Section 17b-262-554 - Prior authorization(a) Prior authorization, on forms and in a manner as specified by the department, shall be required for:(1) professional office or home visits in excess of five per client per provider per month, and(2) HealthTrack Special Services. HealthTrack Special Services are determined medically necessary and medically appropriate on a case-by-case basis. The request for HealthTrack Special Services shall include: (i) a written statement from the prescribing physician, or other licensed practitioner of the healing arts, performing such services within his or her respective scope of practice as defined under state law, justifying the need for the item or service requested;(ii) a description of the outcomes of any alternative measures tried; and(iii) if applicable and requested by the department, any other documentation required in order to render a decision.(b) The procedure or course of treatment authorized shall be initiated within six months of the date of authorization.(c) The initial authorization period shall be up to three months.(d) 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.(e) 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 visit in the same day, approval shall be received before services are rendered.(f) 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 only to those services which normally require prior authorization.(g) Eligibility for Medical Assistance Program coverage must be verified at every visit even though prior authorization has been received for the entire number of visits.(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-262-554
Adopted effective March 6, 1998