reglab/statecodes huggingface dataset:
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of School Based Child Health Services › Section 17b-262-219 - Limitations

Current through July 10, 2024
(a) No payments shall be made by Medicaid:
(1) directly to health professionals or organizations under contract to a LEA for medically appropriate and necessary services covered under section 17b-262-218 above;
(2) for services of an unproven, experimental, cosmetic or research nature or for any diagnostic, therapeutic or treatment procedures in excess of those deemed medically appropriate and necessary by the Department to treat the child's condition;
(3) for any immunizations, biological products and other products or examinations and laboratory tests for preventable diseases available free of charge from the Department of Public Health;
(4) for speech services involving non-diagnostic, non-therapeutic, routine, repetitive and reinforced procedures or services for the child's general good and welfare (e.g., the practicing of word drills which are not planned and performed or supervised by a licensed speech pathologist);
(5) for services which are provided free of charge to all students such as routine screenings; or
(6) for cancelled visits or appointments not kept.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of School Based Child Health Services › Section 17b-262-220 - Documentation and record retention requirements

Current through July 10, 2024
(a) A permanent service record documenting each SBCH Service provided to each medicaid eligible child shall be maintained by the LEA at which the child is enrolled at the time of service. The permanent service record shall include, but is not limited to:
(1) the written evaluation and the results of any diagnostic tests;
(2) the diagnosis(ses), in a manner acceptable to the Department;
(3) the IEP signed by a licensed practitioner of the healing arts in a manner acceptable to the Department; and
(4) the actual service delivery record including: the type of service; the date of the service; the units of service; the name and discipline of the person performing services and, for persons affiliated with an organization under contract to the LEA, the name of the organization; the signature of the individual performing the service; and progress notes signed by a licensed or certified allied health professional who performed or supervised the services within the scope of his or her practice under state law.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of School Based Child Health Services › Section 17b-262-221 - Billing requirements

Current through July 10, 2024
(a) All SBCH Services performed on behalf of Medicaid-eligible children shall be recorded on the required claim forms for the SBCH provider and submitted to the Department in accordance with the billing instructions provided by the Department.
(b) All claims submitted to the Department for payment of services covered under section 17b-262-218 above shall be substantiated by documentation in the eligible child's permanent service record pursuant to section 17b-262-220 above.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of School Based Child Health Services › Section 17b-262-222 - Establishment of rates

Current through July 10, 2024
(a) The Department shall establish payment rates for three (3) types of service specific to type of placement for SBCH Services:
(1) a per month per child unit rate for SBCH treatment services, specific to type of placement;
(2) a rate for initial evaluations and triennial reevaluations, specific to type of placement; and
(3) a rate for Durable Medical Equipment, Other Medical Supplies and Devices. Rates shall be determined based upon annual cost and utilization filings made on forms prescribed by the Commissioner of the Department, except that for the July 1, 1999 through June 30, 2000 rate period, such rates shall be determined based upon the July 1, 1996 through June 30, 1997 cost reports inflated by the increase in the consumer price index (urban-all items). Rates shall be based on cost and utilization data for all children referred for special educational services. The Commissioner may establish interim rates for the billing periods.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of School Based Child Health Services › Section 17b-262-223 - Audit/compliance review

Current through July 10, 2024
All supporting accounting and business records, statistical data, the child's permanent service record and all other records relating to the provision of SBCH Services paid for by the Department shall be subject to audit or compliance review by authorized personnel. If an audit discloses discrepancies in the accuracy or allowability of actual direct or indirect costs or statistical data as submitted for each state fiscal year by the Department of Education and its LEAs, the Department's rates for said period shall be subject to adjustment. All documentation shall be made available to authorized personnel upon request in accordance with 42 CFR, Part 431. SDE shall take full responsibility for any Medicaid claims disallowed due to inadequate documentation by any LEA 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 Services Provided by Intermediate Care Facilities for the Mentally Retarded (ICFs/MR) › Section 17b-262-299 - Scope

Current through July 10, 2024
Sections 17b-262-299 to 17b-262-311, inclusive, of the Regulations of Connecticut State Agencies set forth the requirements for payment of services provided by Intermediate Care Facilities for the Mentally Retarded to clients eligible to receive such services under Medicaid pursuant to section 17b-262 of the Connecticut General Statutes.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Intermediate Care Facilities for the Mentally Retarded (ICFs/MR) › Section 17b-262-301 - Provider participation

Current through July 10, 2024
In order to enroll in Medicaid 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 and be certified, in accordance with federal regulations, to participate in the Medicaid program.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Intermediate Care Facilities for the Mentally Retarded (ICFs/MR) › Section 17b-262-302 - Eligibility

Current through July 10, 2024
Payment to Intermediate Care Facilities for the Mentally Retarded is available on behalf of all clients who are determined to be in need of ICF/MR care by the Department of Mental Retardation and the Department of Social Services, subject to the conditions and limitations set forth in sections 17b-262-299 to 17b-262-311, inclusive, of the Regulations of Connecticut State Agencies. Clients shall be receiving active treatment as described in 42 CFR 483.440(a), as amended from time to time.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Intermediate Care Facilities for the Mentally Retarded (ICFs/MR) › Section 17b-262-303 - Services covered and limitations

Current through July 10, 2024
(a)
Services Covered
(1) The department shall pay an all-inclusive per diem rate, computed in accordance with section 17b-340 of the Connecticut General Statutes and sections 17-311-1 to 17-311-120, inclusive, of the Regulations of Connecticut State Agencies, to the ICF/MR for each client. This rate represents an inclusive payment for all services and items that are required to be provided by the facility as a condition for participation as an ICF/MR, including but not necessarily limited to the following:
(A) services provided by qualified staff engaged by the ICF/MR, as described in 42 CFR 483.430, as amended from time to time;
(B) active treatment services as described in 42 CFR 483.440, as amended from time to time;
(C) client behavior and facility practice as described in 42 CFR 483.450, as amended from time to time;
(D) health care services as described in 42 CFR 483.460, as amended from time to time;
(E) physical environment management as described in 42 CFR 483.470, as amended from time to time;
(F) dietetic services as described in 42 CFR 483.480, as amended from time to time;
(G) routine personal hygiene items as defined in 42 CFR 483.10(c)(8)(i)(E), as amended from time to time;
(H) over the counter medications except insulin;
(I) durable medical equipment, except for those items listed in section 17b-262-676(a)(2) of the Regulations of Connecticut State Agencies where Medicaid payment is available directly to the supplier of durable medical equipment if the item is medically necessary;
(J) supplies used in the routine care of the client that are included on the department's medical and surgical fee schedule including:
(i) antiseptics and solutions;
(ii) bandages and dressing supplies;
(iii) catheters and urinary incontinent supplies;
(iv) diabetic supplies;
(v) diapers and underpads;
(vi) compression, burns and specialized medical garments;
(vii) ostomy supplies;
(viii) respiratory and tracheotomy supplies;
(ix) enteral and parenteral supplies; and
(x) miscellaneous supplies;
(K) services related to the provision or arrangement for provision of customized wheelchairs that are the responsibility of the ICF/MR as described in subsections 17-134d-46(m) and (n) of the Regulations of Connecticut State Agencies; and
(L) transportation services necessary to transport a client to and from any service included in the per diem rate as described in this section.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Intermediate Care Facilities for the Mentally Retarded (ICFs/MR) › Section 17b-262-304 - Need for services and authorization process

Current through July 10, 2024
(a) The decision to admit and the subsequent admission to a facility must be made by the Department of Mental Retardation or the admitting ICF/MR in conjunction with the client's interdisciplinary team, subject to review by DSS.
(b) DSS shall evaluate and approve in writing the client's need for ICF/MR services ordered by the physician, as described in 42 CFR 456.372, as amended from time to time.
(c) In order for DSS to pay for ICF/MR services, the ICF/MR shall document the need for the admission by all of the following:
(1) certification of the need for care by a physician as described in 42 CFR 456.360(a), as amended from time to time;
(2) medical, psychological and social evaluations as described in 42 CFR 456.370, as amended from time to time;
(3) an admissions review as described in 42 CFR 483.440(b), as amended from time to time;
(4) exploration of alternative services as described in 42 CFR 456.371, as amended from time to time;
(5) an OPS; and
(6) a written report of each evaluation and OPS entered in the client's record, as described in 42 CFR 456.381, as amended from time to time.
(7) DSS written approval of the client's need for ICF/MR services in accordance with 42 CFR 456.372, as amended from time to time.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Intermediate Care Facilities for the Mentally Retarded (ICFs/MR) › Section 17b-262-305 - Client's bill of rights

Current through July 10, 2024
(a) An ICF/MR shall protect and promote the rights of each client as described in 42 CFR 483.420, as amended from time to time.
(b) Requirements for the administration of the patient's personal allowance shall be in accordance with sections 17-2-140 to 17-2-145, 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 Intermediate Care Facilities for the Mentally Retarded (ICFs/MR) › Section 17b-262-307 - Bed reserve for home leave

Current through July 10, 2024
(a) DSS shall pay to reserve a bed in an ICF/MR for a client during a temporary absence for home leave for up to thirty-six (36) days per calendar year. The ICF/MR shall not make the reserved bed available for use by any other person.
(b) The ICF/MR shall inform the client and guardian or other responsible person upon admission to the facility, that a bed shall be reserved for home leave if the conditions outlined in subsection (d) of this section are met.
(c) The ICF/MR shall reserve a client's bed for up to thirty-six (36) days per calendar year. No facility shall require, or request, a client to provide payment for authorized home leave.
(d) DSS shall reimburse an ICF/MR at the per diem Connecticut Medicaid program rate of the facility for each day that the facility reserves the bed in accordance with the following conditions:
(1) the client has not used more than thirty-six (36) days of home leave during the calendar year;
(2) the facility has not refused to take the client back during or upon completion of the authorized home leave. If so, no payment shall be made for the entire home leave; and
(3) the client has not failed to return to the ICF/MR. If the client has not returned, the liability for payment to the ICF/MR shall terminate on the date the ICF/MR is notified that the client will not be returning.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Intermediate Care Facilities for the Mentally Retarded (ICFs/MR) › Section 17b-262-308 - Applied income

Current through July 10, 2024
(a) DSS is responsible for calculating the applied income. DSS shall notify the ICF/MR of the amount of any applied income that the facility is responsible for collecting. Applied income shall be deducted from what otherwise would have been the DSS monthly payment to the ICF/MR on behalf of the client.
(b) The ICF/MR shall notify DSS of any errors in the amount of applied income processed against the claim using the form specified by DSS. Payment adjustments resulting from retroactive applied income corrections shall be processed periodically.
(c) In any month that a client returns to the community or dies, and the cost of care is less than the applied income, the department shall adjust the applied income as follows: the applied income shall equal the number of days that the client was in the ICF/MR multiplied by the per diem rate.
(d) Applied income shall not be pro rated. It shall be used to cover the cost of care until it is expended.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Intermediate Care Facilities for the Mentally Retarded (ICFs/MR) › Section 17b-262-309 - Billing and payment procedures

Current through July 10, 2024
(a) The ICF/MR shall submit claims to the department as described in section 17b-262-529 of the Regulations of Connecticut State Agencies and the billing instructions specific to ICFs/MR.
(b) The ICF/MR shall:
(1) complete the daily admission and discharge forms in accordance with DSS instructions;
(2) notify the DSS caseworker if the ICF/MR is aware that the ICF/MR client's asset level exceeds the established resource limit. The report shall be made on the form specified by DSS.
(3) notify the convalescent payment unit of DSS of any and all credits due DSS on the form specified by DSS.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Intermediate Care Facilities for the Mentally Retarded (ICFs/MR) › Section 17b-262-310 - Rates

Current through July 10, 2024
The per diem rates for an ICF/MR shall be determined annually, pursuant to section 17b-340 of the Connecticut general statutes and sections 17-311-1 to 17-311-120, inclusive, of the Regulations of Connecticut State Agencies. DSS shall reimburse the ICF/MR at the per diem rate minus the applied income.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Intermediate Care Facilities for the Mentally Retarded (ICFs/MR) › Section 17b-262-311 - Documentation

Current through July 10, 2024
(a) The ICF/MR shall maintain all documentation required for rate setting purposes for a minimum of 10 years pursuant to section 17-311-56 of the Regulations of Connecticut State Agencies, including all documentation required to support the billing for bed reserve days described in subsection (e)(4) of this section. This documentation shall be subject to review by the department.
(b) The ICF/MR shall maintain all other documentation required by this section for at least five (5) years or longer as required by statute or regulation, and shall be subject to review by authorized department personnel. In the event of a dispute concerning a service provided, the ICF/MR shall maintain all documentation until the end of the dispute, for five (5) years, or for the length of time required by statute or regulation, whichever is longest.
(c) Failure to maintain all required documentation shall result in the disallowance and recovery by the department of any amounts paid to the ICF/MR for which the required documentation is not maintained and provided to the department upon request. Documentation requirements are described in detail in the Provider Agreement for ICFs/MR and sections 17b-262-522 to 17b-262-533, inclusive, of the Regulations of Connecticut State Agencies.
(d) An ICF/MR shall maintain fiscal and medical records to fully disclose services and goods rendered or delivered to Medicaid residents. Records shall be maintained in accordance with the department's Provider Agreement for ICFs/MR.
(e) Required documentation shall include:
(1) all reports, evaluations, certifications, reviews and approvals documenting the need for admission as described in subsection 17b-262-304(b) of the Regulations of Connecticut State Agencies;
(2) all certifications and reviews documenting the need for continued stay as described in subsection 17b-262-304(c) of the Regulations of Connecticut State Agencies;
(3) all admission and discharge forms required by DSS; and
(4) all documentation required to support the ICF's/MR billing for and the DSS payment of bed reserve days as described in sections 17b-262-306 and 17b-262-307 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 Physicians' Services › Section 17b-262-337 - Scope

Current through July 10, 2024
Sections 17b-262-337 to 17b-262-349, inclusive, of the Regulations of Connecticut State Agencies, set forth the Department of Social Services requirements for payment of accepted methods of treatment performed by or under the personal supervision of licensed physicians for clients who are determined eligible to receive services under Connecticut's Medicaid Program pursuant to section 17b-261 of the Connecticut General Statutes.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Physicians' Services › Section 17b-262-338 - Definitions

Current through July 10, 2024
For the purposes of sections 17b-262-337 to 17b-262-349, inclusive, of the Regulations of Connecticut State Agencies, the following definitions shall apply:
(1) "Acute" means symptoms that are severe and HAVE rapid onset and a short course;
(2) "Admission" means the formal acceptance by a hospital of a client who is to receive health care services while lodged in an area of the hospital reserved for continuous nursing services;
(3) "Advanced practice registered nurse" means a person licensed pursuant to section 20-94a of the Connecticut General Statutes;
(4) "Allied Health Professional" or "AHP" means a LICENSED individual other than a physician who:
(A) Is qualified by special training, education, skills and experience in health care and treatment,
(B) is licensed by the Department of Public Health as one or more of the following: Psychologist, licensed clinical social worker, advanced practice registered nurse, nurse-midwife, physician assistant, licensed professional counselor, licensed marital and family therapist, licensed alcohol and drug counselor, physical therapist, occupational therapist, speech pathologist, audiologist, optician, optometrist, respiratory care practitioner or such other category of licensed health care professional that the department permits to enroll individually as a Medicaid provider,
(C) acts within the AHP's scope of practice under state law and
(D) complies with all requirements in 42 CFR 440 applicable to the AHP;
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Physicians' Services › Section 17b-262-339 - Provider participation

Current through July 10, 2024
(a) In order to enroll in Medicaid and for billing providers to receive payment from the department, performing providers and billing providers shall comply with sections 17b-262-522 to 17b-262-533, inclusive, of the Regulations of Connecticut State Agencies and shall maintain their enrollment status pursuant to valid provider enrollment agreements on file with the department.
(b) Performing providers shall enroll in Medicaid as performing providers.
(c) Billing providers shall enroll in Medicaid as billing providers.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Physicians' Services › Section 17b-262-340 - Eligibility

Current through July 10, 2024
Payment to a billing provider for physicians' services billed by the billing provider shall be available on behalf of clients who have a need for such services, provided such services are medically necessary, subject to the conditions and limitations that apply to such services.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Physicians' Services › Section 17b-262-341 - Goods and services covered and limitations

Current through July 10, 2024
The department shall pay billing providers for the following physicians' services:
(1) Those procedures that are medically necessary to treat the client's condition;
(2) physicians' services provided in an office, a general hospital, the client's home, a chronic disease hospital, nursing facility, ICF/MR or other medical care facility;
(3) laboratory services provided by a provider in compliance with 42 USC 263a to 42 USC 263a-7, inclusive;
(4) medical and surgical supplies for out-of-office use by the client;
(5) drugs and devices administered by a provider;
(6) a second opinion for surgery or any other treatment when requested voluntarily by the client or when required by the department. The department shall pay for a second opinion according to the established fees for consultation;
(7) family planning, abortion and hysterectomy services as described in section 17b-262-348(r) of the Regulations of Connecticut State Agencies;
(8) Early and Periodic Screening, Diagnostic and Treatment services, including treatment services which are indicated following screening not otherwise covered, provided that prior authorization is obtained;
(9) surgical services necessary to treat morbid obesity as defined by the ICD that causes or aggravates another medical illness, including illnesses of the endocrine system or the cardio-pulmonary system, or physical trauma associated with the orthopedic system;
(10) family planning services for clients of childbearing age, including minors who can be considered sexually active, and who desire the services;
(11) sterilization for clients who are at least 21 years of age at the time of informed consent; and
(12) a hysterectomy performed during a period of retroactive eligibility as described in 42 CFR 441.255(e).
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Physicians' Services › Section 17b-262-341a - Physician Assistants

Current through July 10, 2024
(a) The department shall pay the billing provider for physicians' services provided by a physician assistant who:
(1) Provides services under the personal supervision of a physician;
(2) acts within the physician assistant's scope of practice under state law and performs only functions delegated by the supervising physician in compliance with sections 20-12c and 20-12d of the Connecticut General Statutes and all applicable requirements of the Department of Public Health; and
(3) is employed by or affiliated with the billing provider.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Physicians' Services › Section 17b-262-342 - Goods and services not covered

Current through July 10, 2024
The department shall not pay for the following goods or services or goods or services related to the following:
(1) Immunizations, biological products and other products available to providers free of charge;
(2) Examinations and laboratory tests for preventable diseases that are furnished free of charge;
(3) Information or services provided to a client by a provider electronically or over the telephone;
(4) Cosmetic surgery;
(5) An office visit for the sole purpose of the client obtaining a prescription where the provider previously determined the need for the prescription;
(6) Cancelled services and appointments not kept;
(7) Services provided in a general hospital if the department determines the admission does not, or retrospectively did not, comply with the department's utilization review requirements in section 17-134d-80 of the Regulations of Connecticut State Agencies;
(8) Infertility treatment;
(9) Sterilizations performed on mentally incompetent individuals or institutionalized individuals;
(10) More than one visit per day to the same provider by a client;
(11) Services to treat obesity other than those described in section 17b-262-341(9) of the Regulations of Connecticut State Agencies; and
(12) Any procedures or services of an unproven, educational, social, research, experimental or cosmetic nature; any diagnostic, therapeutic or treatment services in excess of those deemed medically necessary by the department to treat the client's condition or services not directly related to the client's diagnosis, symptoms or medical history.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Physicians' Services › Section 17b-262-343 - Need for service

Current through July 10, 2024
Payment is available to billing providers for an initial office visit and continuing services that are medically necessary, provided that:
(a) The services are within the provider's scope of practice; and
(b) the provider documents the services 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 Physicians' Services › Section 17b-262-344 - Prior authorization

Current through July 10, 2024
(a) Prior authorization, on forms and in the manner specified by the department, is required in order for payment to be available for the following physicians' services. Prior authorization is also required for services designated by the department and published on its website or by other means accessible to providers.
(1) Electrolysis epilation;
(2) physical therapy services in excess of two visits per calendar week per client per provider;
(3) physical therapy services in excess of nine visits per calendar year per client per provider, when the therapy being prescribed is for the treatment of:
(A) All mental disorders, including diagnoses related to mental retardation and specific delays in development covered by the ICD;
(B) musculoskeletal system disorders of the spine covered by the ICD; and
(C) symptoms related to nutrition, metabolism and development covered by the ICD;
(4) reconstructive surgery, including breast reconstruction following mastectomy;
(5) plastic surgery;
(6) transplant procedures;
(7) Early and Periodic Screening, Diagnostic and Treatment services that are identified during a periodic screening as medically necessary and that are not payable pursuant to the physician fee schedule; and
(8) any service or device that is not on the department's fee schedule.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Physicians' Services › Section 17b-262-345 - Billing procedures

Current through July 10, 2024
(a) Billing providers shall submit claims on a hard copy invoice or by electronic transmission to the department in a form and manner specified by the department, together with all information required by the department to process the claim for payment, including, but not limited to, identifying the performing provider on each claim.
(b) The amount billed to the department shall represent the billing provider's usual and customary charge for the services delivered.
(c) When a client is referred to a provider for consultation, the consultant provider shall include the referring practitioner's name on all applicable claims.
(d) When billing for anesthesia services, anesthesiologists shall include the name of the primary surgeon on the claim.
(e) The department shall pay the billing provider directly for laboratory services performed in the provider's office and the billing provider shall bill the department for such services as separate line items. When a provider refers a client to a private laboratory for services, the laboratory shall bill the department directly and no laboratory charge shall be paid to the provider.
(f) When more than one member of a billing provider provides services, the billing provider shall submit prior authorization requests prior to billing in accordance with the billing instructions in the department's provider manual.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Physicians' Services › Section 17b-262-346 - Payment

Current through July 10, 2024
(a) Fees shall be the same for in-state, border and out-of-state providers.
(b) Payment shall be made at the lowest of:
(1) The billing provider's usual and customary charge;
(2) the lowest Medicare rate;
(3) the amount in the applicable fee schedule as published by the department pursuant to section 4-67c of the Connecticut General Statutes; or
(4) the amount billed by the billing provider.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Physicians' Services › Section 17b-262-349 - Documentation and audit requirements

Current through July 10, 2024
(a) Providers shall maintain a specific record for all services provided to each client including, but not limited to: name, address, birth date, Medicaid identification number, pertinent diagnostic information, treatment notes signed by the provider, documentation of services provided and the dates the services were provided.
(b) The provider shall maintain all required documentation in its original form for at least five years or longer in accordance with statute or regulation, subject to review by authorized department personnel. In the event of a dispute concerning a service provided, the provider shall maintain the documentation until the end of the dispute, five years or the length of time required by statute or regulation, whichever is longest.
(c) The department may disallow and recover any amounts paid to the provider for which the required documentation is not maintained and not provided to the department upon request.
(d) The department may audit all relevant records and documentation and may take any other appropriate quality assurance measures it deems necessary to assure compliance with all regulatory and statutory requirements.
(e) If the provider bills for a service based on the time spent during the encounter, the provider shall document the length of the encounter.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Psychiatrists' Services › Section 17b-262-452 - Scope

Current through July 10, 2024
Sections 17b-262-452 through 17b-262-463 inclusive set forth the Department of Social Services requirements for payment of:
(a) medical and clinical services provided by licensed psychiatrists in private or group practice, and
(b) clinical procedures performed by allied health professionals in the employ of the psychiatrist in private or group practice 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 of Psychiatrists' Services › Section 17b-262-453 - Definitions

Current through July 10, 2024
For the purposes of sections 17b-262-452 through 17b-262-463 the following definitions shall apply:
(1) "Acute" means having rapid onset, severe symptoms, and a short course.
(2) "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.
(3) "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 is not limited to: psychologists, social workers, psychiatric nurses, and other qualified therapists.
(4) "By or Under the Supervision" means the psychiatrist shall assume professional responsibility for the service performed by the allied health professional, overseeing or participating in the work of the allied health professional including, but not limited to:
(A) availability of the psychiatrist to the allied health professional in person and within five minutes;
(B) availability of the psychiatrist on a regularly scheduled basis to review the practice, charts, and records of the allied health professional and to support the allied health professional in the performance of services; and
(C) a predetermined plan for emergency situations, including the designation of an alternate psychiatrist in the absence of the regular psychiatrist.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Psychiatrists' Services › Section 17b-262-454 - 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 of Psychiatrists' Services › Section 17b-262-456 - 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 psychiatrist 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:
(1) psychiatric evaluation;
(2) psychotherapy, including: individual, group, family, hypnosis, and electroshock;
(3) psychiatric consultation;
(4) drugs, as limited in subsection (b) of section 17b-262-456;
(5) all admitting and inpatient services performed by the admitting psychiatrist in an acute care hospital after the psychiatrist has received prior authorization for the admission pursuant to the department's utilization review program as delineated in section 17-134d-80 of the Regulations of Connecticut State Agencies; and
(6) HealthTrack Services and HealthTrack Special Services.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Psychiatrists' Services › Section 17b-262-457 - Need for service

Current through July 10, 2024
The department shall pay for medically necessary and medically appropriate psychiatric services for Medical Assistance Program eligible clients which are provided by a licensed physician who specializes in the study, diagnosis, treatment, and prevention of mental and social diseases.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Psychiatrists' Services › Section 17b-262-458 - Prior authorization

Current through July 10, 2024
(a) Prior authorization, on forms and in a manner as specified by the department, is required for all clients, including clients originally referred by another state agency for:
(1) treatment services in excess of thirteen visits in a calendar quarter;
(2) treatment services to hospitalized clients from the date of admission; and
(3) 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 Psychiatrists' Services › Section 17b-262-459 - Billing procedures

Current through July 10, 2024
(a) Claims from psychiatrists 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 psychiatrist's usual and customary charge for the services delivered.
(c) When a Medical Assistance Program client is referred to a psychiatrist for consultation, the consultant psychiatrist shall include the referring practitioner's provider number and name. If no provider number has been assigned, the consultant psychiatrist shall enter the entire name as well as the state license number of the referring physician on the billing form.
(d) Psychiatric consultations in the hospital, home, or long-term care facility shall be billed as a comprehensive consultation.
(e) All charges billed for supplies and materials provided by a psychiatrist, except glasses, shall be reviewed by the department.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Psychiatrists' Services › Section 17b-262-460 - Payment

Current through July 10, 2024
(a) Payment shall be made at the lowest of:
(1) the provider's usual and customary charge to the general public;
(2) the lowest Medicare rate;
(3) the amount in the applicable fee schedule as published by the department;
(4) the amount billed by the provider; or
(5) the lowest price charged or accepted for the same of 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 Psychiatrists' Services › Section 17b-262-462 - Payment limitations

Current through July 10, 2024
(a) Psychiatrists' services shall be performed at the psychiatrist's private or group practice location, hospital, long-term care facility, clinic, or the client's home.
(b) The psychiatrist who employs allied health professionals shall personally conduct the evaluation and, accordingly, develop the treatment plan in all cases.
(c) In situations where the psychiatrist employs allied health professionals on a salary or fee-for-service basis, the psychiatrist shall be paid at the psychiatrists' rate only under the following conditions:
(1) for clients personally being treated by the psychiatrist; and
(2) when the psychiatrist personally interviews the client as part of the psychiatrist's supervisory responsibilities, but only at that rate which corresponds to the time or service he or she actually provides to the client.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Psychiatrists' Services › Section 17b-262-463 - Documentation

Current through July 10, 2024
(a) Psychiatrists 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 psychiatrist, documentation of services provided, and the dates the services were provided.
(b) All required documentation shall be maintained for at least five years in the psychiatrist'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 psychiatrist for which the required documentation is not maintained or provided to the department upon request.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Psychologists' Services › Section 17b-262-467 - Scope

Current through July 10, 2024
Psychologists' services provide professional therapeutic intervention relating to mental, emotional, and social problems involving individuals or groups, taking into consideration the sum of actions, traits, attitudes, thoughts, and mental state of an individual. Sections 17b-262-467 through 17b-262-478 inclusive set forth the Department of Social Services requirements for payment of accepted methods of treatment by licensed psychologists 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 of Psychologists' Services › Section 17b-262-468 - Definitions

Current through July 10, 2024
For the purposes of sections 17b-262-467 through 17b-262-478 the following definitions shall apply:
(1)
"Client"
means a person eligible for goods or services under the department's Medical Assistance Program.
(2)
"Commissioner"
means the Commissioner of Social Services appointed pursuant to subsection (a) of section 17b-1 of the Connecticut General Statutes.
(3)
"Department"
means the Department of Social Services or its agent.
(4)
"HealthTrack Services"
means the services described in subsection (r) of section 1905 of the Social Security Act.
(5)
"HealthTrack Special Services"
means medically necessary and medically appropriate health care, diagnostic services, treatment, or other measures necessary to correct or ameliorate disabilities and physical and mental illnesses and conditions discovered as a result of a periodic comprehensive health screening or interperiodic encounter. Such services are provided in accordance with 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 Psychologists' Services › Section 17b-262-469 - 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.