reglab/statecodes huggingface dataset:
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Mental Health Rehabilitation Services for Adults Provided by Private Non-Medical Institutions › Section 17b-262-771 - Definitions

Current through July 10, 2024
As used in sections 17b-262-770 to 17b-262-773, inclusive, of the Regulations of Connecticut State Agencies:
(1) "Entity" means a government agency, organization, unit, corporation, partnership, or other business arrangement, including any Medicaid managed care organization, irrespective of the form of business structure or arrangement by which it exists, whether for-profit or not-for profit, which furnishes directly, or otherwise authorizes the furnishing of, the delivery of Medicaid health services where payments made with respect to those services are received, or made, under a State Plan approved under Title XIX, or under any waiver of such plan totaling at least $5,000,000 annually. If an entity furnishes items or services at more than a single location, or under more than one contractual or other payment arrangement, the provisions of sections 17b-262-770 to 17b-262-773, inclusive, of the Regulations of Connecticut State Agencies apply if the aggregate payments to that entity meet the $5,000,000 annual threshold whether the entity submits claims for payments using one or more provider identification or tax identification numbers. An entity meets the $5,000,000 annual threshold as of January 1, 2007, if it received or made payments in that amount in federal fiscal year 2006. Future determinations regarding an entity's responsibility stemming from the requirements of section 1902(a)(68) of the Social Security Act, P.L. 109-171, §
										6032, will be made by January 1 of each subsequent year, based upon the amount of payments an entity either received or made under the State Plan under Title XIX of the Social Security Act during the preceding federal fiscal year. A government component serving as a provider for which Medicaid payments are made (e.g., a state mental health facility or school district providing school-based health services) is an "entity" as defined in this subsection. A government agency which merely administers the Medicaid program, in whole or in part (e.g., managing the claims processing system or determining beneficiary eligibility), is not an "entity" as defined in this subsection;
(2) "Employee" means any officer or employee of an entity and includes management;
(3) "Contractor" or "agent" means any contractor, subcontractor, agent or other person which or who, on behalf of the entity, furnishes, or otherwise authorizes the furnishing of, the delivery of Medicaid health care items or services, performs billing or coding functions, or is involved in the monitoring of health care provided by the entity;
(4) "Department" means the Department of Social Services or its agent; and
(5) "Medicaid" means the program operated by the Department pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act, as amended from time to time.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Mental Health Rehabilitation Services for Adults Provided by Private Non-Medical Institutions › Section 17b-262-772 - Provider participation

Current through July 10, 2024
To receive payment from the Department for the provision of goods or services to Medicaid clients, entities shall comply with sections 17b-262-770 to 17b-262-773, inclusive, of the Regulations of Connecticut State Agencies.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment to Chronic Disease Hospitals › Section 17b-262-779 - Scope

Current through July 10, 2024
Sections 17b-262-779 to 17b-262-791, inclusive, of the Regulations of Connecticut State Agencies, set forth the department of social services' requirements for payment to chronic disease hospitals for services to clients who are determined eligible to receive services under the Connecticut Medicaid program pursuant to section 17b-262 of the Connecticut General Statutes.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment to Chronic Disease Hospitals › Section 17b-262-780 - Definitions

Current through July 10, 2024
As used in sections 17b-262-779 to 17b-262-791, inclusive, of the Regulations of Connecticut State Agencies:
(1) "Applied income" means the amount of income that each client receiving chronic disease hospital services is expected to pay each month toward the cost of his or her care, calculated according to the department's Uniform Policy Manual, section 5045.20;
(2) "Assessment" means a comprehensive written evaluation of an individual's functional performance in relation to a set of measurable medical or physical criteria;
(3) "Client" means a person eligible for goods or services under the department's Medicaid program;
(4) "Chronic disease" means a disease having one or more of the following characteristics:
(a) is permanent;
(b) leaves residual disability;
(c) is caused by non-reversible pathological alteration;
(d) requires special training of the client for rehabilitation; or
(e) is expected to require a long period of supervision, observation or care;
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment to Chronic Disease Hospitals › Section 17b-262-781 - Provider participation

Current through July 10, 2024
(a) To enroll in Medicaid and receive payment from the department, a chronic disease hospital shall comply with the provider participation requirements of sections 17b-262-522 through 17b-262-533, inclusive, of the Regulations of Connecticut State Agencies.
(b) In order to enroll in Medicaid and to receive payment from the department, a chronic disease hospital shall meet the requirements for state licensure described in section 19-13-D5 of the Regulations of Connecticut State Agencies, the requirements for federal certification to participate in the Medicaid program that are described in 42 CFR Part 482, as amended from time to time, and the requirements stated in sections 17b-262-779 to 17b-262-791, inclusive, of these regulations.
(c) In addition to the requirements in subsections (a) and (b) of this section, in order to participate in the Medicaid program, a chronic disease hospital shall be federally certified as either:
(1) a long term care hospital that meets the criteria of 42 CFR 412.23(e);
(2) a rehabilitation hospital that meets the criteria of 42 CFR 412.23(b); or
(3) an acute care hospital with a psychiatric unit excluded from the prospective payment system that meets the criteria of 42 CFR 412.25.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment to Chronic Disease Hospitals › Section 17b-262-783 - Need for service

Current through July 10, 2024
In order for a client to be approved for admission to a chronic disease hospital, the client shall meet the criteria for admission as either a chronic disease client or a rehabilitation client. All care shall be medically necessary and medically appropriate.
(a) The criteria for admission as a chronic disease client are as follows:
(1) Each chronic disease client shall require services that can be provided safely and effectively at a chronic disease hospital level, shall be ordered by a physician and documented in the client's medical record, and shall include at least a daily physician visit and assessment or the 24-hour availability of medical services and equipment available only in a hospital setting; and
(2) The client's medical condition and treatment needs are such that no effective, safe, less costly alternative placement is available to the client.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment to Chronic Disease Hospitals › Section 17b-262-784 - Services covered

Current through July 10, 2024
The department shall pay an all-inclusive per diem rate to the provider for each resident for whom payment has been authorized pursuant to section 17b-262-783 of the Regulations of Connecticut State Agencies. This per diem rate represents payment for the following goods and services:
(a) all services as required by section 19-13-D5 of the Regulations of Connecticut State Agencies and 42 CFR Part 482, as amended from time to time, including, but not limited to:
(1) medical direction in accordance with section 19-13 - D5(c) of the Regulations of Connecticut State Agencies and 42 CFR 482.22;
(2) nursing services in accordance with section 19-13 - D5(e) of the Regulations of Connecticut State Agencies and 42 CFR 482.23, as amended from time to time;
(3) therapeutic recreation in accordance with section 19-13 - D5(k) of the Regulations of Connecticut State Agencies;
(4) rehabilitation services in accordance with section 19-13-D5(k) of the Regulations of Connecticut State Agencies and 42 CFR 482.56, as amended from time to time;
(5) room and board in accordance with sections 19-13-D5(h) and (i) of the Regulations of Connecticut State Agencies and 42 CFR 482.28 and 482.41 as amended from time to time;
(6) diagnostic and therapeutic services in accordance with section 19-13-D5(f) of the Regulations of Connecticut State Agencies and 42 CFR 482.26, as amended from time to time;
(7) pharmacy services in accordance with section 19-13-D5(g) and 42 CFR 482.25, as amended from time to time;
(8) laboratory services in accordance with 42 CFR 482.27, as amended from time to time;
(9) respiratory services in accordance with 42 CFR 482.57, as amended from time to time; and
(10) consultation and assistance to residents in obtaining other needed services including, but not limited to, dental services, vision services, hearing services and services to address mental and psychosocial functioning;
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment to Chronic Disease Hospitals › Section 17b-262-785 - Service limitations

Current through July 10, 2024
Payment shall be made for the date of admission but not for the date of discharge. Exceptions to this are:
(a) payment shall be made for the date of death when the resident dies in the chronic disease hospital.
(b) in the case of a resident admitted and discharged on the same day, payment shall be made for one day of care.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment to Chronic Disease Hospitals › Section 17b-262-786 - Services not covered

Current through July 10, 2024
(a) The department shall not pay a chronic disease hospital that is characterized as an institution for mental diseases except for services to clients aged 65 and older or under age 22 in accordance with section 17-134d-68 of the Regulations of Connecticut State Agencies and 42 CFR 435.1009.
(b) The department shall not reimburse any provider for any costs incurred before the authorized length-of-stay period or after the expiration of the specified length-of-stay period.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment to Chronic Disease Hospitals › Section 17b-262-787 - Authorization process

Current through July 10, 2024
(a) The department shall pay a provider only when the department has authorized payment for the client's admission to that chronic disease hospital.
(b) The provider shall comply with the authorization requirements described in section 17b-262-528 of the Regulations of Connecticut State Agencies and sections 17b-262-779 to 17b-262-791, inclusive, of the Regulations of Connecticut State Agencies. The department, in its sole discretion, shall determine what information is necessary to approve an authorization request. Authorization does not, however, guarantee payment unless all other requirements for payment are met.
(c) An authorization request, on forms and in a manner as specified by the department, shall include documentation of medical need and shall be signed by the licensed practitioner. For individuals who become clients while in the chronic disease hospital, this authorization request shall include, but not be limited to, a treatment plan of care under the direction of a physician that is designed to achieve specified goals within a specified timeframe and developed by a team.
(d) Initial authorizations for treatment shall be authorized by the department for up to 30 days. Subsequent requests for the extension of authorization for the same client may be made for up to three months or longer, on a case-by-case basis.
(e) If a safe discharge is not possible from the chronic disease hospital, the department shall authorize a continued stay and payment at the current Medicaid rate for up to three months or longer, on a case by case basis.
(f) The department shall act on prior authorization requests for readmissions to a chronic disease hospital from an acute care hospital within one business day so that clients do not remain at the acute care hospital level longer than necessary.
(g) No chronic disease hospital shall be required to admit a client if such hospital has not received an authorization for treatment from the department.
(h) The department will process a request for authorization for treatment, and deliver a decision on such request within two full business days from the date a chronic disease hospital notifies the department that a client who is a patient of such hospital has exhausted his or her other third party insurance or whose coverage by such insurance has been denied.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment to Chronic Disease Hospitals › Section 17b-262-788 - Applied income

Current through July 10, 2024
(a) A client who receives chronic disease hospital services is responsible for paying applied income to the chronic disease hospital.
(b) The department shall calculate the applied income. The department shall notify the chronic disease hospital of the amount of any applied income that the chronic disease hospital is responsible for collecting. Applied income shall be deducted from what otherwise would have been the department's monthly payment to the chronic disease hospital.
(c) The chronic disease hospital shall notify the department's caseworker of any errors in the amount of applied income processed against the claim using the form specified by the department. Payment adjustments resulting from retroactive applied income corrections shall be processed periodically.
(d) In any month that a resident returns to the community or dies, and the cost of care is less than the applied income, the department shall adjust the applied income as follows: the applied income shall equal the number of days that the resident was in the chronic disease hospital multiplied by the per diem rate.
(e) Applied income is not pro rated. It is used to cover the cost of care until it is expended.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment to Chronic Disease Hospitals › Section 17b-262-789 - Billing and payment 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) The chronic disease hospital is responsible for:
(1) completing the daily admission and discharge forms in accordance with the department's instructions;
(2) notifying the department's caseworker if the chronic disease hospital is aware that the resident's asset level exceeds the established resource limit. The report shall be made on the form specified by the department;
(3) notifying the department of any and all credits due the department on the form specified by the department; and
(4) exhausting other payment sources of which the chronic disease hospital is aware before billing the department.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment to Chronic Disease Hospitals › Section 17b-262-790 - Rates

Current through July 10, 2024
(a) The per diem rate for a chronic disease hospital is determined annually pursuant to section 17b-239 of the Connecticut General Statutes for freestanding chronic disease hospitals or section 17b-340 of the Connecticut general statutes for chronic disease hospitals associated with chronic and convalescent nursing homes.
(b) the department shall reimburse the chronic disease hospital at the lower of:
(1) the per diem rate minus the applied income; or
(2) the usual and customary charge minus the applied income.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment to Chronic Disease Hospitals › Section 17b-262-791 - Documentation

Current through July 10, 2024
(a) The chronic disease hospital shall maintain all documentation required for rate setting purposes in accordance with section 17-311-56 of the Regulations of Connecticut State Agencies. This documentation is subject to review and audit by the department.
(b) The chronic disease hospital shall maintain all other documentation required by this section for at least five (5) years or longer as required by statute or regulation, subject to review by authorized department personnel. In the event of a dispute concerning a service provided, the chronic disease hospital shall maintain all documentation until the end of the dispute, for five (5) years, or for the length of time required by statute or regulation, whichever is longest.
(c) Failure to maintain all required documentation may result in the disallowance and recovery by the department of any amounts paid to the chronic disease hospital for which the required documentation is not maintained and provided to the department upon request. Documentation requirements are described in detail in the provider agreement and sections 17b-262-522 to 17b-262-533, inclusive, of the Regulations of Connecticut State Agencies.
(d) The department requires that each chronic disease hospital maintain fiscal and medical records to fully disclose services and goods rendered to residents. Records shall be maintained in accordance with the department's Provider Enrollment Agreement as signed by the chronic disease hospital.
(e) Required documentation includes:
(1) certification for chronic disease hospital admission as required by the department. The form shall be signed by a licensed practitioner;
(2) the department's written authorization of the client's need for chronic disease hospital care;
(3) all admission and discharge forms supporting the claim;
(4) medical records in accordance with section 19-13-D5(d) of the Regulations of Connecticut State Agencies and 42 CFR 482.24 that contains all pertinent diagnostic information and documentation of each service provided;
(5) the initial and all subsequent treatment plans of care signed and dated by a licensed practitioner; and
(6) For clients in the rehabilitation level of care, a record that includes:
(A) each team member's goals for the client and progress notes from each team conference;
(B) all decisions reached; and
(C) the reason for any lack of progress in reaching a specific goal.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment to Chronic Disease Hospitals › Section 17b-262-792 - Scope

Current through July 10, 2024
Sections 17b-262-792 to 17b-262-803, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services requirements for payment to providers of hearing aids and supplies that are medically necessary and that are provided to clients who are determined to be eligible to receive such goods and services under Medicaid pursuant to section 17b-262 of the Connecticut General Statutes.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment to Chronic Disease Hospitals › Section 17b-262-794 - Provider participation

Current through July 10, 2024
To enroll in the Medicaid program and receive payment from the department, providers shall comply with sections 17b-262-792 to 17b-262-803, inclusive, of the Regulations of Connecticut State Agencies and sections 17b-262-522 to 17b-262-532, inclusive, of the Regulations of Connecticut State Agencies.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment to Chronic Disease Hospitals › Section 17b-262-795 - Need for service

Current through July 10, 2024
(a) The department shall pay for the purchase or repair of a medically necessary hearing aid or supply, subject to the conditions and limitations described in sections 17b-262-792 to 17b-262-803, inclusive, of the Regulations of Connecticut State Agencies.
(b) All clients who have been identified as having a hearing loss, such as through the performance of a hearing screening, shall receive a medical evaluation by a licensed practitioner, preferably an ear specialist, before a hearing aid is considered to ensure that all medically treatable conditions that affect hearing are identified and treated first. The medical evaluation shall have taken place within the six-month period prior to the date in which the client receives the first hearing aid and may, at the licensed practitioner's discretion, be accompanied by a prescription for a hearing aid.
(c) Medical necessity shall be documented by the provider and shall include:
(1) An estimate of the client's ability to benefit from the use of a hearing aid as demonstrated by improvement in speech discrimination or environmental awareness of sound;
(2) test results showing the client's current hearing level and an estimate of improvement in speech discrimination or environmental awareness of sound;
(3) evidence of a medical evaluation signed by a licensed practitioner; and
(4) a written prescription signed by a licensed practitioner or an order by an audiologist or hearing aid dealer.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment to Chronic Disease Hospitals › Section 17b-262-796 - Eligibility

Current through July 10, 2024
Payment to a provider for hearing aids and related supplies is available for clients who have a need for such products and services which meets the department's definition of a hearing aid when the items are medically necessary, subject to the conditions and limitations set forth in sections 17b-262-792 to 17b-262-803, inclusive, of the Regulations of Connecticut State Agencies.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment to Chronic Disease Hospitals › Section 17b-262-797 - Services covered and limitations

Current through July 10, 2024
(a) The department shall maintain a fee schedule for hearing aids and supplies, subject to the conditions and limitations set forth in sections 17b-262-792 to 17b-262-803, inclusive, of the Regulations of Connecticut State Agencies. This fee schedule is designed to meet the needs of most Medicaid clients.
(b) The department shall pay for the servicing, repair or replacement of hearing aids and supplies, provided that any manufacturer's or dealer's warranty has been exhausted. The provider shall first utilize existing warranties that cover required servicing, repairs and replacement.
(c) The department shall pay for one hearing test provided by either:
(1) A hearing aid provider, who is not an audiologist; or
(2) an audiologist, ear specialist or any other physician under contract to, or employed by a hearing aid provider, who does not separately bill the department for any other hearing test or audiological examination.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment to Chronic Disease Hospitals › Section 17b-262-798 - Goods and services not covered

Current through July 10, 2024
The department shall not pay providers for:
(a) Any hearing aid that is of an unproven, experimental or research nature or 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;
(b) any hearing aid prescribed and ordered for a client who:
(1) Dies prior to delivery of the item; or
(2) 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 › Payment to Chronic Disease Hospitals › Section 17b-262-799 - Payment and payment limitations

Current through July 10, 2024
(a) Fees shall be the same for in-state, border-state 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 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 provider.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment to Chronic Disease Hospitals › Section 17b-262-800 - Prior authorization

Current through July 10, 2024
(a) The department shall require PA for:
(1) Any hearing aid that is identified on the department's fee schedule as requiring PA;
(2) EPSDT special services; and
(3) any service or device that is not on the department's fee schedule.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment to Chronic Disease Hospitals › Section 17b-262-801 - Billing procedure

Current through July 10, 2024
(a) Claims from providers shall be submitted on a hard copy invoice or electronically transmitted to the department in a form and in a manner specified by the department and shall include all information required by the department to process the claim for payment.
(b) A claim submitted for hearing aids and supplies that does not require prior authorization shall include the national provider identifier number of the licensed practitioner or audiologist prescribing the hearing aid, if applicable.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment to Chronic Disease Hospitals › Section 17b-262-802 - Documentation

Current through July 10, 2024
(a) Providers shall maintain all fiscal and medical records related to services and goods rendered or delivered to clients.
(b) All required documentation, including evidence of a medical evaluation for a hearing aid, results of audiometric evaluations, results of any testing to support the need for a hearing aid and expected hearing improvement and notes related to fittings and adjustments shall be maintained for at least five years in the provider's primary place of business and shall be subject to review by the department.
(c) The department shall accept, when feasible, faxed or electronic medical evaluations and other orders. If evidence indicates that the documentation being reviewed has been falsified or the provider is unable to provide adequate assurance of the medical necessity of the items or services, the department may request additional information, including an original signature, in order to obtain that assurance.
(d) Any documentation, including a medical evaluation, that is electronically submitted to a vendor shall identify the sender and display the sender's fax number and date. The department may request the original medical evaluation and results of the hearing test whenever medical necessity is in question.
(e) In the event of a dispute concerning a service or a hearing aid provided, documentation shall be maintained until the end of the dispute or five years, whichever is longer.
(f) Failure to maintain all required documentation shall result in the disallowance and recovery by the department of any amounts paid to the provider for the hearing aid or service for which the required documentation is not maintained or provided to the department upon request.
(g) The provider shall have on file the manufacturer's purchase invoice for any hearing aid dispensed to a client, for any repairs or servicing and for any processing charges associated with replacement of a hearing aid under warranty.
(h) Providers shall maintain signed receipts for all goods and services that are provided to a client regardless of whether the item is delivered or picked up by the client or client's representative. The receipt for hearing aids, services and supplies shall at a minimum, contain the following:
(1) The provider's name;
(2) the client's name;
(3) the client's address;
(4) the date of delivery; and
(5) itemization of the hearing aid, service or supplies delivered, including, but not limited to:
(A) Product description;
(B) brand name;
(C) model name and number, if applicable;
(D) serial number, if applicable;
(E) the quantity delivered;
(F) the amount billed per hearing aid; and
(G) any warranty in effect.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment to Chronic Disease Hospitals › Section 17b-262-803 - Other

Current through July 10, 2024
(a) 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.
(b) The provider shall instruct the client, his or her family or a designated representative on the proper use and care of the hearing aid.
(c) The provider shall maintain a written usual and customary price list that details individual product and service charges. This list, including updates along with any required manufacturer's list pricing, shall be available for review by the department.
(d) A hearing aid purchased by the department shall become the property of the client on the date of delivery to the client.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Psychiatric Residential Treatment Facilities Providers › Section 17b-262-804 - Scope

Current through July 10, 2024
Sections 17b-262-804 to 17b-262-816, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services' requirements for payment for Psychiatric Residential Treatment Facilities (PRTF) services provided to clients who are determined eligible for Connecticut's Medicaid Program pursuant to section 17b-261 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 Psychiatric Residential Treatment Facilities Providers › Section 17b-262-806 - Provider participation

Current through July 10, 2024
In order to enroll in Medicaid and receive payment from the department, a provider shall meet the following requirements:
(a)
General:
(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 Medicaid. 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 Services Provided by Psychiatric Residential Treatment Facilities Providers › Section 17b-262-807 - Eligibility

Current through July 10, 2024
Payment for PRTF services shall be available, subject to the conditions and limitations set forth in sections 17b-262-804 to 17b-262-816, inclusive, of the Regulations of Connecticut State Agencies, for services rendered to clients.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Psychiatric Residential Treatment Facilities Providers › Section 17b-262-808 - Services covered

Current through July 10, 2024
(a) The department shall pay a per diem rate, which is an inclusive payment for all services that are required to be provided by the facility as a condition for participation as a PRTF, including, but not limited to:
(1) therapeutic services provided by PRTF staff;
(2) active treatment services including, but not limited to, individual, group and family therapy;
(3) diagnostic testing and assessment;
(4) room and board; and
(5) case management, discharge planning.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Psychiatric Residential Treatment Facilities Providers › Section 17b-262-809 - Services not covered

Current through July 10, 2024
The department shall not pay for the following PRTF services that are not covered under Medicaid:
(a) procedures or services of an unproven, educational, social, research, experimental or cosmetic nature or for any diagnostic, therapeutic or treatment procedures in excess of those deemed medically necessary and appropriate by the department to treat the client's condition;
(b) services or items furnished for which the provider does not usually charge;
(c) services that do not directly relate to the client's diagnosis, symptoms or medical history;
(d) the day of discharge;
(e) a PRTF admission or a day of care that does not meet all the department's requirements for inpatient services;
(f) a day when the client is absent from the PRTF at the midnight census, unless the absence is a medically authorized overnight pass and part of the treatment plan; or
(g) costs associated with the education or vocational training of the client which shall be excluded from Medicaid payments.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Psychiatric Residential Treatment Facilities Providers › Section 17b-262-810 - Certification of need requirements

Current through July 10, 2024
(a) In order to receive payment for PRTF services for an individual, admissions shall have a certification of need as required in 42 CFR 441 Subpart D, as amended from time to time.
(b) The certification of need shall be based on a determination that:
(1) ambulatory care resources available in the community do not meet the treatment needs of the client;
(2) proper treatment of the client's psychiatric condition requires services on an inpatient basis under the direction of a physician; and
(3) the services shall reasonably be expected to improve the client's condition or prevent further regression so that inpatient services shall no longer be needed.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Psychiatric Residential Treatment Facilities Providers › Section 17b-262-811 - Individual plan of care requirements

Current through July 10, 2024
(a) PRTF services for clients shall involve active treatment, as documented in the professionally developed and supervised individual plan of care.
(b) A physician shall:
(1) assume professional responsibility for the services provided under the plan of care;
(2) assure that the services are medically appropriate;
(3) certify in writing that the services provided are necessary in the setting in which they will be provided; and
(4) be readily available in person or by phone but not necessarily on the premises.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Psychiatric Residential Treatment Facilities Providers › Section 17b-262-812 - Utilization review program

Current through July 10, 2024
(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.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Psychiatric Residential Treatment Facilities Providers › Section 17b-262-813 - Billing procedures

Current through July 10, 2024
Claims from providers shall be submitted on the department's uniform billing 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.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Psychiatric Residential Treatment Facilities Providers › Section 17b-262-814 - Documentation and record retention

Current through July 10, 2024
(a) A provider shall meet the medical record requirements for a PRTF and shall maintain records to support claims made for payment. All documentation shall be made available upon request by and to authorized department, state or federal personnel in accordance with state and federal laws. Documentation shall be retained by the provider for a period of at least five years, except if otherwise required by law or, if any dispute arises concerning a service, until such dispute has been finally resolved.
(b) Failure to maintain all required documentation or to provide it to the department upon request may result in the disallowance and recovery by the department of any amounts paid out for which the required documentation is not maintained or provided.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Psychiatric Residential Treatment Facilities Providers › Section 17b-262-816 - Audit and compliance review

Current through July 10, 2024
All supporting accounting and business records, statistical data and all other records relating to the provision of PRTF services paid for by the department shall be subject to audit or compliance review by authorized personnel. All documentation shall be made available, upon request, to authorized representatives of the department.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment of Behavioral Health Clinic Services › Section 17b-262-817 - Scope

Current through July 10, 2024
Sections 17b-262-817 to 17b-262-828, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services' requirements for payment of accepted methods of treatment performed by behavioral health clinics for clients who are determined eligible to receive such services under Connecticut's Medicaid program pursuant to section 17b-261 of the Connecticut General Statutes.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment of Behavioral Health Clinic Services › Section 17b-262-818 - Definitions

Current through July 10, 2024
For the purposes of sections 17b-262-817 to 17b-262-828, inclusive, of the Regulations of Connecticut State Agencies, the following definitions shall apply:
(1) "Allied Health Professional" or "AHP" means:
(A) A licensed or certified practitioner performing within the practitioner's scope of practice in any of the professional and occupational license or certification categories pertaining to behavioral health covered in title 20 of the Connecticut General Statutes; or
(B) a license-eligible individual as defined in subdivision (23) of this section;
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment of Behavioral Health Clinic Services › Section 17b-262-819 - Provider participation

Current through July 10, 2024
(a) Providers shall meet and maintain all department enrollment requirements, as described in sections 17b-262-522 to 17b-262-533, inclusive, of the Regulations of Connecticut State Agencies, to receive payment from the department.
(b) Clinic services, as defined in 42 CFR §
										440.90, shall be furnished by or under the direction of a physician. The physician shall sign the initial plan of care and all periodic reviews to the plan of care assuring that the services are medically necessary.
(c) Programs serving clients under 18 years of age that are primarily for the treatment of psychiatric conditions shall be licensed by the Department of Children and Families as an Outpatient Psychiatric Clinic for Children as provided in section 17a-20 of the Connecticut General Statutes.
(d) Programs serving clients 18 years of age and older that are primarily for the treatment of psychiatric conditions shall be licensed by the Department of Public Health as a day treatment facility or psychiatric outpatient clinic for adults as provided in section 19a-495-550 of the Regulations of Connecticut State Agencies.
(e) Programs that are primarily for the treatment of substance related conditions, regardless of the age of the client served, shall be licensed by the Department of Public Health as an ambulatory chemical detoxification service; a chemical maintenance treatment service; a day or evening treatment program; or an outpatient treatment service for substance abuse as provided in section 19a-495-570 of the Regulations of Connecticut State Agencies.
(f) All providers, except those licensed solely as a chemical maintenance treatment provider, shall maintain the ability to respond to phone calls 24 hours a day, seven days a week and shall ensure that a client who is in crisis speaks with a physician or an AHP.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment of Behavioral Health Clinic Services › Section 17b-262-821 - Services covered

Current through July 10, 2024
(a) The department shall pay providers for those procedures listed in the department's behavioral health clinic fee schedule, provided such services are:
(1) Within the clinic's scope of practice as described in sections 19a-495-550, 19a-495-570, 17a-20-11 or 17a-147-1 of the Regulations of Connecticut State Agencies;
(2) Medically necessary to treat the client's condition; and
(3) Furnished in the clinic or a satellite site of the clinic.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment of Behavioral Health Clinic Services › Section 17b-262-822 - Service limitations

Current through July 10, 2024
(a) General
(1) Payment for individual, group, family or multiple-family psychotherapy is limited to one visit of each type per day, per provider, per client.
(2) Family and group psychotherapy sessions shall be not less than 45 minutes in length, except in an intermediate care program where family and group psychotherapy sessions shall be not less than 30 minutes.
(3) More than one psychiatric diagnostic interview examination shall only be provided in a single episode of care under the following circumstances:
(A) When it is necessary to have a psychologist perform an interview to initiate or determine the need for psychological testing; or
(B) When a client's presentation requires that a physician or a psychiatric advanced practice registered nurse evaluate the need for medication for a client who is in the care of a non-medical practitioner.
(4) Group psychotherapy sessions, are limited in size to a maximum of twelve participants per group session regardless of the payment source of each participant, except as provided in subdivision (8) of subsection (d) of this section.
(5) Group psychotherapy sessions shall be facilitated by an individual qualified as provided in the applicable licensure category in sections 17a-262-819(c) to (e), inclusive, of the Regulations of Connecticut State Agencies.
(6) Multiple-family group psychotherapy sessions are limited in size to a maximum of 24 participants regardless of the payment source of each participant. Such sessions may be conducted with or without the client present.
(7) Family therapy shall be reimbursable for one identified client per encounter, without regard to the number of family members in attendance or the presence of behavioral health conditions among other family members in attendance.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Payment of Behavioral Health Clinic Services › Section 17b-262-823 - Services not covered

Current through July 10, 2024
The department shall not pay for the following:
(1) Information or services provided to a client over the telephone;
(2) Cancelled services and appointments not kept;
(3) Any services, treatment or items for which the provider does not usually charge;
(4) Any procedures or services whose purpose is solely educational, social, research, recreational, experimental or generally not accepted by medical practice;
(5) Any behavioral health clinic service 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;
(6) Any service not included in the plan of care when treatment is recommended;
(7) Any service requiring authorization or registration for which the provider did not obtain such authorization or registration; or
(8) Off-site and certain other services, including but not limited to: Emergency mobile psychiatric services; home and community based rehabilitation services; and extended day treatment provided only as children's rehabilitation services, as described in sections 17b-262-849 to 17b-262-861, inclusive, of the Regulations of Connecticut State Agencies. Such services are reimbursed as part of the rehabilitation option services rather than as a behavioral health clinic service.