Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Physicians' Services › Section 17b-262-348 - Payment limitations

Current through July 10, 2024
(a) The department shall pay only for physicians' services performed by or under the personal supervision of a physician.
(b) The department shall pay the fee for an initial visit by a provider in an office, home, ICF/MR or nursing facility only once per client. Initial visits refer to the provider's first contact with the client and reflect higher fees for the additional time required for setting up records and developing past history. The only exception to this is when the provider-client relationship has been discontinued for three or more years and is then reinstated.
(c) The department shall pay non-hospital-based providers for evaluation and management services provided to the provider's private practice clients in the emergency room.
(d) The department shall pay fees to a consultant provider only when another provider or other appropriate referral source requests the opinions and advice of the consultant provider. The consultant provider shall document such provider's opinion and any services ordered or performed by the consulting provider in the client's medical record and submit a written report describing such opinion and services to the requesting physician or other appropriate referral source. The referring provider remains responsible for carrying out the plan of care after seeking a consultation.
(e) If a client is referred to a provider for treatment of a condition that the referring provider does not usually treat, the department shall pay the treating provider the fee for an office visit rather than the fee for a consultation.
(f) When the consultant provider assumes the continuing care of the client, the department shall pay the consultant provider for any subsequent service according to the fee listed for the procedure.
(g) If a client's medical condition necessitates the concurrent services and skills of two or more providers, the department shall pay each provider the listed fee for the service that each provider provides.
(h) When a provider examines a Medicaid applicant for the purpose of substantiating whether a medical condition exists that would enable the department to determine eligibility for Medicaid disability, the department shall pay the billing provider only for the tests required to establish eligibility as requested by the department. The department shall not pay the billing provider for any other procedures.
(i)
Surgery
(1) When a billing provider submits a claim for multiple surgical procedures performed on the same date, the department shall pay the listed fee for the primary surgical procedure. THE department shall pay for additional surgical procedures performed on that day at 50% of the listed fee.
(2) When an assistant surgeon, in addition to staff provided by the general hospital or chronic disease hospital, is required, the department shall pay the assistant surgeon 20% of the listed fee for the surgery.
(3) The department shall not pay for related evaluation and management encounters on the same day of surgery.
(4) The listed fees for all surgical procedures include the surgery and typical postoperative follow-up care provided to clients in a general hospital or chronic disease hospital. The department shall pay for follow-up visits after a client is discharged from the general hospital or chronic disease hospital as office visits.
(5) The listed fees for surgery on the musculoskeletal system includes payment for the application of the first cast or traction device.