reglab/statecodes huggingface dataset:
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Provider Participation in the Connecticut Medical Assistance Program › Section 17b-262-532 - Payment for out-of-state goods or services

Current through July 10, 2024
(a) Pursuant to 42 CFR 431.52, payment for Medical Assistance Program goods or services furnished to clients while they are out-of-state shall be made by the department to the same extent as payment is made to in-state providers, unless otherwise specified in state statutes or regulations which govern the provider's assigned type and specialty, only when any of the following conditions is met:
(1) Medical Assistance Program goods or services are needed by a client because a medical emergency occurred while the client was outside of the state;
(2) Medical Assistance Program goods or services are needed because a client's health would be endangered if required to travel to Connecticut;
(3) the department determines that the Medical Assistance Program goods or services are[more readily] available only in another state and prior authorization was granted to the provider; or
(4) it is general practice for clients in a particular locality of Connecticut to use the medical resources in a bordering state. The department shall allow providers, who are designated by the department to be border providers, to be treated in the same manner as in-state providers.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Provider Participation in the Connecticut Medical Assistance Program › Section 17b-262-533 - Sums paid in excess of the authorized schedules of payment or for other reasons of ineligibility for payment

Current through July 10, 2024
Any payment, or part thereof, for Medical Assistance Program goods or services which represents an excess over the payment authorized, or a violation due to abuse or fraud, shall be payable to the department. Any such sum not returned to the department by a provider may be recovered in an action brought by the department against the provider. Such sums may also be recouped from current payment due the provider in accordance with law.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Chiropractic Services › Section 17b-262-535 - Scope

Current through July 10, 2024
Sections 17b-262-535 through 17b-262-545 inclusive set forth the Department of Social Services requirements for payment of chiropractic services, performed by licensed practitioners of chiropractic in private or group practices, 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 Chiropractic Services › Section 17b-262-536 - Definitions

Current through July 10, 2024
For the purposes of sections 17b-262-535 through 17b-262-545 the following definitions shall apply:
(1) "Acute" means having rapid onset, severe symptoms, and a short course.
(2) "Chiropractic" means the services described in Title 42 of the Code of Federal Regulations (CFR), Part 440, section 440.60, and subsection (1) of section 20-24 of the Connecticut General Statutes.
(3) "Client" means a person eligible for goods or services under the department's Medical Assistance Program.
(4) "Commissioner" means the Commissioner of Social Services appointed pursuant to subsection (a) of section 17b-1 of the Connecticut General Statutes.
(5) "Department" means the Department of Social Services or its agent.
(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 client's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.
(7) "HealthTrack Services" means the services described in subsection (r) of section 1905 of the Social Security Act.
(8) "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 Chiropractic Services › Section 17b-262-537 - 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 Chiropractic Services › Section 17b-262-539 - Services covered and limitations

Current through July 10, 2024
(a) Except for the limitations and exclusions listed below, the department shall pay for the following:
(1) the manual manipulation of the spine, but not for any procedures or services 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;
(2) services provided in the provider's office, client's home, hospital, nursing facility, rest home, home for the aged, boarding home, or intermediate care facility for the mentally retarded (ICF/MR); and
(3) 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 Chiropractic Services › Section 17b-262-540 - Services not covered

Current through July 10, 2024
The department shall not pay for the following chiropractic services which are not covered under the Medical Assistance Program:
(a) chiropractic practice does not include the prescription or administration of any medicine or drug or the performance of any surgery;
(b) x-rays furnished by a practitioner of chiropractic;
(c) an initial visit for exam and diagnosis;
(d) manipulation of other parts of the body such as: the shoulder, arm, knee-even when for subluxation of the spine;
(e) lab work ordered by a practitioner of chiropractic;
(f) for information or services provided to a client over the telephone; and
(g) for cancelled office visits or appointments not kept.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Chiropractic Services › Section 17b-262-541 - Need for service

Current through July 10, 2024
The department shall pay for medically necessary and medically appropriate treatment only when:
(a) provided by a licensed practitioner of chiropractic and the services are within the scope of practice of the practitioner, and
(b) the services are made part of the client's medical record.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Chiropractic Services › Section 17b-262-542 - Prior authorization

Current through July 10, 2024
(a) Prior authorization, on forms and in a manner as specified by the department, is required for:
(1) manipulation of the spine in excess of five per client per provider per month; and
(2) 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:
(A) a written statement from the prescribing physician, or other licensed practitioner of the healing arts, performing such services within his or her respective scope of practice as defined under state law, justifying the need for the item or service required;
(B) a description of the outcomes of any alternative measures tried; and
(C) if applicable and requested by the department, any other documentation required in order to render a decision.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Chiropractic Services › Section 17b-262-543 - Billing procedures

Current through July 10, 2024
(a) The amount billed to the department shall represent the practitioner of chiropractic's usual and customary charge for the services delivered.
(b) Claims from practitioners of chiropractic shall be submitted on a hard copy invoice or electronically transmitted to the department's fiscal agent, in a form and manner as specified by the department, and shall include all information required by the department to process the claim.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Chiropractic Services › Section 17b-262-544 - 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 or substantially similar goods or services by the provider from any person or entity.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Chiropractic Services › Section 17b-262-545 - Documentation

Current through July 10, 2024
(a) Practitioners of chiropractic 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 provider, 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 practitioner of chiropractic's file subject to review by authorized department personnel. In the event of a dispute concerning a service provided, documentation shall be maintained until the end of the dispute or five years, whichever is greater.
(c) Failure to maintain all required documentation shall result in the disallowance and recovery by the department of any amounts paid to the provider for which the required documentation is not maintained 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 Natureopathic Services › Section 17b-262-547 - Scope

Current through July 10, 2024
Sections 17b-262-547 through 17b-262-557 inclusive set forth the Department of Social Services requirements for payment of natureopathic services provided by licensed natureopaths 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 Natureopathic Services › Section 17b-262-548 - Definitions

Current through July 10, 2024
For the purposes of sections 17b-262-547 through 17b-262-557 the following definitions shall apply:
(1) "Acute" means having rapid onset, severe symptoms, and a short course.
(2) "Client" means a person eligible for goods or services under the department's Medical Assistance Program.
(3) "Commissioner" means the Commissioner of Social Services appointed pursuant to subsection (a) of section 17b-1 of the Connecticut General Statutes.
(4) "Department" means the Department of Social Services or its agent.
(5) "Emergency" means a medical condition, including labor and delivery, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the client's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily part or organ.
(6) "HealthTrack Services" means the services described in subsection (r) of section 1905 of the Social Security Act.
(7) "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 Natureopathic Services › Section 17b-262-549 - Provider participation

Current through July 10, 2024
In order to participate 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 Natureopathic Services › Section 17b-262-551 - 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 natureopath which conform to accepted methods of diagnosis and treatment, but shall not pay for any procedures or services of an unproven, educational, social, research, experimental, or cosmetic nature; for services in excess of those deemed medically necessary and medically appropriate by the department to treat the client's condition; or for services not directly related to the client's diagnosis, symptoms, or medical history.
(a) The department shall pay for the following:
(1) services provided in the provider's office or client's home, hospital, nursing facility, rest home, home for the aged, boarding home, or intermediate care facility for the mentally retarded (ICF/MR), and
(2) 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 Natureopathic Services › Section 17b-262-552 - Services not covered

Current through July 10, 2024
The department shall not pay for the following natureopathic services:
(a) the administration of internal medication or substances simulating medicine, or the form of medicine;
(b) the administration of dehydrated foods;
(c) for information or services provided to a client over the telephone; and
(d) for cancelled office visits or appointments not kept.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Natureopathic Services › Section 17b-262-553 - Need for service

Current through July 10, 2024
The department shall pay for medically necessary and medically appropriate treatment only when:
(a) provided by a licensed natureopath and the services are within the scope of the natureopath's scope of practice, and
(b) the services are made part of the client's medical record.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Natureopathic Services › Section 17b-262-554 - Prior authorization

Current through July 10, 2024
(a) Prior authorization, on forms and in a manner as specified by the department, shall be required for:
(1) professional office or home visits in excess of five per client per provider per month, and
(2) 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 Natureopathic Services › Section 17b-262-555 - Billing procedures

Current through July 10, 2024
(a) Claims for natureopathic services shall be submitted on hard copy invoice or electronically transmitted to the department's fiscal agent, in a form and manner as specified by the department, and shall include all information required by the department to process the claim.
(b) The amount billed to the department shall represent the provider's usual and customary charge for the services delivered.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Natureopathic Services › Section 17b-262-556 - 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 or substantially similar goods or services by the provider from any person or entity.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Natureopathic Services › Section 17b-262-557 - Documentation

Current through July 10, 2024
(a) Natureopathic care providers 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 provider, 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 natureopathic care provider's file subject to review by authorized department personnel. In the event of a dispute concerning a service provided, documentation shall be maintained until the end of the dispute or five years, whichever is greater.
(c) Failure to maintain all required documentation shall result in the disallowance and recovery by the department of any amounts paid to the provider for which the required documentation is not maintained 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 Vision Care Services › Section 17b-262-559 - Scope

Current through July 10, 2024
Sections 17b-262-559 through 17b-262-571, inclusive, set forth the Department of Social Services requirements for payment of accepted methods of treatment provided by an ophthalmologist, optometrist, or optician 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 Vision Care Services › Section 17b-262-561 - 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 the 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 Vision Care Services › Section 17b-262-563 - Services covered and limitations

Current through July 10, 2024
(a) Except for the limitations and exclusions listed below, the department shall pay for the professional services of a licensed ophthalmologist, optometrist, or optician 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.
(b) The department shall pay providers for:
(1) only those procedures listed in the provider's fee schedule and within the scope of the provider's practice;
(2) services provided in the provider's office, client's home, hospital, nursing facility, rest home, intermediate care facility for the mentally retarded (ICF/MR), chronic disease hospital, boarding home, state-owned or state-operated institution, or home for the aged;
(3) two pairs of eyeglasses, distance and near, permitted in lieu of bifocals, when need for same is substantiated in the client's medical record by clinical data from the provider; and
(4) Early periodic screening, diagnostic and treatment services.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Vision Care Services › Section 17b-262-564 - Services not covered

Current through July 10, 2024
The department shall not pay for the following:
(a) information or services provided to a client by a provider over the telephone;
(b) cancelled office visits and appointments not kept;
(c) a spare pair of eyeglasses; and
(d) visual analysis within forty-two consecutive days from the date of an eye examination.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Vision Care Services › Section 17b-262-565 - Need for service

Current through July 10, 2024
The department shall pay for medically necessary and medically appropriate vision care services for Medical Assistance Program eligible clients, in relation to the diagnosis for which care is required, provided that:
(a) the services are within the scope of the provider's practice;
(b) the services are made part of the client's medical record; and
(c) for contact lenses, glasses, or vision training, only when prescribed by a physician, doctor of osteopathy, or optometrist.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Vision Care Services › Section 17b-262-566 - Early periodic screening, diagnostic and treatment services

Current through July 10, 2024
(a) Prior authorization for EPSDT services not on the Vision Care fee schedule or which are on such fee schedule but for which there are limitations in the amount, frequency or circumstances under which such services can be used, either in the fee schedule or in the Regulations of Connecticut State Agencies published by the department, may be obtained using the following procedures:
(1) Services not on the fee schedule, or for which there are limitations on their use, may be authorized on a case-by-case basis. Requests for prior authorization to provide services shall be made on forms and in a manner as specified by the department.
(2) Providers requesting prior authorization to provide services shall be required to provide pertinent medical or social information adequate for evaluating the client's medical need for services. This information shall include:
(A) a written statement from the prescribing physician, or other practitioner of the healing arts, performing such services within such practitioner's respective scope of practice as defined under state law, justifying the need for the item or service requested;
(B) a description of the outcomes of any alternative measures tried; and
(C) if applicable and requested by the department, any other documentation required in order to render a decision.
(3) Except in emergency situations, or when authorization is being requested for more than one visit in the same day, approval shall be received before services are rendered. In an emergency situation which occurs after working hours or on a weekend or holiday, the provider shall secure verbal approval on the next working day for the services provided.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Vision Care Services › Section 17b-262-567 - Billing procedures

Current through July 10, 2024
(a) Claims from providers shall be submitted on the department's designated form or electronically submitted to the department's fiscal agent and shall include all information required by the department to process the claim for payment.
(b) Claims for a full or partial eye examination in a nursing facility or a state-owned or state-operated institution shall contain the name of the prescribing practitioner.
(c) The amount billed to the department shall represent the provider's usual and customary charge for the services delivered.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Vision Care Services › Section 17b-262-568 - Payment

Current through July 10, 2024
(a) Payment rates shall be the same for in-state and out-of-state providers.
(b) Payment for professional services shall be made at the lowest of:
(1) the provider's usual and customary charge;
(2) the lowest Medicare rate;
(3) the amount in the applicable fee schedule as published by the department; or
(4) the amount billed by the provider.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Vision Care Services › Section 17b-262-570 - Payment limitations

Current through July 10, 2024
(a) Contact lenses shall be covered, when such lenses provide better management of a visual or ocular condition than can be achieved with spectacle lenses, including, but not limited to the diagnosis of: Unilateral Aphakia, Keratoconus, Corneal Transplant, and High Anisometropia.
(b) Prescription sunglasses shall be covered when light sensitivity which will hinder driving or seriously handicap the outdoor activity of a client is evident.
(c) Trifocals shall be covered only when the client has a special need due to a job training program or extenuating circumstances.
(d) Oversize lens shall be covered only when needed for physiological reasons, and not for cosmetic reasons.
(e) Services and materials covered shall be limited to those listed in the department's fee schedule.
(f) Extended wear contact lenses shall be covered for aphakia and for clients whose coordination or physical condition makes daily usage of contact lenses impossible.
(g) When the preliminary findings of an eye examination reveal that a visual analysis cannot or should not be completed, payment shall be made only for an incomplete eye exam.
(h) Providers shall be limited to a maximum of six full or partial eye examinations in a chronic disease hospital, boarding home, home for the aged, nursing facility, ICF/MR, or state-owned or state-operated institution in any one day, in any one home or institution.
(i) A written request shall be provided by the provider from the prescribing practitioner of a nursing facility and state-owned or state-operated institution, for a full or partial eye examination, to be performed on a client in the facility or institution.
(j) Payment for ocular prosthesis shall be made only to the provider performing the actual fitting.
(k) The payment limitations set forth in section 17b-262-448 of the department's regulations governing physicians' services are hereby incorporated by reference and made applicable to services provided by ophthalmologists.
(l) The department shall pay for eyeglasses for a client, as long as the client was eligible on the date the eyeglasses were ordered or requested by the client.
(m) The department shall pay for eyeglass frames when the client meets all eligibility requirements. The Medical Assistance Program published fee shall be considered maximum payment in full. A provider shall not bill the Medical Assistance Program for eyeglass frames and receive payment from the client for the difference in cost.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Vision Care Services › Section 17b-262-571 - Documentation

Current through July 10, 2024
(a) Vision care providers shall maintain a specific record for all services and supplies 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 provider, documentation of services and supplies provided, and the dates the services or supplies were provided.
(b) All required documentation in its original form shall be maintained for at least five years in the vision care provider's file subject to review by authorized department personnel. In the event of a dispute concerning a service or supply 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 vision care provider for which the required documentation is not maintained and not 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 Nurse-Midwifery Services › Section 17b-262-573 - Scope

Current through July 10, 2024
Sections 17b-262-573 through 17b-262-585 inclusive set forth the Department of Social Services requirements for payment of nurse-midwifery services performed by licensed nurse-midwifes for clients who are determined eligible to receive such 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 Nurse-Midwifery Services › Section 17b-262-575 - Provider participation

Current through July 10, 2024
In order to enroll in the Medical Assistance Program and receive payment from the department, a nurse-midwife shall:
(a) meet 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 the 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 Nurse-Midwifery Services › Section 17b-262-576 - Eligibility

Current through July 10, 2024
Payment for nurse-midwifery services shall be available on behalf of all women and newborns, only throughout the maternity cycle, eligible for the Medical Assistance program subject to the conditions and limitations which apply to these services.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Nurse-Midwifery Services › Section 17b-262-577 - 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 and certified nurse-midwife which conform to accepted methods of diagnosis and treatment, but shall not pay for any procedures or services of an unproven, educational, social, research, experimental, or cosmetic nature; for services in excess of those deemed medically necessary and medically appropriate by the department to treat the client's condition; or for services not directly related to the client's diagnosis, symptoms, or medical history.
(a) The department shall pay for the following:
(1) services provided in the provider's office, client's home, hospital, nursing facility, intermediate care facility for the mentally retarded (ICF/MR), chronic disease hospital, boarding home, state-owned or -operated institution, or home for the aged;
(2) family planning services as described in the Regulations of Connecticut State Agencies; and
(3) 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 Nurse-Midwifery Services › Section 17b-262-578 - Services not covered

Current through July 10, 2024
The department shall not pay for the following:
(a) nurse-midwifery services to newborns occurring beyond the maternity cycle;
(b) any examinations, laboratory tests, biological products, immunizations, or other products which are furnished free of charge;
(c) information or services provided to a client by a provider over the telephone;
(d) an office visit for the sole purpose of the client obtaining a prescription where the need for the prescription has already been determined; and
(e) cancelled office visits and appointments not kept.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Nurse-Midwifery Services › Section 17b-262-579 - Need for service

Current through July 10, 2024
The department shall pay for medically necessary and appropriate nurse-midwifery services for Medical Assistance Program eligible clients:
(a) requiring care during an essentially normal maternity cycle or requiring well-woman gynecological care;
(b) of child-bearing age who indicate a need for family planning services and are free from coercion or mental pressure and are free to choose the method of family planning to be used;
(c) provided by a licensed and certified nurse-midwife within the scope of the nurse-midwife's practice; and
(d) if the services are made part of the client's medical record.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Nurse-Midwifery Services › Section 17b-262-580 - Prior authorization

Current through July 10, 2024
(a) Prior authorization, on forms and in a manner as specified by the department, is required for:
(1) more than one visit per day per client; and
(2) HealthTrack Special Services.
(A) HealthTrack Special Services are determined medically necessary and medically appropriate on a case-by-case basis; and
(B) 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 services required;
(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 Nurse-Midwifery Services › Section 17b-262-581 - Billing procedures

Current through July 10, 2024
(a) Claims from nurse-midwifes 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) If a provider assumes the continuing care of a client or provides services to a client as a result of a referral by a nurse-midwife because the services cannot be provided by the nurse-midwife, an obstetrical-gynecological surgical procedure as an example, this procedure would be billed as a separate procedure, by any provider giving this service.
(c) When a Medical Assistance Program client is referred to a provider for consultation, the consultant provider shall include the referring practitioner's provider number and name. If no provider number has been assigned, the consultant provider shall enter the entire name as well as the state license number of the referring provider on the billing form.
(d) The fee for routine care of a newborn in the hospital shall be all inclusive and shall be billed only once per child. The fee includes initiation of diagnostic and treatment programs, preparation of hospital records, history and physical examination of the baby, and conferences with the parents. Subsequent hospital care for evaluation and management of a normal newborn is paid per day.
(e) The following routine laboratory tests shall be included in the fee for an office visit and shall not be billed on the same date of service: urinalysis without microscopy, hemoglobin determination, and urine glucose. Payment for these tests is included in the fee for a routine workup.
(f) Laboratory services performed in the nurse-midwife's office are payable to the nurse-midwife. Nurse-midwife's shall bill for these services as separate line items. When a nurse-midwife refers a client to a private laboratory for services, the laboratory shall bill directly. No laboratory charge shall then be paid to the nurse-midwife.
(g) Payment for laboratory services shall be limited to services provided by Medical Assistance providers who are in compliance with the provisions of the Clinical Laboratory Improvement Amendments of 1988 (CLIA).
(h) When a newborn requires other than routine care following delivery, the provider shall bill for the appropriate critical care. The department shall not pay both the critical care and routine care for the same child.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Nurse-Midwifery Services › Section 17b-262-582 - Payment

Current through July 10, 2024
Payment shall be made at the lowest of:
(a) the provider's usual and customary charge to the general public;
(b) the lowest Medicare rate;
(c) the amount in the applicable fee schedule as published by the department;
(d) the amount billed by the provider; or
(e) the lowest price charged or accepted for the same or substantially similar goods or services by the provider from any person or entity.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Nurse-Midwifery Services › Section 17b-262-583 - Payment rate

Current through July 10, 2024
(a) The commissioner establishes the fees contained in the department's fee schedule pursuant to section 4-67c of the Connecticut General Statutes.
(b) Payment rates shall be the same for in-state and out-of-state providers.
(c) Nurse-midwifery rates for each procedure shall be set at 90% of the department's fee for physician procedure codes.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Nurse-Midwifery Services › Section 17b-262-584 - Payment limitations

Current through July 10, 2024
(a) The department shall pay for an initial visit by a nurse-midwife only once per client. Initial visits refer to the nurse-midwife's first contact with the client and reflect higher fees for the additional time required for setting up records and developing past history. The only exception to this is when the nurse-midwife-client relationship has been discontinued for three or more years and is then reinstated.
(b) The department shall pay for an initial visit once per inpatient hospitalization.
(c) Nurse-midwifes who are fully or partially salaried by a general hospital, public or private institution, group practice, or clinic shall not receive payment from the department unless the nurse-midwife maintains an office for private practice at a separate location from the hospital, institution, group, or clinic in which the nurse-midwife is employed. Nurse-midwifes who are solely hospital, institution, group, or clinic based, either on a full- or part-time salary are not entitled to payment from the department for services rendered to Medical Assistance Program clients.
(d) A nurse-midwife who maintains an office for private practice separate from the hospital, institution, group, or clinic, shall be able to bill for services provided at the private practice location or for services provided to the nurse-midwife's private clients in the hospital, institution, group, or clinic only if the client is not a client of the hospital, institution, group, or clinic.
(e) Fees for medical procedures shall include the fee for an emergency room visit. The department shall not pay a provider at a higher rate for any medical procedure which is performed in an emergency room.
(f) Payment for the total obstetric care procedure, shall include office visits for maternity care six months prior to delivery and six weeks after delivery.
(g) If antepartum care, vaginal delivery, or postpartum care are billed as separate procedures, total payment shall not exceed the fee for the total obstetric care procedure.
(h) If a client's medical problem necessitates the concurrent services and skills of two or more providers, each provider shall be entitled to the listed fee for the service.
(i) There shall be no payment for consultation and collaborative management services with an obstetrician-gynecologist when functioning as part of the health care team in the evaluation and treatment of a client.
(j) Although a nurse-midwife shall always function within a health care system in a team relationship with a physician which is directed and shall never be independent of physician back-up for consultation and collaborative management, or referral, directed does not necessarily imply the physical presence of the physician when care is being given by a certified and licensed nurse-midwife.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Nurse-Midwifery Services › Section 17b-262-585 - Documentation

Current through July 10, 2024
(a) Nurse-midwifes shall maintain a specific medical record for all services rendered to 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 nurse-midwife, 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 nurse-midwife's file subject to review by the 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 nurse-midwife 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 Personal Care Assistance Services for Adults › Section 17b-262-587 - Purpose and scope

Current through July 10, 2024
Sections 17b-262-587 through 17b-262-596 b, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services' requirements for payment of personal care assistance services for adults. The Department operates the Personal Care Assistance Waiver Program that assists eligible disabled adults by paying for personal care assistance services. The purpose of sections 17b-262-587 through 17b-262-596 b, inclusive, of the Regulations of Connecticut State Agencies is to describe the program requirements, services available and limitations under (1) the Personal Care Assistance Waiver Program, which is conducted under a federal waiver under section 1915(c) of the Social Security Act to the Medical Assistance Program pursuant to section 17b-262 of the Connecticut General Statutes (CGS).