Section 17b-262-827 - Payment(a) The commissioner shall establish fees in accordance with section 4-67c of the Connecticut General Statutes. Fees shall be the same for in-state, border and out-of-state providers.(b) If the client is present for up to half of the intermediate care program day and attends at least one individual, family or group session, the provider may bill half of the applicable Medicaid fee or rate. If the client is present for more than a half of the intermediate care program day but less than a full day and attends at least two individual, family or group sessions, the provider may bill the full day charge on file. If the client does not attend at least one individual, group or family session the provider is not entitled to any payment from the department.(c) A single per diem fee shall be billed for intermediate care programs inclusive of all medication evaluation or management services, treatment and rehabilitative services, administrative services and coordination with or linkages to other health care services. A provider may bill separately for medically necessary individual or family psychotherapy services provided outside of the program hours of operation if such services are necessary for the purpose of client transition or continuity of care.(d) If a session includes a combination of individual and family psychotherapy, the provider shall bill for the type of psychotherapy that comprises the greater part of the session. Individual and family psychotherapy shall not both be billed for the same date of service unless each type of session individually meets the minimum time requirement for the modality.(e) Practitioners who are clinic-based either on a full-time or part-time basis are not entitled to individual payment from the department for services rendered to clients at the clinic. The clinic shall bill for the services, except as provided in section 17b-262-460(c) of the Regulations of Connecticut State Agencies.(f) Payment for services provided to a client is contingent upon the client's eligibility on the date that services are rendered.(g) The department shall pay the lower of:(1) The amount in the applicable fee schedule;(2) The amount on the provider's rate letter; or(3) The amount billed by the provider.(h) The department may establish higher reimbursement for providers that meet special requirements.(1) The special requirements shall be established by the department and may vary by provider type and specialty. The department, in its sole discretion, shall determine whether a provider meets the requirements for the higher reimbursement.(2) The special requirements shall be related to improvements in access, quality, outcomes or other service characteristics that the department reasonably determines may result in better care and outcomes.(3) The department may grant provisional qualifications for higher reimbursement by means of an application process in which providers submit a plan that demonstrates the feasibility of meeting the requirements.(4) The department shall conduct periodic qualifications reviews. If a provider fails to continue to meet the requirements, the department may grant a probationary period of not less than 120 days during which the provider continues to qualify for higher reimbursement and is permitted an opportunity to submit a corrective action plan and to demonstrate compliance to the department.(5) The department may conduct provider audits to determine whether a provider is performing in compliance with the special requirements.Conn. Agencies Regs. § 17b-262-827
Effective October 9, 2013