Section 17b-262-344 - Prior authorization(a) Prior authorization, on forms and in the manner specified by the department, is required in order for payment to be available for the following physicians' services. Prior authorization is also required for services designated by the department and published on its website or by other means accessible to providers.(1) Electrolysis epilation;(2) physical therapy services in excess of two visits per calendar week per client per provider;(3) physical therapy services in excess of nine visits per calendar year per client per provider, when the therapy being prescribed is for the treatment of: (A) All mental disorders, including diagnoses related to mental retardation and specific delays in development covered by the ICD;(B) musculoskeletal system disorders of the spine covered by the ICD; and(C) symptoms related to nutrition, metabolism and development covered by the ICD;(4) reconstructive surgery, including breast reconstruction following mastectomy;(6) transplant procedures;(7) Early and Periodic Screening, Diagnostic and Treatment services that are identified during a periodic screening as medically necessary and that are not payable pursuant to the physician fee schedule; and(8) any service or device that is not on the department's fee schedule.(b) Prior authorization is required for all hospital admissions pursuant to section 17-134d-80 of the Regulations of Connecticut State Agencies.(c) The department shall make payment available to the billing provider only if the provider initiates the authorized procedure or course of treatment not more than six months after the date of authorization.(d) The initial authorization period shall not exceed six months.(e) If prior authorization is needed beyond the initial authorization period, the department shall consider requests for continued treatment beyond the initial authorization period for up to an additional six-month period per request or longer as determined by the department on a case-by-case basis.(f) Except in emergency situations, the provider shall receive prior authorization before rendering services.(g) In an emergency situation involving services that require prior authorization that occurs after working hours or on a weekend or holiday, the provider shall secure verbal approval from the department on the next working day for the services provided.(h) In order to receive payment from the department, a billing 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 guarantee payment unless all other requirements for payment are met.Conn. Agencies Regs. § 17b-262-344
Adopted effective January 31, 2008; Amended March 11, 2013