reglab/statecodes huggingface dataset:
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Psychologists' Services › Section 17b-262-471 - Services covered and limitations

Current through July 10, 2024
Except for the limitations and exclusions listed below, the department shall pay for the professional services of a licensed psychologist which conform 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 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.
(a) The department shall pay for the following psychological services:
(1) Psychodiagnostic Evaluations
(A) Intellectual Evaluation - Individual
Evaluation of intellectual functioning by means of appropriate psychological procedures, such as the Wechsler Adult Intelligence Scale, Wechsler Intelligence Scale for Children, and Stanford-Binet Intelligence Scale;
(B) Scholastic Achievement or Group Intelligence
(i) Scholastic Achievement: Determination of acquired abilities in areas of educational achievement through the administration and evaluation of tests, California Reading Test, and Wide Range Achievement Test; and
(ii) Group Intellectual Evaluation: Determination of intellectual functioning by means of group intelligence tests such as the Lorge-Thorndike Intelligence Test, Otis Quick-Scoring Mental Ability Test, and California Short-Form Test of Mental Maturity;
(C) Personality Diagnosis and Evaluation
Study of personality dynamics, interpersonal relations, emotional adjustment, and stability, through the utilization of psychological procedures such as Rorschach, MMPI, Thematic Apperception Test, Children's Apperception Test, and Figure-Drawing;
(D) Evaluation of Organic Brain Involvement: Organicity
Assessment of functions requiring memory, concept formation, visual motor skills, by means of psychological procedures such as the Wechsler Memory Scale, Goldstein-Scheerer Battery Graham-Kendall Memory for Designs, and Bender Visual Motor Gestalt Test;
(E) Evaluation of Aptitudes, Interests, and Educational Adjustment
Assessment of vocational aptitudes and interests and educational achievement by means of such procedures as manipulation tests of dexterity and coordination, vocational aptitude tests, interest tests, and achievement tests; and
(F) Neuropsychological Evaluation
Assessment of perceptual or motor functions; attention; memory; and learning; intellectual processes; and emotion, behavior, and personality by means of appropriate psychological procedures administered by a qualified neuropsychologist, such as the Wechsler Adult Intelligence Scale, the Wide Range Achievement Test, the Wechsler Memory Scale, the Luria Nebraska Neuropsychological Battery, and the Halstead-Reitan Neuropsychological Battery.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Psychologists' Services › Section 17b-262-472 - Services not covered

Current through July 10, 2024
The department shall not pay for the following psychological services:
(a) information or services furnished by the psychologist to the client over the telephone;
(b) all evaluations, diagnostic interviews, and therapy services performed in hospital inpatient or outpatient settings;
(c) concurrent services involving similar treatment modalities for the same client by different health professionals;
(d) cancelled office visits or for appointments not kept; and
(e) psychological services which are primarily for vocational or educational guidance.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Psychologists' Services › Section 17b-262-473 - Need for service and authorization process

Current through July 10, 2024
(a)
Need for Service
The department shall pay for psychological services which are provided by a licensed psychologist and are medically necessary and medically appropriate for the prevention, diagnosis, and treatment of intellectual functioning and mental illness.
(b)
Prior Authorization
(1) Prior authorization, on forms and in a manner as specified by the department, is required for:
(A) all clients for all counseling and psychotherapy interviews in excess of thirteen visits in a calendar quarter, per type of treatment for the same provider and client; and
(B) 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:
(i) 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;
(ii) a description of the outcomes of any alternative measures tried; and
(iii) 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 Psychologists' Services › Section 17b-262-474 - Billing procedures

Current through July 10, 2024
(a) Claims from psychologists 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 amount billed to the department shall represent the psychologist's usual and customary charge for the services delivered.
(c) Claims submitted for services not requiring prior authorization shall include the name of the physician, person, or agency making the referral-if there was a referral.
(d) When a psychologist is requested to attend a staff conference for a Medical Assistance Program client, the name of the referring practitioner, clinic, or agency shall be entered in the appropriate section of the claim form.
(e) Neuropsychological evaluations shall be billed as one unit regardless of the number of sessions.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Psychologists' Services › Section 17b-262-475 - Payment

Current through July 10, 2024
(a) Psychologists who are fully or partially salaried by a general hospital, public or private institution, group practice, or clinic shall not receive payment from the department unless the psychologist maintains an office for private practice at a separate location from the hospital, institution, or clinic in which the psychologist is employed and bills for a service provided to the psychologist's private practice client at the psychologist's private practice location only.
(b) Payment for services directly performed by a psychologist in private practice 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 Psychologists' Services › Section 17b-262-477 - Payment limitations

Current through July 10, 2024
(a) The psychologist's interview of the client's family during the course of treatment in the psychologist's office shall be paid at the rate for individual therapy regardless of the number of persons in attendance.
(b) The fees for evaluative and treatment services, as stipulated in the psychologist's fee schedule, represent one unit of service, and only one unit shall be billed per day per service regardless of the number of days to complete the unit billed.
(c) The department shall not reimburse the psychologist for services performed by allied health professionals or paraprofessionals who are in the employ of the psychologist. The psychologist shall be paid for services only to the clients personally being treated by the psychologist.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Psychologists' Services › Section 17b-262-478 - Documentation

Current through July 10, 2024
(a) Psychologists shall maintain a specific record for all services received for each client eligible for Medical Assistance Program payment including, but not limited to: name, address, birth date, Medical Assistance Program identification number, pertinent diagnostic information, a current treatment plan signed by the psychologist, documentation of services provided, and the dates the services were provided.
(b) The evaluation report for psychodiagnostic tests, including the Aptitudes, Interests, and Education Adjustment Evaluation, shall be on file with the psychologist to justify medical necessity and medical appropriateness of treatment.
(c) All required documentation shall be maintained for at least five years in the psychologist'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.
(d) Failure to maintain all required documentation shall result in the disallowance and recovery by the department of any amounts paid to the psychologist for which the required documentation is not maintained and provided to the department upon request.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Client Copayment on Prescription Drugs, Over-The-Counter Drugs, and Refills Under the Medical Assistance Program › Section 17b-262-493 - Scope

Current through July 10, 2024
Sections 17b-262-493 to 17b-262-498 inclusive, set forth the copayment requirements for clients who are eligible to receive prescription drugs, over-the-counter drugs, or refills covered under the Medicaid, General Assistance and State Administered General Assistance Programs and furnished by a pharmacy provider enrolled in the Connecticut Medical Assistance Program pursuant to section 17b-259a and section 17b-262 of the Connecticut General Statutes and subject to the exclusions as set forth in section 17b-262-496.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Client Copayment on Prescription Drugs, Over-The-Counter Drugs, and Refills Under the Medical Assistance Program › Section 17b-262-494 - Definitions

Current through July 10, 2024
For the purposes of sections 17b-262-493 to 17b-262-498 inclusive, the following definitions shall apply:
(1) "Client" means a person eligible for services under the department's Medical Assistance Program.
(2) "Compounded Prescriptions" means two or more drugs mixed together in which at least one ingredient is a legend drug. A compounded prescription shall include the name, strength, and amount of each prescribed ingredient.
(3) "Copayment" means the set portion of the department's fee for prescription drugs, over-the-counter drugs, or refills which shall be the responsibility of the client to pay to the pharmacy provider for such services furnished to the client.
(4) "Department" means the department of social services.
(5) "Medical Assistance Program" means the medical assistance provided pursuant to Chapter 319V of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act. The program is also referred to as Medicaid.
(6) "Pharmacy" means a facility licensed by the Commission of Pharmacy in the Department of Consumer Protection under Section 20-594 of the Connecticut General Statutes or by the appropriate regulatory body of the state in which it is located.
(7) "Provider" means any individual or entity enrolled in the department's Medical Assistance Program and performing within the scope of his or her practice under state law and capable of furnishing services or goods to Medical Assistance clients under the terms of a provider agreement with the department.
(8) "Provider Agreement" means the signed, written, contractual agreement between the department and the provider of services or goods.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Client Copayment on Prescription Drugs, Over-The-Counter Drugs, and Refills Under the Medical Assistance Program › Section 17b-262-495 - Services requiring a copayment

Current through July 10, 2024
Except for the exclusions specified in section 17b-262-496 below, a copayment shall be imposed on each prescription, over-the-counter drug, or refill which is furnished to a client and covered in the department's fee schedule for pharmacy providers.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Client Copayment on Prescription Drugs, Over-The-Counter Drugs, and Refills Under the Medical Assistance Program › Section 17b-262-496 - Copayment exclusions

Current through July 10, 2024
The following list contains those clients and services not subject to a copayment:
(a) The categories of clients and services described in subsection (b) of section 1916 of the Social Security Act and Part 447, section 447.53, of Title 42 of the Code of Federal Regulations (CFR), are specifically excluded from the copayment requirement;
(b) Children who are at least 18 years of age but under 21 years of age; and
(c) Compounded prescriptions.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Client Copayment on Prescription Drugs, Over-The-Counter Drugs, and Refills Under the Medical Assistance Program › Section 17b-262-497 - Copayment responsibilities

Current through July 10, 2024
(a) Each pharmacy provider shall collect the copayment amount from the client at the time of the service unless the pharmacy provider, in dispensing a prescription, over-the-counter drug, or refill, does not have face-to-face contact with the client, in which case, the pharmacy shall bill the client for the amount of the copayment;
(b) The copayment shall be automatically deducted from the maximum allowable amount paid by the department to the pharmacy provider for each prescription drug, over-the-counter drug, or refill;
(c) A pharmacy provider participating in the Connecticut Medical Assistance Program may not deny prescription drugs, over-the-counter drugs, or refills to any client because of the client's inability to pay the copayment amount. The client's inability to pay does not eliminate the client's liability for the copayment charge or prevent the provider from attempting to collect the copayment amount from the client at a later time;
(d) The client's own declaration that he or she is unable to pay the copayment amount at the time of the service is the basis for determining when a client is unable to pay; and
(e) No pharmacy provider may waive the copayment requirement or in any way compensate the client for the copayment amount.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Client Copayment on Prescription Drugs, Over-The-Counter Drugs, and Refills Under the Medical Assistance Program › Section 17b-262-498 - Copayment rate

Current through July 10, 2024
The copayment amount shall be $1.00 for each prescription drug, over-the-counter drug or refill.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Inpatient Psychiatric Hospital Services › Section 17b-262-499 - Scope

Current through July 10, 2024
Sections 17b-262-499 through 17b-262-510 inclusive set forth the Department of Social Services requirements for payment for Connecticut's Medical Assistance Program, when clients under age twenty-one and age sixty-five or over receive inpatient psychiatric hospital services in accordance with section 17b-262-499 through section 17b-262-510.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Inpatient Psychiatric Hospital Services › Section 17b-262-500 - Definitions

Current through July 10, 2024
For the purposes of sections 17b-262-499 through 17b-262-510 the following definitions shall apply:
(1) "Active Treatment" means the definition contained in 42 Code of Federal Regulations (CFR), Part 441, section 441.154.
(2) "Acute" means having rapid onset, severe symptoms, and a short course.
(3) "Acute Care" means medical care needed for an illness, episode, or injury which requires short-term, intense care, and hospitalization for a short period of time.
(4) "Allied Health Professional (AHP)" means a professional or paraprofessional individual who is qualified by special training, education, skills, and experience in mental health care and treatment and shall include, but shall not be limited to: psychologists, social workers, psychiatric nurses, and other qualified therapists.
(5) "Certification of Need Review" means an evaluation process for clients under the age of twenty-one who are requesting inpatient admission to a psychiatric hospital. This evaluation is conducted by the department acting as the independent team.
(6) "Client" means a person eligible for goods or services under the department's Medical Assistance Program.
(7) "Client Age Sixty-Five or Over" means the definition contained in 42 CFR, Part 441, section 441.100.
(8) "Client Under Age Twenty-One" means the definition contained in 42 CFR, Part 441, section 441.151.
(9) "Department" means the Department of Social Services or its agent.
(10) "Elective Admission" means any psychiatric admission to a psychiatric hospital or psychiatric facility that is nonemergency, including urgent admissions and transfers from one facility to another.
(11) "HealthTrack Services" means the services described in subsection (r) of section 1905 of the Social Security Act.
(12) "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 subdivision (5) of subsection (r) of section 1905 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 Inpatient Psychiatric Hospital Services › Section 17b-262-501 - Provider participation

Current through July 10, 2024
In order to enroll in the Medical Assistance Program and receive payment from the department, providers 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 the Medical Assistance 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 Inpatient Psychiatric Hospital Services › Section 17b-262-502 - Eligibility

Current through July 10, 2024
Payment for inpatient psychiatric hospital services shall be available on behalf of Medical Assistance Program clients under age twenty-one and age sixty-five or over under the conditions and limitations which apply to these services.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Inpatient Psychiatric Hospital Services › Section 17b-262-503 - Services covered

Current through July 10, 2024
The department shall pay for the following:
(a) medically necessary and medically appropriate inpatient psychiatric services for clients under age twenty-one or age sixty-five or over when the need for services as stated in section 17b-262-499 through section 17b-262-511 are met and provided by an enrolled Medical Assistance Program provider;
(b) inpatient hospital tests when the tests are specifically ordered by the attending physician or other licensed practitioner who is responsible for the diagnosis and treatment of the client, and who is acting within the scope of practice as defined under state law;
(c) HealthTrack Services; and
(d) HealthTrack Special Services. HealthTrack Special Services require prior authorization on a case-by-case basis to determine that the services are medically necessary and medically appropriate.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Inpatient Psychiatric Hospital Services › Section 17b-262-504 - Services not covered

Current through July 10, 2024
The department shall not pay for the following inpatient psychiatric hospital services which are not covered under the Medical Assistance Program:
(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 that do not directly relate to the client's diagnosis, symptoms, or medical history;
(c) services or items furnished for which the provider does not usually charge;
(d) the day of discharge or transfer;
(e) an inpatient psychiatric hospital admission or a day of care that does not meet all the department's requirements for inpatient services;
(f) an inpatient psychiatric hospital admission or a day of care that is denied by the hospital's Utilization Review Committee;
(g) a day when the client, who is age sixty-five or over, is absent from the psychiatric hospital at the midnight census, even though the leave or transfer is medically authorized and part of the treatment plan;
(h) a day when the client, who is under age twenty-one, is absent from the psychiatric hospital at the midnight census, even though the leave or transfer is medically authorized and part of the treatment plan; or
(i) costs associated with the education or vocational training of the client which shall be excluded from Medical Assistance Program payments.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Inpatient Psychiatric Hospital Services › Section 17b-262-505 - Certification of need review requirements for inpatient psychiatric services for a client under age twenty-one in a psychiatric hospital

Current through July 10, 2024
(a) In order to receive payment for inpatient psychiatric hospital services for individuals under age twenty-one, each individual admission, including elective and emergency admissions, shall have a certification of need review.
(b) The certification of need review shall be a part of the client's medical record, with written documentation certifying 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 inpatient care 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 Inpatient Psychiatric Hospital Services › Section 17b-262-506 - Individual plan of care requirements for inpatient psychiatric services for a client under age twenty-one in a psychiatric hospital

Current through July 10, 2024
(a) Inpatient psychiatric services for clients under age twenty-one shall constitute active treatment, as documented in the professionally developed and supervised individual plan of care.
(b) Before admission or before authorization for payment, the interdisciplinary team shall establish a written plan of care for each applicant or client, designed to achieve the client's discharge from inpatient status at the earliest possible time. This plan shall:
(1) be based on a diagnostic evaluation that includes examinations of the medical, psychological, social, behavioral, and developmental aspects of the client's situation and thereby reflect the need for inpatient psychiatric care;
(2) be developed by the interdisciplinary team of professionals in consultation with the client, and his or her parents, legal guardian, or others into whose care he or she will be released after discharge;
(3) state the treatment objective;
(4) prescribe an integrated program of therapies, activities, and experiences designed to meet the treatment objectives;
(5) include, at an appropriate time, post-discharge plans and coordination of inpatient services with partial discharge plans and related community services to ensure continuity of care with the client's family, school, and community upon discharge; and
(6) be a recorded document which is maintained in the client's medical record.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Inpatient Psychiatric Hospital Services › Section 17b-262-507 - Individual plan of care for a client age sixty-five or over in a psychiatric hospital

Current through July 10, 2024
(a) A written, individual plan of care shall be developed to ensure that institutional care maintains the client at, or restores them to, the greatest possible degree of health and independent functioning. The plan of care for an elective admission shall be completed by the attending or staff physician prior to admission. The plan of care for clients age sixty-five or over, in addition to the requirements specified in the definitions, shall also include:
(1) an initial review of the client's medical, psychiatric, and social needs;
(2) periodic review of the client's medical, psychiatric, and social needs;
(3) a determination, at least every ninety days, of the client's need for continuing institutional care and for alternative care arrangements;
(4) appropriate medical treatment in the institution; and
(5) appropriate social services.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Inpatient Psychiatric Hospital Services › Section 17b-262-508 - Utilization review program for inpatient psychiatric services for clients under age twenty-one or age sixty-five or over

Current through July 10, 2024
(a) The department's Utilization Review Program conducts utilization review activities for services delivered by the inpatient psychiatric hospital to clients where the Medical Assistance Program has been determined to be the appropriate payer.
(b) To determine that inpatient psychiatric services or admissions are medically necessary and medically appropriate, the department may:
(1) require preadmission review or prior authorization of each inpatient psychiatric hospital admission, including a certificate of need review, for clients under age twenty-one, unless the department notifies the providers that a specific admission, diagnosis, or procedure 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 Inpatient Psychiatric Hospital Services › Section 17b-262-509 - Billing procedures

Current through July 10, 2024
Claims from inpatient psychiatric 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 Inpatient Psychiatric Hospital Services › Section 17b-262-510 - Documentation and record retention

Current through July 10, 2024
(a) A provider shall meet the special medical record requirements for a psychiatric hospital 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 five years, 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 to Independent Radiology and Ultrasound Centers › Section 17b-262-512 - Scope

Current through July 10, 2024
Sections 17b-262-512 through 17b-262-520 inclusive set forth the Department of Social Services requirements for the payment of radiology services performed by an independent radiology or ultrasound center provided in a freestanding center, which is not part of a physician's office nor a hospital outpatient department or clinic, for clients who are determined eligible to receive services under Connecticut's Medical Assistance 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 to Independent Radiology and Ultrasound Centers › Section 17b-262-513 - Definitions

Current through July 10, 2024
For the purposes of sections 17b-262-512 through 17b-262-520 the following definitions shall apply:
(1) "Acute" means having rapid onset, severe symptoms, and a short course.
(2) "Client" means a person eligible for goods or services under the department's Medical Assistance Program.
(3) "Commissioner" means the Commissioner of Social Services appointed pursuant to subsection (a) of section 17b-1 of the Connecticut General Statutes.
(4) "Department" means the Department of Social Services or its agent.
(5) "Electrocardiogram (EKG) Services" means diagnostic services derived from an electrocardiogram device which measures the electrical variations in heart muscles.
(6) "Electroencephalogram (EEG) Services" means diagnostic services derived from an electroencephalogram instrument which records the electrical activity of the brain.
(7) "Emergency" means a medical condition, including labor and delivery, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the client's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.
(8) "Freestanding Radiology or Ultrasound Center" means those centers which offer radiology or ultrasound services but which are not part of a physician's office nor an inpatient or outpatient hospital service.
(9) "HealthTrack Services" means the services described in subsection (r) of section 1905 of the Social Security Act.
(10) "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 subdivision (5) of subsection (r) of section 1905 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 to Independent Radiology and Ultrasound Centers › Section 17b-262-514 - Provider participation

Current through July 10, 2024
In order to enroll in the Medical Assistance Program and receive payment from the department, providers shall:
(a) meet and maintain all applicable licensing, accreditation, and certification requirements;
(b) meet and maintain all departmental enrollment requirements; and
(c) have a valid provider agreement on file which is signed by the provider and the department upon application for enrollment into the Medical Assistance 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 to Independent Radiology and Ultrasound Centers › Section 17b-262-515 - Eligibility

Current through July 10, 2024
Payment for radiology or ultrasound center services shall be available on behalf of all persons eligible for the Medical Assistance Program subject to the conditions and limitations which apply to these services.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment to Independent Radiology and Ultrasound Centers › Section 17b-262-516 - Services covered

Current through July 10, 2024
The department shall pay for:
(a) medically appropriate and medically necessary radiology or ultrasound center services as published in the department's fee schedule when ordered by a licensed physician or other licensed practitioner of the healing arts; and
(b) HealthTrack Services and HealthTrack Special Services.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment to Independent Radiology and Ultrasound Centers › Section 17b-262-517 - Need for service and authorization process

Current through July 10, 2024
(a)
Need for Service
The department shall pay for independent radiology and ultrasound center services which are ordered by a duly licensed physician or other licensed practitioner of the healing arts and which the department deems to be medically necessary and medically appropriate.
(b)
Prior Authorization
Prior authorization, on forms and in a manner as specified by the department, shall be required for HealthTrack Special Services:
(1) HealthTrack Special Services are determined medically necessary and medically appropriate on a case-by-case basis; and
(2) the request for HealthTrack Special Services shall include:
(A) 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;
(B) a description of the outcomes of any alternative measures tried; and
(C) 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 to Independent Radiology and Ultrasound Centers › Section 17b-262-518 - Billing procedures

Current through July 10, 2024
(a) Claims from independent radiology or ultrasound center 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 payment for radiology or ultrasound center services includes all consultation services as well as the written report to the referring physician.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment to Independent Radiology and Ultrasound Centers › Section 17b-262-519 - Payment rate and limitations

Current through July 10, 2024
(a) The commissioner shall establish the fees contained in the department's published fee schedule for independent radiology and ultrasound centers pursuant to section 4-67c of the Connecticut General Statutes.
(b) The payment rate 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 to Independent Radiology and Ultrasound Centers › Section 17b-262-520 - Documentation

Current through July 10, 2024
(a) Independent radiology or ultrasound center providers shall maintain a specific record for each client eligible for Medical Assistance Program payment including, but not limited to: name, address, birth date, Medical Assistance Program identification number, pertinent diagnostic information, documentation of the 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 and provided to the department by request.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Provider Participation in the Connecticut Medical Assistance Program › Section 17b-262-522 - Scope

Current through July 10, 2024
Sections 17b-262-522 through 17b-262-532, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services general requirements to which providers of Medical Assistance Program goods and services shall adhere in order to participate in, and receive payment from, the Connecticut Medical Assistance 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 › Requirements for Provider Participation in the Connecticut Medical Assistance Program › Section 17b-262-524 - Provider participation

Current through July 10, 2024
(a) To enroll in the Medical Assistance Program and receive payment from the department for the provision of goods or services to Medical Assistance Program clients, providers shall:
(1) Meet and maintain all applicable licensing, accreditation and certification requirements;
(2) meet and maintain all departmental enrollment requirements including the timely submission of a completed provider enrollment or reenrollment form and submission of all enrollment information and such affidavits as the department may require; and
(3) have a valid provider agreement on file which is signed by the provider and the department. This agreement, which shall be periodically updated, shall continue to be in effect for the duration specified in the agreement. The provider agreement specifies conditions and terms that 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 Provider Participation in the Connecticut Medical Assistance Program › Section 17b-262-525 - Termination or suspension of provider agreement

Current through July 10, 2024
(a) Providers shall be subject to all of the conditions contained in section 17b-99 of the Connecticut General Statutes and sections 17-83k-1 through 17-83k-7 of the Regulations of Connecticut State Agencies.
(b) A provider agreement may be terminated by mutual consent or without cause by either the department or the provider by giving a thirty day written notification to the affected party, or as otherwise provided by federal or state law.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Provider Participation in the Connecticut Medical Assistance Program › Section 17b-262-528 - Prior authorization

Current through July 10, 2024
(a) Prior authorization, to determine medical appropriateness and medical necessity, shall be required as a condition of payment for certain Medical Assistance Program goods or services as set forth in the regulations of the department governing specific provider types and specialties. The department shall not make payment for such goods and services when such authorization is not obtained by the provider of the goods or services.
(b) Prior authorization shall be granted by the department to a provider to furnish specified goods or services within a defined time period as set forth in the regulations of the department governing specific provider types and specialties.
(c) Payment for medical goods or services provided to a client, for which prior authorization is given, is contingent upon the client's eligibility at all times such goods and services are furnished.
(d) In order to receive payment from the department a provider shall comply with all prior authorization requirements. The department in its sole discretion determines what information is necessary in order to approve a prior authorization request. Prior authorization does not, however, guarantee payment unless all other requirements for payment are met.
(e) Coverable Medical Assistance Program goods or services requiring prior authorization may be so identified on the department's applicable fee schedule or identified in regulation.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Provider Participation in the Connecticut Medical Assistance Program › Section 17b-262-529 - 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 within twelve months of the date the service was provided or the good was delivered and shall include all information required by the department to process the claim for payment, as set forth in the Regulations of Connecticut State Agencies and specified in the department's provider billing manuals. The date of service is the actual date on which the service was provided.
(b) Exceptions to the procedures set forth in subsection (a) of section 17b-262-529 of the Regulations of Connecticut State Agencies shall be as follows:
(1) when an individual is an applicant of the Medical Assistance Program or an applicant for a categorically related program which qualifies the individual for the Medical Assistance Program, and the determination of eligibility comes after the last date of service and eligibility is retroactive, the provider shall submit claims for goods or services received within one year of the effective date of the determination of eligibility or effective date of award, whichever comes later;
(2) when there is an issue related to Medical Assistance Program eligibility or to payment for goods or services which is subject to the grievance process, the provider shall submit claims within the guidelines in subsection (a) of section 17b-262-529 of the Regulations of Connecticut State Agencies or within twelve months of the effective date of the resolution in favor of Medical Assistance Program payments for goods or services, whichever is later; and
(3) when a provider has submitted a claim to a third party insurer and has not received a response within a reasonable time, the one year shall begin twelve months from the date of receipt of the explanation of benefits form. The provider shall be responsible for any followup to the third party insurers.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Provider Participation in the Connecticut Medical Assistance Program › Section 17b-262-530 - Payment rates

Current through July 10, 2024
(a) All schedules of payment for coverable Medical Assistance Program goods and services shall be established by the commissioner and paid by the department in accordance with all applicable federal and state statutes and regulations.
(b) A provider whose rates are established by the department based on the provider's cost may be required to submit data in a format prescribed by the department which may include but not be limited to, the following:
(1) a copy of the provider's financial statement and an independent auditor's report for the most recently completed fiscal year, or anticipated costs if the program or service is new;
(2) a copy of the provider's financial statement for the current year to date;
(3) a current copy of the provider's usual and customary charges to the general public; and
(4) the provider's most recent Medicare cost report, if one is required to be filed by the provider.