Connecticut Administrative Code › Title 17 - Public Assistance and Welfare Services › 134d - Medical Assistance › Long Term Care Facility Preadmission Screening and Community Based Services Program › Section 17-134d-63 - Medicaid payment to out-of-state and border hospitals

Current through July 10, 2024
(a)
Definitions
For the purposes of this regulation, the following
				  definitions apply:
(1) "Allowed Cost"
				means the Medicaid costs reported by each Connecticut instate hospital in their
				most recent inpatient cost report as filed as of July 31st of each year by the
				hospitals for the hospital fiscal year.
(2) "Border Hospital" means an out-of-state
				general hospital which has a common medical delivery area with the State of
				Connecticut and is deemed a border hospital by the Department on a hospital by
				hospital basis.
(3) "Connecticut
				In-state Hospital" means a general hospital located within the boundaries of
				the State of Connecticut and licensed by the Connecticut State Department of
				Health Services.
(4) "Department"
				means the State of Connecticut Department of Income Maintenance.
(5) "Department's Manual" means the
				Department's Connecticut Medical Assistance Provider Manual which contains the
				Medical Services Policy as amended from time to time.
(6) "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
				patient's health in serious jeopardy, serious impairment to bodily functions,
				or serious dysfunction of any bodily organ or part.
(7) "General Hospital" means a short-term
				hospital having facilities, medical staff and all necessary personnel to
				provide diagnosis, care and treatment of a wide range of acute conditions,
				including injuries, and shall include a children's general hospital which means
				a short-term hospital having facilities, medical staff and all necessary
				personnel to provide diagnosis, care and treatment of a wide range of acute
				conditions among children, including injuries.
(8) "Inpatient" means a patient who has been
				admitted to a general hospital for the purpose of receiving medically
				necessary, appropriate, and quality medical, dental, or other health related
				services and is present at midnight for the census count.
(9) "Medical Necessity" means medical care
				provided to:
(A) Correct or diminish the
				adverse effects of a medical condition;
(B) Assist an individual in attaining or
				maintaining an optimal level of well-being;
(C) Diagnose a condition; or
(D) Prevent a medical condition from
				occurring.
(10)
				"Out-of-State Hospital" means a general hospital located outside of the State
				of Connecticut and is not deemed by the Department to be a border
				hospital.
(11) "Outpatient" means a
				person receiving medical, dental, or other health related services in the
				outpatient department of an approved general hospital which is not providing
				room and board and professional services on a continuous 24-hour-a-day
				basis.
(12) "Prior Authorization"
				means approval for a service from the Department or the Department's agent
				which may be required by the Department before the provider actually provides
				the service. Prior authorization is necessary in order to receive reimbursement
				from the Department. The Department in its sole discretion determines what
				information is necessary in order to approve a prior authorization
				request.
(13) "Provider Agreement"
				means the signed written contractual agreement between the Department and the
				provider of medical services or goods. It is signed by the provider upon
				application for enrollment and is effective on the approved date of enrollment.
				The provider is mandated to adhere to the terms and conditions set forth in the
				provider agreement in order to participate in the program.
(14) "Rate Year" means the twelve (12) month
				period beginning on October 1st of each year.
(15) "Total Customary Charges" means the
				revenue generated by the aggregate of the total customary charges reported by
				each Connecticut in-state hospital in their most recent inpatient cost report
				as filed as of July 31st of each year by the hospitals for the hospital fiscal
				year.