reglab/statecodes huggingface dataset:
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Home Health Care Services › Section 17b-262-735 - Documentation

Current through July 10, 2024
(a) All required documentation shall be maintained for at least five years, or longer by the provider in accordance with statute or regulation, subject to review by the department. Documentation as set forth in sections 19-13-D75 and 19-13-D77 of the Regulations of Connecticut State Agencies shall be maintained for seven years. In the event of a dispute concerning a service provided, documentation shall be maintained until the end of the dispute, five years or the length of time required by statute or regulation, whichever is longest.
(b) Failure to maintain and provide all required documentation to the department upon request shall result in the disallowance and recovery by the department of any future or past payments made to the provider for which the required documentation is not maintained and not provided to the department upon request.
(c) The following information shall be documented in writing or electronically, consistent with the requirements described in the Provider Enrollment Agreement and maintained on file with the home health care agency for each Medicaid client:
(1) initial and subsequent care plans signed and dated by the licensed practitioner in accordance with section 19-13-D73 of the Regulations of Connecticut State Agencies;
(2) verbal and telephone orders signed and dated by a licensed practitioner in accordance with section 17b-242 of the Connecticut General Statutes;
(3) Medicaid identification number;
(4) pertinent diagnostic information;
(5) documentation of each service provided and its duration;
(6) dates of services provided;
(7) for pregnancy-related preventive prenatal or postpartum nursing care services, evidence that the client is high risk as described in section 17-262-731 of the Regulations of Connecticut State Agencies;
(8) time sheets documenting all home health aide hours worked and duties performed that are signed by the client or his or her representative. A client representative shall not be an employee of, or under contract to, the home health care agency. All signatures shall be accompanied by a printed name; and
(9) all information described in section 19-13-D75(b) of the Regulations of Connecticut State Agencies.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment to Providers of Orthotic and Prosthetic Devices › Section 17b-262-736 - Scope

Current through July 10, 2024
Sections 17b-262-736 to 17b-262-746, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services requirements for payment to providers of orthotic and prosthetic devices that are prescribed by a licensed practitioner on behalf of clients who are determined to be eligible to receive such goods and services under Medicaid pursuant to section 17b-262 of the Connecticut General Statues.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment to Providers of Orthotic and Prosthetic Devices › Section 17b-262-738 - 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-262-522 to 17b-262-533, inclusive, of the Regulations of Connecticut State Agencies.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment to Providers of Orthotic and Prosthetic Devices › Section 17b-262-739 - Eligibility

Current through July 10, 2024
A provider may receive reimbursement from the department for the provision of an orthotic and prosthetic device to a client. No reimbursement shall be made unless a licensed practitioner has prescribed the orthotic or prosthetic device subject to the conditions and limitations set forth in sections 17b-262-736 to 17b-262-746, inclusive, of the Regulations of Connecticut State Agencies.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment to Providers of Orthotic and Prosthetic Devices › Section 17b-262-740 - Services covered and limitations

Current through July 10, 2024
(a)
Services Covered
(1) The department shall pay for the purchase or repair of a medically necessary and medically appropriate orthotic or prosthetic device, except as limited by sections 17b-262-736 to 17b-262-746, inclusive, of the Regulations of Connecticut State Agencies, provided such device is prescribed by a licensed practitioner in conformance with accepted methods of diagnosis and treatment.
(2) The department shall pay for an orthotic or prosthetic device for a client who lives at home or in a nursing facility, ICF/MR, hospital or chronic disease hospital, except as limited by sections 17b-262-736 to 17b-262-746, inclusive, of the Regulations of Connecticut State Agencies.
(3) The department shall maintain a fee schedule for orthotic and prosthetic devices, subject to the conditions and limitations set forth in sections 17b-262-736 to 17b-262-746, inclusive, of the Regulations of Connecticut State Agencies. This fee schedule is designed to meet the needs of most Medicaid clients. An item is not covered unless it is on the fee schedule. A provider or client may request that an item be added to the fee schedule. The department, at its discretion, may decide to add requested items during its regular revisions to the fee schedule, as published by the department.
(4) The department shall pay for early and periodic screening, diagnostic and treatment services (EPSDT) described in subsection 1905(r) 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 to Providers of Orthotic and Prosthetic Devices › Section 17b-262-741 - Goods and services not covered

Current through July 10, 2024
The department shall not pay providers for:
(1) any orthotic or prosthetic device 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;
(2) any non-customized orthotic or prosthetic device that does not require prior authorization and that is prescribed and ordered for a client who:
(A) dies prior to delivery of the device; or
(B) is not otherwise eligible on the date of delivery. It shall be the provider's responsibility to verify that the client is eligible on the date the device is delivered; or
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment to Providers of Orthotic and Prosthetic Devices › Section 17b-262-742 - Prior authorization

Current through July 10, 2024
(a) The department shall require PA for any orthotic or prosthetic device identified on the department's published fee schedule as requiring PA.
(b) To receive reimbursement from the department a provider shall comply with all prior authorization requirements. The department in its sole discretion shall determine what information is necessary to approve a prior authorization request. Prior authorization does not, however, guarantee payment unless all other requirements are met.
(c) A PA request, on a form and in a manner specified by the department, shall include documentation of medical necessity and shall be signed by the prescribing licensed practitioner and the provider. A copy of the prescription from the licensed practitioner may be attached to the completed PA request in lieu of the actual signature of the licensed practitioner on the PA request form. The licensed practitioner's original prescription shall be on file with the provider and be subject to review by the department.
(d) A provider may send a prior authorization request to the department via facsimile if the request is medically necessary to:
(1) facilitate institutional discharge or
(2) avoid imminent hospitalization. Specifics that substantiate the nature of the request shall be clearly identified in the facsimile. All other PA requests for an orthotic or prosthetic device shall be submitted by mail.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment to Providers of Orthotic and Prosthetic Devices › Section 17b-262-743 - 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 or its agent 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 an orthotic or prosthetic device that did not require prior authorization shall include the name of the licensed practitioner prescribing the device. A licensed practitioner's original prescription for the device shall be on file with the provider and shall be subject to review by the department.
(c) Providers shall bill and the department shall pay at the lowest of:
(1) the usual and customary charge;
(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 to the department; or
(5) the amount the department indicates in writing in a prior authorization.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment to Providers of Orthotic and Prosthetic Devices › Section 17b-262-744 - Payment limitations

Current through July 10, 2024
(a) The department shall reimburse a provider when all requirements of sections 17b-262-736 to 17b-262-746, inclusive, of the Regulations of Connecticut State Agencies have been met.
(b) The department shall pay for a customized orthotic or prosthetic device for a client who dies or is not otherwise eligible on the date of delivery provided the client was eligible:
(1) on the date prior authorization was given by the department; or
(2) on the date the client ordered the device, if the device does not require prior authorization. For purposes of this section, the date the client orders the device means the date on which the written medical order for the device is presented to or received by the provider. The provider shall verify to the department the date the client ordered the device.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment to Providers of Orthotic and Prosthetic Devices › Section 17b-262-745 - Documentation

Current through July 10, 2024
(a) All required documentation shall be maintained for at least five (5) years in the provider's primary place of business and shall be subject to review by the department. In the event of a dispute concerning a service or a device provided, documentation shall be maintained until the end of the dispute or five (5) years, whichever is longer.
(b) 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 device or service for which the required documentation is not maintained or provided to the department upon request.
(c) The licensed practitioner's original prescription for an orthotic or prosthetic device and documentation of all notes related to fittings and adjustments shall be kept at the provider's primary place of business and shall be subject to review by the department.
(d) Providers shall maintain all fiscal and medical records related to services and goods rendered or delivered to Medicaid clients.
(e) Providers shall require and retain a signed receipt for all deliveries of orthotic and prosthetic devices, documenting that the client or, if the client is unable to sign, a designated representative other than the provider or the provider's employee, took delivery of the device. The receipt for an orthotic or prosthetic device, regardless of the format used, shall, at a minimum, contain the following elements:
(1) the provider's name;
(2) the client's name;
(3) the delivery address;
(4) the date of delivery; and
(5) itemization of the orthotic and prosthetic devices delivered, including:
(A) a product description;
(B) a brand name;
(C) a model name and number, if applicable;
(D) a serial number, if applicable;
(E) the quantity delivered; and
(F) the amount billed per device.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment to Providers of Orthotic and Prosthetic Devices › Section 17b-262-746 - 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 device.
(c) Providers shall initiate necessary reimbursement adjustments to the department resulting from returns of non-customized orthotic and prosthetic devices delivered to a client.
(d) 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 authorized department personnel.
(e) An orthotic or prosthetic device purchased by the department shall be new and 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 Private Non-Medical Institutions › Section 17b-262-747 - Scope

Current through July 10, 2024
Sections 17b-262-747 to 17b-262-757, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services' requirements for payment of rehabilitative services provided by private non-medical institutions to children 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 Private Non-Medical Institutions › Section 17b-262-748 - Definitions

Current through July 10, 2024
As used in sections 17b-262-747 through 17b-262-757, inclusive, of the Regulations of Connecticut State Agencies the following definitions shall apply:
(1) "Billing provider" means the Connecticut Department of Children and Families.
(2) "Child" means a person who is under twenty-one (21) years of age.
(3) "Department" or "DSS" means the Department of Social Services or its agent.
(4) "DCF" means the Department of Children and Families.
(5) "Individual treatment plan" means a written plan developed by the performing provider in accordance with section 17b-262-749(a)(5) of the Regulations of Connecticut State Agencies.
(6) "Licensed clinical staff" means:
(A) a doctor of medicine or osteopathy licensed under chapter 370 of the Connecticut General Statutes;
(B) a psychologist who is licensed under chapter 383 of the Connecticut General Statutes;
(C) a marriage and family therapist who is licensed under chapter 383a of the Connecticut General Statutes;
(D) a clinical social worker who is licensed under chapter 383b of the Connecticut General Statutes;
(E) an alcohol and drug counselor who is licensed under chapter 376b of the Connecticut General Statutes;
(F) an advanced practice registered nurse who is licensed under chapter 378 of the Connecticut General Statues; or
(G) a registered nurse who is licensed under chapter 378 of the Connecticut General Statutes and who has a minimum of one year of experience in the mental health field.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Private Non-Medical Institutions › Section 17b-262-749 - Provider and billing provider requirements

Current through July 10, 2024
To participate in the Medicaid program and provide PNMI rehabilitative services that are eligible for Medicaid reimbursement from the department, the following requirements shall be met:
(1) The performing provider shall:
(A) Enroll with the department and have on file a valid provider agreement.
(B) Be licensed or approved by DCF or another state agency as (A) a residential treatment facility, group home, maternity home, or similar institution; or (B) a child placing agency that offers therapeutic foster care or a professional parent program.
(C) Comply with all Medicaid record keeping, documentation and other requirements, including, but not limited to, those delineated in the department's administrative manuals, provider agreements and memoranda of understanding.
(D) Follow all laws, rules, regulations, policies and amendments that govern the Medicaid program as they relate to reimbursement for PNMI rehabilitative services.
(E) Develop an individual treatment plan for each PNMI client in accordance with section 17a-145-94 of the Regulations of Connecticut State Agencies not later than thirty days after the PNMI client's admission to the program. The individual treatment plan shall be developed in conjunction with DCF, the child and the child's family, whenever possible, and shall be signed and dated by a licensed clinical staff member employed by or under contract with the performing provider. Such plan shall contain specific behavioral health goals and objectives that are based on an evaluation and diagnosis for the maximum reduction of a client's behavioral health problems and shall identify the type, amount, frequency and duration of services to be provided.
(F) Ensure that a licensed clinical staff member employed by or under contract with the performing provider reviews and signs the individual treatment plan within each six month calendar period following the date of a PNMI client's admission.
(G) Keep current service and progress notes in a permanent case record for each PNMI client in accordance with sections 17a-145-94 and 17a-145-98 of the Regulations of Connecticut State Agencies. Such entries shall be made on at least a monthly basis.
(H) Furnish information and documentation to the billing provider that is sufficient to allow the billing provider to prepare PNMI claims for rehabilitative services.
(I) Cooperate with the department and the billing provider in the rate setting process; licensing; or any quality assurance reviews or periodic audits to ensure compliance with PNMI program requirements.
(J) Assign billing responsibilities related to the claiming of federal financial participation for state PNMI Medicaid costs to the billing provider.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Private Non-Medical Institutions › Section 17b-262-750 - Eligibility

Current through July 10, 2024
Payment for PNMI rehabilitative services shall be subject to available appropriations and shall be available for services rendered to PNMI clients under the conditions and limitations that are set forth in sections 17b-262-747 to 17b-262-757, inclusive, of the Regulations of Connecticut State Agencies.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Private Non-Medical Institutions › Section 17b-262-751 - Need for services

Current through July 10, 2024
Payment for PNMI rehabilitative services shall be made by the department only if all of the following conditions are met:
(1) The client shall be assessed by the billing provider or its agent to determine that the PNMI rehabilitative services are medically necessary or medically appropriate.
(2) For up to 30 days of a PNMI client's initial stay in a PNMI program, the PNMI rehabilitative services shall be provided in accordance with an initial assessmentof need that is completed by DCF and signed by a licensed clinical staff member of the performing provider. This assessment shall, for up to 30 days of a PNMI client's initial stay, be deemed to meet the PNMI requirements for an individual treatment plan set forth in section 17b-262-749(a)(5) of the Regulations of Connecticut State Agencies.
(3) After the first 30 days of a client's stay in a PNMI program, the PNMI rehabilitative services shall be provided in accordance with a written individual treatment plan developed in accordance with section 17b-262-749(a)(5) of the Regulations of Connecticut State Agencies. Within each 90 day period thereafter, the individual treatment plan shall be reviewed by the licensed, clinical staff employed by or under contract with the performing provider.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Private Non-Medical Institutions › Section 17b-262-752 - Covered services

Current through July 10, 2024
PNMI rehabilitative services shall include the following services:
(1) Assessment, treatment planning and support activities that assist the client in gaining access to authorized services. These services include:
(A) Intake and assessment, which means assessing and reassessing the client's behavioral health needs in the context of medical, social, educational and other needs through face-to-face contact with the client, the client's family and through consultation with other professionals; and
(B) Development of an individual treatment plan in accordance with sections 17b-262-749(a)(5) and 17b-262-751 of the Regulations of Connecticut State Agencies; and
(C) Care coordination, which means facilitating the child's access to behavioral health services identified in the individual treatment plan, including:
(i) Arranging for services;
(ii) Assuring that prescribed services are received;
(iii) Assessing the effectiveness of those services;
(iv) Attending case conferences to review and modify individual treatment plans as necessary; and
(v) Arranging home visits, discharge and aftercare services.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Private Non-Medical Institutions › Section 17b-262-753 - Limitations

Current through July 10, 2024
Coverage of PNMI rehabilitative services shall be subject to the following limitations:
(1) PNMI rehabilitative services shall be pre-authorized by DCF based on a written service recommendation.
(2) The PNMI rehabilitative service shall be based on the individual treatment plan developed pursuant to section 17b-262-749(a)(5) of the Regulations of Connecticut State Agencies and shall be performed by the performing provider or under the supervision of licensed clinical staff employed by or under contract to the performing provider.
(3) The department shall not pay for programs, services or components of services that are of an unproven, experimental, cosmetic or research nature.
(4) The department shall not pay for programs, services or components of services that do not relate to the client's diagnosis, symptoms or medical history.
(5) The department shall not pay for programs, services or components of services, which are not included in the fee schedule established by the department.
(6) The department shall not pay for programs, services that are academic in nature such as tutoring, study sessions or instruction in English, science, history, mathematics or foreign languages.
(7) The department shall not pay for programs, services or components of services that are intended solely to prepare individuals for paid or unpaid employment or for vocational equipment and uniforms.
(8) The department shall not pay for programs, services or components of services designed to provide socialization or recreational activities for clients unless such services are provided to meet a client's need for motivational, diversionary or behavior management activities for which specific goals and objectives are identified in the client's individual treatment plan.
(9) The department shall not pay for costs associated with room and board for clients.
(10) The department shall not pay PNMI rehabilitative services that are provided out-of-state unless the services are pre-authorized by a placing state agency and are not available within Connecticut.
(11) The department shall not pay any organization that is directly under contract to a performing provider for services covered under this regulation.
(12) The department shall not pay for care coordination services that are provided within a PNMI program if such services duplicate Medicaid-reimbursed case management services that are provided outside the facility. PNMI program staff providing care coordination services shall coordinate with any Medicaid-reimbursed case management services provided outside of the program so that such duplication does not occur.
(13) The department shall not pay other providers for services to PNMI clients that if the services are not part of a client's individual treatment plan developed pursuant to section 17b-262-749(a)(5) of the Regulations of Connecticut State Agencies.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Private Non-Medical Institutions › Section 17b-262-754 - Documentation and record retention requirements

Current through July 10, 2024
PNMI rehabilitative services shall be reimbursed by the department when documentation of compliance with the following requirements is on file with the billing provider or the performing providers:
(1) Individual treatment plan requirement.
(A) An individual treatment plan shall be maintained.
(B) An initial assessment of need completed by DCF in conformance with section 17b-262-751 of the Regulations of Connecticut State Agencies is maintained.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Private Non-Medical Institutions › Section 17b-262-755 - Billing requirements

Current through July 10, 2024
(a) Claims for payment of PNMI rehabilitation services shall be submitted by the billing provider 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.
(b) All claims submitted to the department for payment of services covered under sections 17b-262-747 to 17b-262-757, inclusive, of the Regulations of Connecticut State Agencies shall be substantiated by documentation in the PNMI client's permanent case record.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Private Non-Medical Institutions › Section 17b-262-756 - Payment

Current through July 10, 2024
Payment by the department for PNMI rehabilitative services shall be made in accordance with the following provisions.
(1) The department shall make payments on the basis of monthly rates for each of three types of PNMI programs:
(A)  residential treatment centers,
(B) group homes or maternity homes and
(C) therapeutic foster care and professional parent programs. The Department shall establish interim PNMI rates each year based upon the cost to the public agency for the purchase of PNMI services during the most recently completed year. These rates shall be adjusted based upon actual cost experience of the public agency at the close of the fiscal year by adjusting the interim rate for the subsequent year accordingly. To identify costs not covered by the Medicaid program, the Department shall establish a method for cost allocation acceptable to the Centers for Medicare and Medicaid Services.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Private Non-Medical Institutions › Section 17b-262-757 - 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 PNMI rehabilitative services paid for by the department shall be subject to audit or compliance review by authorized personnel. All documentation shall be made available to authorized personnel upon request in accordance with 42 C.F.R. section 431. The Department of Children and Families shall take full financial responsibility for any Medicaid claims disallowed due to inadequate documentation by any performing provider or failure to comply with requirements set forth in statute or regulations.
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-262-758 - Scope

Current through July 10, 2024
Sections 17b-262-758 to 17b-262-769, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services' requirements for payment of rehabilitative services provided by private non-medical institutions to adults 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 Mental Health Rehabilitation Services for Adults Provided by Private Non-Medical Institutions › Section 17b-262-759 - Definitions

Current through July 10, 2024
As used in sections 17b-262-758 to 17b-262-769, inclusive, of the Regulations of Connecticut State Agencies:
(1) "Adult" means a person who is 18 years of age or older;
(2) "Department" or "DSS" means the Department of Social Services or its agent;
(3) "DMHAS" means the Department of Mental Health and Addiction Services;
(4) "DPH" means the Department of Public Health;
(5) "Group home" means a privately operated, community-based residential facility that serves sixteen or fewer adult clients, is licensed by the Department of Public Health as either a private freestanding mental health residential living center or a private freestanding community residence pursuant to sections 19a-495-551 or 19a-495-560 of the Regulations of Connecticut State Agencies, is certified by the Department of Mental Health and Addiction Services as a provider of mental health rehabilitation services pursuant to section 17a-485d of the Connecticut General Statutes, and meets the requirements of section 17b-262-760 of the Regulations of Connecticut State Agencies for participation in the Medicaid program as a provider of PNMI rehabilitative services;
(6) "Licensed clinician" means:
(A) a doctor of medicine or osteopathy licensed under chapter 370 of the Connecticut General Statutes;
(B) a psychologist who is licensed under chapter 383 of the Connecticut General Statutes;
(C) a marriage and family therapist who is licensed under chapter 383a of the Connecticut General Statutes;
(D) a clinical social worker who is licensed under chapter 383b of the Connecticut General Statutes;
(E) an advanced practice registered nurse who is licensed under chapter 378 of the Connecticut General Statutes;
(F) a registered nurse who is licensed under chapter 378 of the Connecticut General Statutes and who has a minimum of one year of experience in the mental health field; or
(G) a professional counselor who is licensed under chapter 383c of the Connecticut General Statutes;
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-262-761 - Eligibility

Current through July 10, 2024
Payment for PNMI rehabilitative services shall be available for services rendered to PNMI clients under the conditions and limitations that are set forth in sections 17b-262-758 to 17b-262-769, inclusive, of the Regulations of Connecticut State Agencies.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Mental Health Rehabilitation Services for Adults Provided by Private Non-Medical Institutions › Section 17b-262-762 - Need for services

Current through July 10, 2024
Payment for PNMI rehabilitative services shall be made by the department only if all of the following conditions are met:
(1) For up to thirty days of a PNMI client's initial stay in a PNMI program, the PNMI rehabilitative services shall be provided in accordance with an initial assessment of need that is completed and signed by a licensed clinician. This assessment shall, for up to thirty days of a PNMI client's initial stay, be utilized as the individual residential rehabilitation plan;
(2) After the first thirty days of a client's stay in a PNMI program, the PNMI rehabilitative services shall be provided in accordance with a written individual residential rehabilitation plan developed in accordance with section 17b-262-760(5) of the Regulations of Connecticut State Agencies. This plan shall be reviewed and signed by the licensed clinical staff employed by, or under contract with, the performing provider at least every ninety days thereafter;
(3) The group home has provided one qualifying billable unit of service for that month;
(4) The client's mental illness is so serious and disabling as to require care in a group home setting;
(5) The client is sufficiently stable to be able to function outside of a twenty-four hour medically managed setting and participate in community-based treatment services; and
(6) The client has functional disabilities secondary to serious and persistent mental illness and such disabilities are so great as to require that the client reside in a non-medical residential setting with rehabilitative services and supports.
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-262-763 - Covered services

Current through July 10, 2024
PNMI rehabilitative services are services designed to assist individuals with a serious and persistent mental illness to achieve their highest degree of independent functioning and recovery. These services include the following services, depending upon the particular needs of each client and the individual rehabilitation plan:
(1) Intake and assessment, which means assessing and reassessing the client's behavioral health needs in the context of medical, social, educational and other needs through face-to-face contact with the client, the client's family and through consultation with other professionals;
(2) Development of an individual residential rehabilitation plan in accordance with sections 17b-262-760(5) and 17b-262-762 of the Regulations of Connecticut State Agencies;
(3) Socialization skills development, which means client-centered skills development activities that are provided to support the goals and objectives in the PNMI client's individual residential rehabilitation plan and that are directed at reducing mental disabilities of clients in care, restoring them to their best possible functioning level and assisting clients in becoming responsible for their own actions;
(4) Behavior management training and intervention;
(5) Supportive counseling directed at solving daily problems related to community living and interpersonal relationships;
(6) Psycho-educational groups pertaining to the alleviation and management of psychiatric disorders;
(7) Teaching, coaching and assisting with daily living and self-care skills such as the use of transportation, meal planning and preparation, personal grooming, management of financial resources, shopping, use of leisure time, interpersonal communication and problem solving;
(8) Assistance in developing skills necessary to support a full and independent life in the community;
(9) Support with connecting individuals to natural community supports;
(10) Orientation to, and assistance with, accessing self help and advocacy resources;
(11) Development of self-advocacy skills;
(12) Health education;
(13) Teaching of recovery skills in order to prevent relapse;
(14) Other rehabilitative support necessary to develop or maintain social relationships, to provide for independent participation in social, interpersonal or community activities and to achieve full community reintegration; and
(15) Individual, family, and group counseling.
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-262-764 - Limitations

Current through July 10, 2024
Coverage of PNMI rehabilitative services shall be subject to the following limitations:
(1) PNMI rehabilitative services shall be pre-authorized by the department or its agent based on a written service recommendation.
(2) PNMI rehabilitative services shall be based on the individual residential rehabilitation plan developed pursuant to section 17b-262-760(5) of the Regulations of Connecticut State Agencies and the requirements of sections 17b-262-758 to 17b-262-769, inclusive, of the Regulations of Connecticut State Agencies, and shall be performed by, or under the supervision of, a licensed clinician employed by, or under contract to, the performing provider.
(3) The department shall not pay for programs, services or components of services that are of an unproven, experimental, cosmetic or research nature.
(4) The department shall not pay for programs, services or components of services that do not relate to the client's diagnosis, symptoms, functional limitations or medical history.
(5) The department shall not pay for programs, services or components of services that are not included in the fee established by the department.
(6) The department shall not pay for programs, services or components of services that are intended solely to prepare individuals for paid or unpaid employment or for vocational equipment and uniforms.
(7) The department shall not pay for programs, services or components of services designed to provide socialization or recreational activities for clients.
(8) The department shall not pay for time spent by the provider transporting clients.
(9) The department shall not pay for services that are solely, educational or vocational.
(10) The department shall not pay for costs associated with room and board for clients.
(11) The department shall not pay for PNMI rehabilitative services that are provided out-of-state unless the services are pre-authorized and are not available within Connecticut.
(12) The department shall not pay any organization or individual for services covered under sections 17b-262-758 to 17b-262-769, inclusive, of the Regulations of Connecticut State Agencies, if such organization or individual is directly under contract to a provider for services covered under sections 17b-262-758 to 17b-262-769, inclusive, of the Regulations of Connecticut State Agencies.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Mental Health Rehabilitation Services for Adults Provided by Private Non-Medical Institutions › Section 17b-262-765 - Prior authorization

Current through July 10, 2024
(a) Prior authorization of the need for PNMI adult rehabilitative services is required in order for Medicaid payment to be available for the services. Prior authorization shall be obtained on forms and in the manner specified by the department.
(b) The initial authorization period shall be for up to six months.
(c) If authorization is needed beyond the initial authorization period, requests for continued treatment beyond the initial authorization period shall be submitted prior to the end of the existing authorization and shall be considered for up to six months per request.
(d) Except in emergency situations, approval shall be received before services are rendered.
(e) In an emergency situation that occurs after working hours or on a weekend or holiday, the provider shall secure approval on the next working day for the admission to the PNMI.
(f) In order to receive payment from the department, a provider shall comply with all prior authorization requirements. The department or its agent 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.
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-262-767 - Billing requirements

Current through July 10, 2024
(a) Claims for payment of PNMI rehabilitation services shall be 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.
(b) All claims submitted to the department for payment of services covered under sections 17b-262-758 to 17b-262-769, inclusive, of the Regulations of Connecticut State Agencies shall be substantiated by documentation in the recipient's permanent case record.
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-262-768 - Payment

Current through July 10, 2024
Payment by the department for PNMI rehabilitative services shall be made in accordance with the following provisions.
(a) The department shall make payments on the basis of monthly rates for PNMI programs.
(b) A statewide capitated monthly rate will be established annually and applied uniformly to all facility providers and to all Medicaid eligible recipients provided with a qualified billable unit of service.
(c) The statewide capitated rate shall be based upon annual audited cost reports filed by licensed and certified service providers to include cost allocations based upon semi-annual time studies of facility staff hours related to rehabilitative services.
(d) The Department shall establish interim PNMI rates for the first and second year of service coverage based upon estimated costs. The interim rates will be replaced based upon cost report filings for the period and related payment adjustments will be made accordingly.
(e) Prospective rates for subsequent periods will be based upon allowable costs for the cost period ending twelve months prior to the start of the rate period. These rates will be updated, within available appropriations, by the projected increase or decrease in the consumer price index for urban consumers for the twenty-four months between the mid-point of the cost period and the mid-point of the rate year.
(1) Allowable costs for purposes of establishing the statewide capitated rate are the reasonable and necessary costs attributable to the provision of rehabilitative services covered under this regulation but shall exclude any other costs such as transportation, recreation or vocational services that are not part of rehabilitative services. Allowable costs will be determined based on a survey of all group homes covered under this regulation.
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-262-769 - 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 PNMI rehabilitative 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 DPH, DMHAS, and DSS.
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-262-770 - Scope

Current through July 10, 2024
Sections 17b-262-770 to 17b-262-773, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services requirements for the establishment by Medicaid entities of policies and procedures for the education of employees regarding false claims recoveries and methodologies for oversight of entities' compliance with these requirements.