Section 17b-262-812 - Utilization review program(a) The department conducts utilization review activities for services delivered by the PRTF for clients where Medicaid has been determined to be the appropriate payer.(b) To determine whether admission to a PRTF is medically necessary and medically appropriate, the department or the Administrative Service Organization shall: (1) authorize each PRTF admission, unless the department notifies the providers that a specific admission or diagnosis does not require such authorization; and(2) perform retrospective reviews, at the department's discretion, which may be a random or targeted sample of the admissions and services delivered. The review may be focused on the appropriateness, necessity or quality of the health care services provided.(c) All claims for payment for admission and all days of stay and services that are provided shall be documented. Lack of said documentation may be adequate grounds for the department, in its discretion, to deny or recoup payment for the admission for some or all of the days of stay or services provided.(d) The department may conduct medical reviews and inspections of care in PRTFs.Conn. Agencies Regs. § 17b-262-812
Adopted effective September 4, 2009