reglab/statecodes huggingface dataset:
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Podiatric Services › Section 17b-262-624 - Services not covered

Current through July 10, 2024
The department shall not pay a podiatrist:
(1) for information or services provided to a client by a podiatrist over the telephone;
(2) for any product available to podiatrists free of charge;
(3) for more than one visit per day per client to the same podiatrist;
(4) for cosmetic surgery;
(5) for simplified tests requiring minimal time or equipment and employing materials nominal in cost, including, but not limited to, urine testing for glucose, albumin and blood;
(6) for simple foot hygiene;
(7) for repairs to devices judged by the department to be necessitated by willful or malicious abuse on the part of the client;
(8) for repairs to devices under guarantee or warranty. The podiatrist shall first seek payment from the manufacturer;
(9) for an office visit for the sole purpose of the client obtaining a prescription where the need for the prescription has already been determined;
(10) for cancelled services and appointments not kept;
(11) for services provided in a general hospital if the department determines the admission does not, or retrospectively did not, fit the department's utilization review requirements pursuant to section 17-134d-80 of the Regulations of Connecticut State Agencies; or
(12) for any procedures or services of an unproven, educational, social, research, experimental or cosmetic nature; for any diagnostic, therapeutic or treatment services in excess of those deemed medically necessary and medically appropriate by the department to treat the client's condition; or for services not directly related to the client's diagnosis, symptoms or medical history.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Podiatric Services › Section 17b-262-625 - Need for service

Current through July 10, 2024
Payment for an initial office visit and continuing services which the department deems medically necessary and medically appropriate, in relation to the diagnosis for which care is required, is available provided that:
(1) the services are within the scope of the podiatrist's practice; and
(2) the services are made part of the client's medical record.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Podiatric Services › Section 17b-262-626 - Prior authorization

Current through July 10, 2024
(a) To receive payment from the department, a podiatrist shall comply with the prior authorization requirements described in section 17b-262-528 of the Regulations of Connecticut State Agencies. The department, in its sole discretion, shall determine 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.
(b) Prior authorization, on forms and in the manner specified by the department, shall be required for:
(1) physical therapy services in excess of two visits per calendar week per client per podiatrist;
(2) physical therapy services in excess of nine visits per calendar year per client per podiatrist, when the therapy is for the treatment of the following diagnoses:
(A) cases involving musculoskeletal system disorders of the spine covered by the ICD, as amended from time to time; and
(B) cases involving symptoms related to nutrition, metabolism and development covered by the ICD, as amended from time to time;
(3) reconstructive surgery;
(4) plastic surgery;
(5) EPSDT services that are identified during a periodic screening as medically necessary and which are not listed on the existing fee schedule; and
(6) other services and supplies identified as requiring prior authorization on the fee schedule.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Podiatric Services › Section 17b-262-627 - Billing procedures

Current through July 10, 2024
(a) Claims from podiatrists shall be submitted on the department's designated form or electronically transmitted to the department, in a form and manner as specified by the department, and shall include all information required by the department to process the claim for payment.
(b) The amount billed to the department shall represent the podiatrist's usual and customary charge for the services delivered.
(c) When a client is referred to a podiatrist for consultation, the consultant podiatrist shall include the referring practitioner's name.
(d) Laboratory services performed in the podiatrist's office shall be payable to the podiatrist and shall be billed as separate line items. When a podiatrist refers a client to a private laboratory for services, the laboratory shall bill directly and no laboratory charge shall be paid to the podiatrist.
(e) All charges billed for supplies and materials provided by a podiatrist may be reviewed by the department.
(f) When services are provided by more than one member of a group, the authorization request shall be submitted prior to billing as described in the billing instructions in the provider manual.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Podiatric Services › Section 17b-262-628 - Payment

Current through July 10, 2024
(a) The commissioner shall establish, and may periodically update, the fees for covered services in the department's fee schedule pursuant to section 4-67c of the Connecticut General Statutes.
(b) Fees shall be the same for in-state, border and out-of-state podiatrists.
(c) Payment shall be made at the lowest of:
(1) the podiatrist's usual and customary charge;
(2) the lowest Medicare rate;
(3) the amount in the applicable fee schedule as published by the department pursuant to section 4-67c of the Connecticut General Statutes; or
(4) the amount billed by the podiatrist.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Podiatric Services › Section 17b-262-629 - Documentation and audit requirements

Current through July 10, 2024
(a) Podiatrists shall maintain a specific record for all services received by each client eligible for Medicaid payment including, but not limited to: name, address, birth date, Medicaid identification number, pertinent diagnostic information, a current treatment plan and treatment notes signed by the podiatrist, documentation of services provided and the dates the services were provided and a signed receipt for all devices dispensed. The receipt for any dispensed device, regardless of the format used, shall, at a minimum, contain the following elements:
(1) the podiatrist's name;
(2) the client's name;
(3) the delivery address;
(4) the date of delivery; and
(5) itemization of the device delivered, including:
(A) a product description;
(B) a brand name;
(C) a model name and number, if applicable;
(D) a serial number, if applicable;
(E) the quantity delivered; and
(F) the amount billed per device.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Independent Licensed Audiologists, Physical Therapists, Occupational Therapists and Speech Pathologists › Section 17b-262-630 - Scope

Current through July 10, 2024
Sections 17b-262-630 to 17b-262-640, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services requirements for payment of services provided by independent licensed audiologists, physical therapists, occupational therapists and speech pathologists for clients who are determined eligible to receive services under Connecticut's Medicaid program pursuant to section 17b-261 of the Connecticut General Statutes. Sections 17b-262-630 to 17b-262-640, inclusive, of the Regulations of Connecticut State Agencies shall not apply to therapy services provided by home health agencies, clinics, rehabilitation centers, hospitals or other health care providers.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Independent Licensed Audiologists, Physical Therapists, Occupational Therapists and Speech Pathologists › Section 17b-262-632 - Provider participation

Current through July 10, 2024
In order to participate in Medicaid and receive payment from the department, providers shall:
(a) Comply with all applicable licensing, accreditation and certification requirements;
(b) comply with all departmental enrollment requirements, including sections 17b-262-522 to 17b-262-532, inclusive, of the Regulations of Connecticut State Agencies;
(c) comply with sections 17b-262-630 to 17b-262-640, inclusive, of the Regulations of Connecticut State Agencies; and
(d) have a valid provider agreement on file with the department.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Independent Licensed Audiologists, Physical Therapists, Occupational Therapists and Speech Pathologists › Section 17b-262-633 - Eligibility

Current through July 10, 2024
Payment for independent therapy services prescribed by a licensed practitioner is available on behalf of all clients who have a need for such services and which are medically necessary subject to the conditions and limitations which apply to such services.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Independent Licensed Audiologists, Physical Therapists, Occupational Therapists and Speech Pathologists › Section 17b-262-634 - Services covered and limitations

Current through July 10, 2024
Subject to the limitations and exclusions in this section, the department shall pay for independent therapy which conforms to accepted methods of diagnosis and treatment, but shall not pay for anything of an unproven, educational, social, research, experimental or cosmetic nature; for services in excess of those deemed medically necessary by the department to treat the client's condition; or for services not directly related to the client's diagnosis, symptoms or medical history.
(a) The department shall pay for the following:
(1) Services provided in the provider's office or the client's home; and
(2) EPSDT Special Services.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Independent Licensed Audiologists, Physical Therapists, Occupational Therapists and Speech Pathologists › Section 17b-262-635 - Need for service

Current through July 10, 2024
(a) The department shall pay for independent therapy that is medically necessary when a licensed practitioner prescribes the client's need for the service.
(b) A licensed practitioner shall reestablish the need for service by performing an evaluation not more than twelve months after the previous evaluation.
(c) The provider shall document the initial and subsequent need for service in the client's record.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Independent Licensed Audiologists, Physical Therapists, Occupational Therapists and Speech Pathologists › Section 17b-262-636 - Prior authorization

Current through July 10, 2024
(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.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Independent Licensed Audiologists, Physical Therapists, Occupational Therapists and Speech Pathologists › Section 17b-262-637 - Billing procedures

Current through July 10, 2024
Providers shall submit claims on a hard copy invoice or by electronic transmission to the department in a form and manner specified by the department, together with all information required by the department to process the claim for payment.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Independent Licensed Audiologists, Physical Therapists, Occupational Therapists and Speech Pathologists › Section 17b-262-638 - Payment

Current through July 10, 2024
(a) Payment rates shall be the same for in-state, border and out-of-state providers.
(b) Payment shall be made at the lowest of:
(1) The provider's usual and customary charge;
(2) the lowest Medicare rate;
(3) the amount in the independent therapy fee schedule as published by the department;
(4) the amount billed by the provider; or
(5) the lowest price charged or accepted for the same or substantially similar goods or services by the provider from any person or entity.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Independent Licensed Audiologists, Physical Therapists, Occupational Therapists and Speech Pathologists › Section 17b-262-639 - Payment rates

Current through July 10, 2024
The commissioner shall establish the fees contained in the department's fee schedule pursuant to section 4-67c of the Connecticut General Statutes.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Independent Licensed Audiologists, Physical Therapists, Occupational Therapists and Speech Pathologists › Section 17b-262-640 - Documentation

Current through July 10, 2024
(a) Providers shall maintain a specific record for all services provided to each client including, but not limited to: name, address, birth date, Medicaid identification number, pertinent diagnostic information, a current treatment plan and treatment notes signed by the provider, documentation of services provided and the dates the services were provided.
(b) The provider shall maintain all required documentation in its original form, paper or electronic, for at least five years or longer, as required by applicable statutes and regulations in the provider's file, subject to review by authorized department personnel. In the event of a dispute concerning a service provided, the provider shall maintain the documentation until the end of the dispute or five years, whichever is greater.
(c) The department may disallow and recover any amounts paid to the provider for which the required documentation is not maintained and not provided to the department upon request.
(d) The department may audit any relevant records and documentation and take any other appropriate quality assurance measures it deems necessary to assure compliance with all regulatory and statutory requirements.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Laboratory Services › Section 17b-262-641 - Scope

Current through July 10, 2024
Sections 17b-262-641 through 17b-262-650, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services requirements for payment of laboratory services provided by licensed clinical laboratories, in settings other than hospital inpatient or outpatient departments or a physician's, nurse-midwife's, or nurse practitioner's office, for clients who are determined eligible to receive services under Connecticut's Medicaid Program pursuant to section 17b-262 of the Connecticut General Statutes (CGS).
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Laboratory Services › Section 17b-262-642 - Definitions

Current through July 10, 2024
For the purposes of sections 17b-262-641 through 17b-262-650, inclusive, of the Regulations of Connecticut State Agencies the following definitions shall apply:
(1)
"Client"
means a person eligible for goods or services under the department's Medicaid Program.
(2)
"Commissioner"
means the Commissioner of Social Services appointed pursuant to section 17b-1(a) of the Connecticut General Statutes.
(3)
"Department"
means the Department of Social Services or its agent.
(4)
"HealthTrack Services"
means the services described in section 1905(r) of the Social Security Act.
(5)
"HealthTrack Special Services"
means medically necessary and medically appropriate health care, diagnostic services, treatment, or other measures necessary to correct or ameliorate disabilities and physical and mental illnesses and conditions discovered as a result of a periodic comprehensive health screening or interperiodic encounter. Such services are provided in accordance with section 1905(r)(5) of the Social Security Act, and are:
(A) services not covered under the State Plan or contained in a fee schedule published by the department; or
(B) services covered under the State Plan and contained in a fee schedule published by the department which exceed the limit on the amount of services established by the department that are contained in regulation.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Laboratory Services › Section 17b-262-643 - Provider participation

Current through July 10, 2024
In order to enroll in the Medicaid Program and receive payment from the department, providers shall:
(1) be in compliance with the provisions of the Clinical Laboratories Improvement Amendments (CLIA) of 1988 for the procedures performed at the laboratory for which claims are submitted, including but not limited to, 42 CFR 493.1809;
(2) meet and maintain all applicable licensing, accreditation, and certification requirements;
(3) meet and maintain all departmental enrollment requirements; and
(4) have a valid provider agreement on file which is signed by the provider and the department upon application for enrollment into the Medicaid Program. This agreement, which shall be periodically updated, shall continue to be in effect for the duration of the agreement or for the stated period in the agreement. The provider agreement specifies conditions and terms which govern the program and to which the provider is mandated to adhere in order to participate in the program.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Laboratory Services › Section 17b-262-645 - Services covered and limitations

Current through July 10, 2024
(a) The department shall pay for the following:
(1) medically appropriate and medically necessary clinical laboratory services, for which the laboratory holds certification according to the provisions of CLIA, which are listed in the department's fee schedule; and
(2) for HealthTrack and HealthTrack Special Services.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Laboratory Services › Section 17b-262-647 - Prior authorization

Current through July 10, 2024
(a) Prior authorization, on forms and in a manner as specified by the department, is required for 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:
(1) 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;
(2) a description of the outcomes of any alternative measures tried; and
(3) if applicable and requested by the department, any other documentation required in order to render a decision.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Laboratory Services › Section 17b-262-648 - Billing procedures

Current through July 10, 2024
(a) Claims from providers shall be submitted on the department's designated form or electronically transmitted to the department's fiscal agent and shall include all information required by the department to process the claim for payment.
(b) Laboratory services performed in a physician's, nurse-midwife's, or nurse practitioner's office shall be payable pursuant to respective Regulations of Connecticut State Agencies which describe these services.
(c) Payment for services performed in a laboratory shall not be made to the referring physician, nurse-midwife, or nurse practitioner.
(d) Payment for the components of a panel or profile of tests consists of the following:
(1) the sum of any number of the components of a panel or profile of tests shall not exceed the total charged for the group offering, the panel or profile, whether done by automation or bench testing and whether or not the equipment is available in the facility where some Medicaid Program clients reside; and
(2) where multiple tests constitute a panel or profile, they shall be billed in that manner.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Laboratory Services › Section 17b-262-649 - Payment

Current through July 10, 2024
(a) Payment shall be made at the lowest of:
(1) the provider's usual and customary charge to the general public;
(2) the lowest Medicare rate;
(3) the amount in the applicable fee schedule as published by the department;
(4) the amount billed by the provider; or
(5) the lowest price charged or accepted for the same or substantially similar goods or services by the provider from any person or entity.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Laboratory Services › Section 17b-262-650 - Documentation

Current through July 10, 2024
(a) Independent clinical laboratory providers shall maintain a specific record for all services received for each client eligible for Medicaid Program payment including, but not limited to: name, address, birth date, Medicaid Program identification number, pertinent diagnostic information, documentation of services provided, and the dates the services were provided.
(b) All required documentation shall be maintained for at least five years in the provider's file subject to review by authorized department personnel. In the event of a dispute concerning a service provided, documentation shall be maintained until the end of the dispute or five years, whichever is greater.
(c) Failure to maintain all required documentation shall result in the disallowance and recovery by the department of any amounts paid to the provider for which required documentation is not maintained or provided to the department upon request.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Dialysis Services › Section 17b-262-651 - Scope

Current through July 10, 2024
Sections 17b-262-651 through 17b-262-660, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services requirements for payment of dialysis services provided by physicians, general hospitals, and freestanding dialysis clinics for clients who are determined eligible to receive services under Connecticut's Medicaid Program pursuant to section 17b-262 of the Connecticut General Statutes (CGS).
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Dialysis Services › Section 17b-262-652 - Definitions

Current through July 10, 2024
For the purposes of sections 17b-262-651 through 17b-262-660, inclusive, of the Regulations of Connecticut State Agencies the following definitions shall apply:
(1)
"Border Hospital"
means an out-of-state general hospital which has a common medical delivery area with the State of Connecticut and is deemed a border hospital by the department on a hospital by hospital basis.
(2)
"Client"
means a person eligible for goods or services under the department's Medicaid Program.
(3)
"Commissioner"
means the Commissioner of Social Services appointed pursuant to section 17b-1(a) of the Connecticut General Statutes.
(4)
"Department"
means the Department of Social Services or its agent.
(5)
"Dialysis"
means dialysis as defined in 42 CFR 405.2102.
(6)
"Freestanding Dialysis Clinic"
means those centers licensed by the Department of Public Health (DPH) and certified, pursuant to section 19-13-D55a of the Regulations of Connecticut State Agencies, to provide dialysis services.
(7)
"General Hospital"
means a short-term acute care hospital having facilities, medical staff, and all necessary personnel to provide diagnosis, care, and treatment of a wide range of acute conditions, including injuries. This includes a children's general hospital. It shall also include a border hospital.
(8)
"HealthTrack Services"
means the services described in section 1905(r) of the Social Security Act.
(9)
"HealthTrack Special Services"
means medically necessary and medically appropriate health care, diagnostic services, treatment, or other measures necessary to correct or ameliorate disabilities and physical and mental illnesses and conditions discovered as a result of a periodic comprehensive health screening or interperiodic encounter. Such services are provided in accordance with section 1905(r)(5) of the Social Security Act, and are:
(A) services not covered under the State Plan or contained in a fee schedule published by the department; or
(B) services covered under the State Plan and contained in a fee schedule published by the department which exceed the limit on the amount of services established by the department that are contained in regulation.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Dialysis Services › Section 17b-262-653 - Provider participation

Current through July 10, 2024
In order to enroll in the Medicaid Program and receive payment from the department, providers shall:
(1) meet and maintain all applicable licensing, accreditation, and certification requirements;
(2) meet and maintain all departmental enrollment requirements; and
(3) have a valid provider agreement on file which is signed by the provider and the department upon application for enrollment into the Medicaid Program. This agreement, which will be periodically updated, shall continue to be in effect for the duration of the agreement or for the stated period in the agreement. The provider agreement specifies conditions and terms which govern the program and to which the provider is mandated to adhere in order to participate in the program.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Dialysis Services › Section 17b-262-655 - Services covered and limitations

Current through July 10, 2024
Subject to the limitations and exclusions listed below and those set forth in the Regulations of Connecticut State Agencies dealing with physicians, general hospitals, and freestanding dialysis clinics, the department shall pay for dialysis services which conform to accepted methods of diagnosis and treatment.
(a) The department shall pay for the following:
(1) for services provided by an enrolled provider in a home, clinic, hospital, or institution having an organized and approved dialysis program; and
(2) for HealthTrack Services and HealthTrack Special Services.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Dialysis Services › Section 17b-262-656 - Need for service and authorization process

Current through July 10, 2024
(a) The department shall pay for medically necessary and medically appropriate dialysis services for Medicaid Program clients, in relation to the diagnosis for which care is required, provided that:
(1) the services are within the scope of the provider's practice;
(2) a physician documents the need in writing and orders the service; and
(3) the services are made part of the client's medical record.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Dialysis Services › Section 17b-262-658 - Payment

Current through July 10, 2024
(a) Payment shall be made at the lowest of:
(1) the provider's usual and customary charge to the general public;
(2) the lowest Medicare rate;
(3) the amount in the applicable fee schedule as published by the department;
(4) the amount billed by the provider; or
(5) the lowest price charged or accepted for the same or substantially similar goods or services by the provider from any person or entity.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Dialysis Services › Section 17b-262-659 - Payment rate

Current through July 10, 2024
(a) The commissioner establishes the fees contained in the provider's fee schedule pursuant to section 4-67c of the Connecticut General Statutes.
(b) Payment rates for physicians and physician groups are found in the department's fee schedule for physicians' services.
(c) Payment rates for dialysis services performed by freestanding dialysis clinics shall be based on the fee published by the department and contained in the department's fee schedule for clinics.
(d) Payment rates for dialysis services performed in a hospital on an inpatient basis are paid through the inpatient hospital interim per diem rate and published in the department's fee schedule for general hospital inpatient services.
(e) Payment rates for dialysis services performed in a hospital on an outpatient basis are paid as published in the department's fee schedule for general hospital outpatient services.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Dialysis Services › Section 17b-262-660 - Documentation

Current through July 10, 2024
(a) Providers shall maintain a specific medical record for all services received for each client eligible for Medicaid Program payment including, but not limited to: name, address, birth date, Medicaid identification number, pertinent diagnostic information, documentation of services provided, and the dates the services were provided.
(b) All required documentation shall be maintained for at least five years in the provider's file subject to review by authorized department personnel. In the event of a dispute concerning a service provided, documentation shall be maintained until the end of the dispute or five years, whichever is greater.
(c) Failure to maintain all required documentation shall result in the disallowance and recovery by the department of any amounts paid to the provider for which the required documentation is not maintained or provided to the department upon request.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Durable Medical Equipment › Section 17b-262-672 - Scope

Current through July 10, 2024
Sections 17b-262-672 through 17b-262-682 of the Regulations of Connecticut State Agencies set forth the Department of Social Services requirements for the payment of durable medical equipment (DME) to providers, for clients who are determined eligible to receive services under Connecticut Medicaid pursuant to section 17b-262 of the Connecticut General Statutes (CGS).
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Durable Medical Equipment › Section 17b-262-673 - Definitions

Current through July 10, 2024
For the purposes of sections 17b-262-672 through 17b-262-682 of the Regulations of Connecticut State Agencies, the following definitions shall apply:
(1) "Chronic disease hospital" means an institution as defined in section 19-13-D1 of the Regulations of Connecticut State Agencies;
(2) "Client" means a person eligible for goods or services under the Medicaid program;
(3) "Certificate of Medical Necessity" or "CMN" means an approved Medicare form or a similar form which has been submitted to and approved by the department for use. This form shall contain all the documentation required for DME;
(4) "Commissioner" means the commissioner of social services;
(5) "Customized equipment" means devices or equipment prescribed by a licensed practitioner which is specifically manufactured to meet the special medical, physical, and psychosocial needs of the client. The equipment shall be individualized to preclude its use by any other person except the client for whom it was originally developed;
(6) "Department" means the department of social services or its agent;
(7) "Documented in writing" means that the prescription has been handwritten, typed, or computer printed;
(8) "Durable medical equipment" or "DME" means equipment that meets all of the following requirements:
(A) can withstand repeated use;
(B) is primarily and customarily used to serve a medical purpose;
(C) generally is not useful to a person in the absence of an illness or injury; and
(D) is nondisposable;
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Durable Medical Equipment › Section 17b-262-674 - Provider participation

Current through July 10, 2024
In order to enroll in the Medicaid program and receive payment from the department, providers shall comply with sections 17b-262-522 to 17b-262-533, inclusive, of the Regulations of Connecticut State Agencies.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Durable Medical Equipment › Section 17b-262-675 - Eligibility

Current through July 10, 2024
Payment for DME and related equipment is available for Medicaid clients who have a medical need for such equipment which meets the department's definition of DME when the item is prescribed by a licensed practitioner, subject to the conditions and limitations set forth in sections 17b-262-672 to 17b-262-682, inclusive, of the Regulations of Connecticut State Agencies.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Durable Medical Equipment › Section 17b-262-676 - Services covered and limitations

Current through July 10, 2024
(a)
Services Covered
(1) The department shall pay for the purchase or rental and the repair of DME, except as limited by sections 17b-262-672 to 17b-262-682, inclusive, of the Regulations of Connecticut State Agencies, that conforms to accepted methods of diagnosis and treatment and is medically necessary and medically appropriate.
(2) DME services are available to all clients who live at home. Additionally, the department shall pay for ventilators, customized wheelchairs, and Group 2 Pressure Reducing Support Surfaces for residents of nursing facilities and ICFs/MR.
(3) The department shall maintain a non-exclusive fee schedule of items which it has already determined meet the department's definition of DME and for which coverage shall be provided to eligible clients, subject to the conditions and limitations set forth in sections 17b-262-672 to 17b-262-682, inclusive, of the Regulations of Connecticut State Agencies. This fee schedule includes, but is not limited to:
(A) wheelchairs and accessories;
(B) walking aides, such as walkers, canes, and crutches;
(C) bathroom equipment such as commodes and safety equipment;
(D) inhalation therapy equipment such as IPPB machines, suction machines, nebulizers, and related equipment;
(E) hospital beds and accessories; and
(F) enteral/parenteral therapy equipment.
(4) When the item for which Medicaid coverage is requested is not on the department's fee schedule, prior authorization is required by the department. The recipient requesting Medicaid coverage for a prescribed item not on the list shall submit such prior authorization request to the department through an enrolled provider of DME. Such request shall include a signed prescription and shall include documentation showing the recipient's medical need for the prescribed item. If the item for which Medicaid coverage is requested is not on the department's fee schedule, the provider shall also include documentation showing that the item meets the department's definition of DME and is medically appropriate for the client requesting coverage of such item.
(5) In the last quarter of each calendar year, the department shall make modifications to its non-exclusive DME fee schedule. In deciding which items to add to this schedule, the department shall give consideration to:
(A) items requested for individual consideration through the process described in subdivision (4) of this subsection;
(B) input from the provider community; and
(C) input from the consumer community.
Providers and consumers who wish to provide input may make suggestions to the department's Medical Operations unit. Any suggestions shall be considered during the department's annual modification of its fee schedule.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Durable Medical Equipment › Section 17b-262-677 - Services not covered

Current through July 10, 2024
The Department shall not pay DME providers for:
(1) standard or stock DME items prescribed and ordered for a client who:
(A) dies prior to delivery of the item, or
(B) is not otherwise eligible on the date of delivery. It shall be the provider's responsibility to verify that the client is eligible on the date the item is delivered;
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Durable Medical Equipment › Section 17b-262-678 - Prior authorization

Current through July 10, 2024
(a) In order to receive reimbursement 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 are met.
(b) The department requires prior authorization for:
1) any item identified on the department's published fee schedule as requiring prior authorization; and
2) any item requested under section 17b-262-676(a)(4) of the Regulations of Connecticut State Agencies.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Durable Medical Equipment › Section 17b-262-679 - Billing procedure

Current through July 10, 2024
(a) Claims from DME providers shall be submitted on a hard copy invoice or electronically transmitted to the department or its agent, in a form and manner as specified by the department, and shall include all information required by the department to process the claim for payment.
(b) Claims submitted for DME not requiring prior authorization shall include the name of the licensed practitioner or clinic making the referral. A licensed practitioner's original prescription for these items shall be on file with the provider and shall be subject to review by the department.
(c) DME providers shall bill and the department shall pay at the lowest of:
(1) the usual and customary charge to the general public;
(2) the lowest Medicare rate;
(3) the amount in the applicable fee schedule as published by the department;
(4) the amount prior authorized in writing by the department; or
(5) the lowest price charged or accepted for the same or substantially similar goods or services by the provider from any person or entity.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Durable Medical Equipment › Section 17b-262-680 - Payment limitations

Current through July 10, 2024
(a) Payment shall be made for customized DME for a client who dies or is not otherwise eligible on the date of delivery providing the client was eligible:
(1) on the date prior authorization was given by the department; or
(2) on the date the client ordered the item, if the item does not require prior authorization. For purposes of this section, the date the client orders the item means the date on which the written medical order for the item is presented to the provider. The provider shall verify to the department the date the client ordered the item.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Durable Medical Equipment › Section 17b-262-681 - Documentation

Current through July 10, 2024
(a) All required documentation shall be maintained for at least five (5) years in the DME provider's file subject to review by the department. In the event of a dispute concerning a service or an item provided, documentation shall be maintained until the end of the dispute or five (5) years, whichever is greater.
(b) Failure to maintain all required documentation shall result in the disallowance and recovery by the department of any amounts paid to the DME provider for the item or service for which the required documentation is not maintained or provided to the department upon request.
(c) The licensed practitioner's original prescription for DME shall be on file with the DME provider and shall be subject to review by the department. Such prescription shall specify the items ordered.
(d) The department requires that DME providers maintain fiscal and medical records to fully disclose services and goods rendered or delivered to Medicaid clients. A new prescription is required prior to replacement of DME.
(e) A signed receipt is required for all deliveries of DME, documenting that the client or, if the client is unable to sign, a designated representative other than the DME provider or the DME provider's employees, took delivery of the item. The receipt for DME, regardless of format used, shall, at a minimum, contain the following elements:
(1) provider's name;
(2) client's name;
(3) itemization of DME delivered, including:
(A) product description;
(B) brand name;
(C) model name and number;
(D) serial number (if applicable);
(E) quantity delivered;
(F) amount billed per item; and
(4) date of delivery.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Durable Medical Equipment › Section 17b-262-682 - Other

Current through July 10, 2024
(a) All equipment or devices purchased by the department shall be new and shall become the property of the client as of the date of delivery to the client.
(b) Where brand names or stock or model numbers are specified on the prescription or the PA, no substitution shall be permitted without the written approval of the department.
(c) Used equipment when rented shall be completely refurbished and in proper condition to meet the client's specific medical need.
(d) The provider shall instruct the client, or his or her family, on the proper use and care of the equipment. This instruction shall be provided as a part of the cost of the item. Additionally, the services and items shall be appropriate to both the environment and the client's current medical necessity.
(e) When the DME item is delivered, the provider shall ensure that proper assembly occurs and that the item meets the client's needs.
(f) DME providers shall notify the department of returns of DME items delivered to a client. Providers shall initiate necessary reimbursement adjustments resulting from such returns.
(g) It shall be the department's decision to rent or purchase DME, except in cases where the rental or payment option is determined by the primary payor source.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment Under the Connecticut Pharmaceutical Assistance Contract to the Elderly and the Disabled (ConnPACE) › Section 17b-262-684 - Scope (Repealed)

Current through July 10, 2024
For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment Under the Connecticut Pharmaceutical Assistance Contract to the Elderly and the Disabled (ConnPACE) › Section 17b-262-685 - Definitions (Repealed)

Current through July 10, 2024
For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment Under the Connecticut Pharmaceutical Assistance Contract to the Elderly and the Disabled (ConnPACE) › Section 17b-262-686 - Provider participation (Repealed)

Current through July 10, 2024
For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment Under the Connecticut Pharmaceutical Assistance Contract to the Elderly and the Disabled (ConnPACE) › Section 17b-262-687 - Eligibility (Repealed)

Current through July 10, 2024
For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment Under the Connecticut Pharmaceutical Assistance Contract to the Elderly and the Disabled (ConnPACE) › Section 17b-262-688 - Services covered and limitations (Repealed)

Current through July 10, 2024
For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)