Section 17b-262-732 - Prior authorization(a) To receive payment from the department the provider shall comply with the prior authorization requirements described in section 17b-262-528 of the Regulations of Connecticut State Agencies and this section. The department, in its sole discretion, shall determine what information is necessary to approve a prior authorization request. Prior authorization does not, however, guarantee payment unless all other requirements for payment are met.(b) Prior authorization, on forms and in a manner as specified by the department, shall be required for: (1) nursing care services in excess of an initial evaluation and two visits per week;(2) all extended nursing services;(3) pregnancy-related preventive prenatal nursing care services in excess of two visits during the prenatal period;(4) pregnancy-related preventive postpartum nursing care services in excess of two visits during the postpartum period;(5) home health aide services in excess of fourteen hours per week;(6) physical therapy services in excess of an initial evaluation and two visits per week;(7) speech therapy services in excess of an initial evaluation and two visits per week;(8) occupational therapy services in excess of an initial evaluation and one visit per week;(9) physical therapy, occupational therapy or speech therapy services in excess of nine visits per therapy type per calendar year per provider per client, when the therapy is for the treatment of the following diagnoses:(A) all mental disorders including diagnoses relating to mental retardation and specific delays in development covered by the International Classification of Diseases (ICD), as amended from time to time;(B) cases involving musculoskeletal system disorders of the spine covered by the ICD, as amended from time to time; or(C) cases involving symptoms related to nutrition, metabolism and development covered by the ICD, as amended from time to time; and(10) Early and periodic screening, diagnostic and treatment services requested under section 1905(r)(5) of the Social Security Act, as amended from time to time.(c) The provider shall obtain, and the department may give, the initial prior authorization either verbally or by mail. The length of the initial authorization is at the department's discretion, but shall be for no longer than a three-month period. The provider shall submit subsequent prior authorization requests in writing by mail at least thirty days in advance of providing services or delivering goods beyond the period of initial approval. If there is a need to change the prior authorization request, the provider shall notify the department not more than two working days after the modification was made. Any authorization period for home health aide services shall be for at least one month.(d) If continued treatment is needed beyond an initial or subsequent authorization period, the department shall consider, and may approve, an additional prior authorization request that shall be for a period of up to twelve months. The provider shall submit subsequent prior authorization requests in writing by mail at least thirty days in advance.(e) The provider shall present pertinent medical or social information adequate for evaluating the client's medical need for services when requesting prior authorization. The home health care agency shall maintain a valid practitioner's order on file. Except in emergency situations, the provider shall obtain approval from the department before services are rendered.(f) In an emergency situation that occurs after working hours or on a weekend or holiday, the provider shall secure verbal authorization on the next working day for the services provided. This applies only to those services that normally require prior authorization. If verbal authorization is obtained, the provider shall submit a written request not more than ten days after the date of service.Conn. Agencies Regs. § 17b-262-732
Adopted effective March 7, 2007