Section 17b-262-473 - Need for service and authorization process(a)Need for ServiceThe department shall pay for psychological services which are provided by a licensed psychologist and are medically necessary and medically appropriate for the prevention, diagnosis, and treatment of intellectual functioning and mental illness.
(b)Prior Authorization(1) Prior authorization, on forms and in a manner as specified by the department, is required for: (A) all clients for all counseling and psychotherapy interviews in excess of thirteen visits in a calendar quarter, per type of treatment for the same provider and client; and(B) 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.(2) For services requiring prior authorization, the procedure or course of treatment shall be initiated within six months of the date of authorization.(3) The initial authorization period shall be up to three months.(4) All authorization request forms shall include an explanation of the need for additional treatment for services in excess of the limitations described in subparagraph (A) of subdivision (1) of subsection (b) of section 17b-262-473, and the future gains expected.(5) If prior authorization is needed beyond the initial authorization period, requests for continued treatment beyond the initial authorized period shall be considered for up to six months per request.(6) The provider shall determine as soon as possible whether the number of service visits necessary shall exceed thirteen visits in a calendar quarter. If the number of visits shall exceed the limit, authorization shall be obtained from the department prior to the onset of the service visits for which authorization is needed.(7) The authorization request form shall include the name of the physician, person, or agency making the referral.(8) In urgent situations involving services which require prior authorization, the provider of service may request verbal approval by the department during normal working hours, or no later than the next business day if the urgent situation occurs outside of the department's normal working hours, when such authorization may be given. However, approval in such a manner shall be limited to psychological services that are immediately necessary and vital to the health and safety of the client.(9) 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-262-473