Conn. Agencies Regs. § 17b-262-614

Current through December 27, 2024

Section 17b-262-614 - Prior authorization

(a) Prior authorization, on forms and in a manner as specified by the department, is required for the following services:

(1) more than one visit on the same day for the same client by the same provider. Authorization for additional visits need not be submitted in advance of the service, but providers shall submit the authorization request prior to billing for the second or subsequent visits;

(2) admissions to acute care hospitals pursuant to section 17-134d-80 of the Regulations of Connecticut State Agencies;

(3) electrolysis epilation;

(4) physical therapy services in excess of two treatments per calendar week per client per provider;

(5) physical therapy services in excess of nine treatments per calendar year per client per provider, involving the following primary diagnoses:

(A) all mental disorders including diagnoses related 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 covered by ICD, as amended from time to time; and

(C) cases involving symptoms related to nutrition, metabolism, and development covered by ICD, as amended from time to time;

(6) reconstructive surgery, including breast reconstruction following mastectomy;

(7) plastic surgery;

(8) transplant procedures; and

(9) HealthTrack Special Services.

(A) HealthTrack Special Services are determined medically necessary and medically appropriate on a case-by-case basis; and

(B) 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 required;

(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 nurse practitioner 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) 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-262-614

Effective August 10, 1998