Section 17b-262-656 - Need for service and authorization process(a) The department shall pay for medically necessary and medically appropriate dialysis services for Medicaid Program clients, in relation to the diagnosis for which care is required, provided that:(1) the services are within the scope of the provider's practice;(2) a physician documents the need in writing and orders the service; and(3) the services are made part of the client's medical record.(b) Prior authorization, on forms and in a manner as specified by the department, is required for HealthTrack Special Services:(1) HealthTrack Special Services are determined medically necessary and medically appropriate on a case-by-case basis; and(2) the request for HealthTrack Services shall include:(A) a written statement from the prescribing physician, or other licensed practitioner of the healing arts, performing such services within his or her scope of practice as defined under state law, justifying the need for the item or services requested;(B) a description of the outcomes of any alternative measures tried; and(C) if applicable and requested by the department, any other documentation required in order to render a decision.(c) The procedure or course of treatment authorized shall be initiated within six months of the date of authorization.(d) The initial authorization period shall be up to three months.(e) If prior authorization is needed beyond the initial authorization period, requests for continued treatment beyond the initial authorization period shall be considered up to six months per request.(f) For services requiring prior authorization, a provider shall be required to provide pertinent medical or social information adequate for evaluating the client's medical need for services. Except in emergency situations, or when authorization is being requested for more than one visits in the same day, approval shall be received before services are rendered.(g) In an emergency situation which occurs after working hours or on a weekend or holiday, the provider shall secure verbal approval on the next working day for the services provided. This applies to only those services which normally require prior authorization.(h) In order to receive payment from the department a provider shall comply with all prior authorization requirements. The department in its sole discretion determines what information is necessary in order to approve a prior authorization request. Prior authorization does not, however, guarantee payment unless all other requirements for payment are met.Conn. Agencies Regs. § 17b-262-656
Adopted effective May 10, 2000