Section 17b-262-636 - Prior authorization(a) Prior authorization, on forms and in a manner as specified by the department, is required for:(1) All audiology, physical therapy, occupational therapy and speech pathology evaluation services in excess of one evaluation per calendar year, per client, per provider;(2) all audiology, physical therapy, occupational therapy and speech pathology treatment services in excess of nine treatments per calendar year per provider per client, involving the following primary diagnoses:(A) All mental disorders including diagnoses relating to mental retardation and specific delays in development covered by the ICD;(B) cases involving musculoskeletal system disorders of the spine covered by the ICD; and(C) cases involving symptoms related to nutrition, metabolism and development covered by the ICD;(3) all audiology, physical therapy, occupational therapy and speech pathology treatment services in excess of two services per calendar week, per client, per provider;(4) EPSDT Special Services, as follows: (A) EPSDT Special Services are determined medically necessary on a case-by-case basis; and(B) the request for EPSDT Special Services shall include:(i) A written statement from a licensed practitioner justifying the need for the item or services requested; and(ii) any other documentation required by the department in order to render a decision; and(5) any service that is not on the department's fee schedule.(b) The length of the initial authorization period is at the department's discretion, but shall be for no longer than three months;(c) 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 or longer if determined appropriate by the department on a case- by-case basis.(d) For services requiring prior authorization, a provider shall provide pertinent medical or social information adequate to evaluate the client's medical need for the services.(e) 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 guarantee payment unless all other requirements for payment are met.Conn. Agencies Regs. § 17b-262-636
Adopted effective December 1, 2000; Amended September 6, 2012