current authorization period, requests for prior authorization for continued treatment shall be submitted prior to the end of the current authorization period; and(2) Except in emergency situations or for the purpose of initial assessment, prior authorization shall be received before services are rendered.(e) The following requirements shall apply to all services provided to a client whose eligibility is granted retroactively: (1) A provider may request retroactive authorization, for services provided during the period of retroactive eligibility, from the department for a client who is granted eligibility retroactively or in cases where it was not possible to determine eligibility at the time of service;(2) For a client who is granted retroactive eligibility, the department may conduct retroactive medical necessity reviews. The provider shall be responsible for initiating this review to enable retroactive authorization and payment for services; and(f) The department may deny prior authorization, registration or retroactive authorization based on non-compliance by the provider with the department's utilization management policies and procedures.Conn. Agencies Regs. § 17b-262-825
Effective October 9, 2013