Provider Manual
Amendment History
Version Version
Date Reason for Revision Section Page(s)
1.0 02/20/2013 Initial Release. Includes revised Prior Authorization Forms and incorporates changes to Prior
Authorization processes as the result of transition to the new Administrative Services Organization (ASO).
All All
2.0 05/14/2014 Update. Includes termination of Charter Oak Health Plan, change to prior authorization requirements for members with OI, and change in time allowed for processing of retrospective authorization requests for inpatient hospital stays.
1.1, 1.3 5, 30
3.0 02/10/2015 Update. Reflects need for providers to submit additional pricing information when requesting authorization for manually priced MEDS items.
1.2 17, 21, 24
Table of Contents
1.1 Overview ... 4
1.2 Professional and Miscellaneous Prior Authorization ... 6
1.3 Hospital Inpatient Services ... 28
1.4 Chronic Disease Hospital Services ... 33
1.5 Laboratory Services Prior Authorization ... 35
This chapter contains Prior Authorization (PA) information for services requiring authorization of services or goods prior to the service being performed or the goods being delivered. The chapter includes the new DSS standard Prior Authorization Request Form, instructions for completing the form and Prior Authorization submission guidelines. The chapter also identifiesthe appropriate entity that is responsible for making the Prior Authorization determination. The information in this chapter is important for the proper adjudication of claims submitted by providers that participate in the Connecticut Medical Assistance Program.
Prior Authorization means the approval from DSS or its contracted administrative services organization (ASO), for the provision of a service or the delivery of goods from the department before the provider actually performs the service or delivers the goods.
To receive reimbursement from the Department of Social Services, a provider must comply with all Prior Authorization requirements. The Department of Social Services has sole discretion to determine what information is necessary to approve a Prior Authorization request. Obtaining PA does not guarantee payment or ensure client eligibility. It is the responsibility of the provider to verify client eligibility for the appropriate date(s) of service.
Authorization when Clients have Other Insurance (OI) or Medicare
Effective for dates of service May 1, 2014 and forward, providers are required to obtain authorization prior to the service being rendered when the client has OI. Prior authorization is not needed when the client has Medicare as their primary insurance. Dates of services prior to May 1, 2014 can still be submitted to CHNCT for retrospective review if the OI denied or paid less than the Medicaid rate. Providers should submit a completed PA Form, the explanation of benefits (EOB) from the other insurance company and medical records to
substantiate the medical necessity of the requested service to CHNCT. PA will be authorized retroactively on a case by case basis and if approved, the PA will be backdated to the date of service.
1.2 Professional and Miscellaneous Prior
Authorization
Overview The term Prior Authorization (PA) refers to approval from the Department of Social Services (DSS), or the Department of Social Services’ ASO, for a service or the delivery of goods before the provider actually performs the service or delivers the goods. To receive reimbursement from DSS, a provider must comply with all Prior Authorization requirements. The Department of Social Services has sole discretion to determine what information is necessary to approve a Prior Authorization request. PA does not guarantee payment or ensure client eligibility. It is the responsibility of the provider to verify client eligibility on the date(s) of service.
The Department of Social Services requires providers to complete the Prior Authorization Request Form for pre-approval of the following selected services for HUSKY Health clients. All of the Prior Authorization requests in this section are reviewed and processed by the Department’s ASO Community Health Network of Connecticut (CHNCT).
Note: Prior authorization (PA ) requests for Behavioral Health, Non-Emergent Transportation and Dental services are reviewed and processed by different ASOs. PA instructions for these services can be found via the following links:
Behavioral Health:
Prior Authorization requests for behavioral health services, those services where a behavioral health diagnosis is the primary reason for the service (diagnosis codes 291-316), must be obtained from Value Options (VO). Please refer to the Connecticut Behavioral Health Partnership (CT BHP) section in Chapter 9. This chapter is available at www.ctdssmap.com by selecting Information>Publications and then scrolling down to Chapter 9 Prior Authorization.
Non-Emergency Transportation:
The Department of Social Services contracts with LogistiCare to coordinate all non-emergency medical transportation services for HUSKY A, HUSKY C and HUSKY D clients.
Please refer to the Transportation Services section in Chapter 9 for prior authorization requirements for non-emergency transportation. This chapter is available at www.ctdssmap.com by selecting
Information>Publications, and then scrolling down to Chapter 9 Prior Authorization.
**Note: Non-emergency medical transportation is not a covered service for HUSKY B clients. Dental:
Prior Authorization requests for dental services for HUSKY A, HUSKY B, HUSKY C, and HUSKY D clients should be submitted to the Connecticut Dental Health Partnership (CTDHP). Please refer to the CTDHP section in Chapter 9. This chapter is available at www.ctdssmap.com by selecting Information>Publications, and then scrolling down to Chapter 9 Prior Authorization
Waiver Programs:
Prior Authorization Requests for members in the following programs must continue to be submitted to Hewlett Packard (HP):
• Home Care Program for the Elders
• Money Follows the Person
The prior authorization submission instructions for HP are available by going to www.ctdssmap.com and selecting Information>Publications, and then scrolling down to Chapter 9 Prior Authorization>Section 9.2>page 10
• Durable Medical Equipment (DME)*
• Durable Medical Equipment (DME) – Customized Wheelchairs* • Hearing Aids
• Home Health* (requests for Money Follow the Person and Home Care Program for the Elders must continue to be submitted to HP) • Hospice* • Laboratory* • Medical/Surgical Supplies* • Occupational Therapy*
• Orthotics & Prosthetic Devices*
• Oxygen*
• Physical Therapy*
• Professional/Surgical Services*(when service performed on an outpatient basis) • Radiology Services*
• Speech/Audiology Therapy*
• Vision Care Services
*The providers or service types above with an asterisk indicates that there are additional instructions that apply to these provider or service types on the following pages.
The services listed above will be authorized by CHNCT. Requests for authorization can be made via the secure web portal. CMAP enrolled providers may submit requests for the following authorizations via the web:
• Home Health Care Services
• Orthotic and Prosthetic Devices
• Oxygen
• Medical/Surgical Supplies • Hearing Aids
• Durable Medical Equipment • Professional/Surgical Services
• Physical, Occupational and Speech Therapies performed by independent therapists, rehabilitation
clinics and hospital outpatient programs
Providers may use the web portal to view the status of their request online, verify eligibility, and attach documents to support requests for authorization.
1. For technical questions (access, user IDs, passwords, connection to system), please call 1-877-606-5172 or 203-626-7105 and choose the prompt for Clear Coverage.
2. For questions on the status of an authorization or clinical questions about an authorization call 1-800-440-5071 option #2 for authorizations.
Providers may also call in their request for authorization to the Prior Authorization Intake Unit at
Services Requiring Prior Authorization
Benefit and authorization grids providing a general summary of benefits and authorization requirements for the HUSKY Health Program are located on the HUSKY Health Program website. Please refer to either of the following website for information on benefit or authorization requirements:
• www.huskyhealth.com
From either of those websites, click For Providers followed by Benefits & Authorizations.
For a definitive list of benefits and limitations please review the CMAP fee Schedules and regulations at www.ctdssmap.com. For fee schedule
Information, click on Provider, followed by Provider Fee Schedule Download. For Regulations, click on Information, then Publications and view Chapter 7. How to Obtain Prior
Authorization Form for Professional and Miscellaneous Services
Providers can obtain the Prior Authorization Request Form by downloading the form from the Web portal at www.huskyhealth.com, click on For Providers, Providers Bulletins, Updates and Forms and then accessing the Outpatient Authorization Request Form, or by telephoning CHNCT Provider Assistance Center at 1-800-440-5071 (in-state toll free) between the hours of 8:00am-7:00pm Monday through Friday, excluding holidays.
Where to Send Completed Prior Authorization Form
Providers submitting for initial Home Health, Occupational, Physical and Speech/Audiology Requests when the primary reason for the visit is not behavioral health related (diagnosis codes 291-316) must fax their requests to:
(203) 265 3994
Note: Prior Authorization requests for home health services must be received prior to the first visit. Authorization requests for service performed after hours, on a weekend or holiday must be received on the next business day.
Prior Authorization requests with a behavioral health primary reason for the visit (diagnosis codes 291-316) must be obtained from ValueOptions (VO).
The prior authorization submission instructions for Value Options are available by going to www.ctdssmap.com and selecting Information>Publications, and then scrolling down to Chapter 9 Prior Authorization>Section 9.5>page 43
Providers submitting for in-patient Hospice Care beyond the fifth day of care and DME urgent requests must fax their requests to:
(203) 265 3994
All other providers, including those submitting for reauthorization of Home Health Agency Services with a primary reason for the visit other than diagnosis codes 291-316, should fax their requests to CHNCT.
(203) 265 3994
Request for changes to existing home health authorizations must be faxed to CHNCT at:
(203) 265-3994
For additional detailed instructions for professional or miscellaneous services, please refer to the Instructions for Specific Professional or Miscellaneous Services or Provider Types located below.
Upon receiving the completed PA form and all the necessary supporting information, CHNCT reviews the information and either approves or denies the PA request.
!
010814 This form may be filled out by typing in the field, or printing and writing in the fields.
Please fax completed form to CHNCT at 1-203-265-3994. Please call CHNCT’s provider line at 1-800-440-5071 with any questions.
11 Fairfield Blvd., Suite 1 • Wallingford, CT 06492 800.440.5071 • Fax 203.265.3994 • www.huskyhealth.com OUTPATIENT PRIOR AUTHORIZATION REQUEST FORM
BILLING PROVIDER INFORMATION MEMBER INFORMATION
1. Medicaid Billing Number:
7. Member ID Number:
2. Billing Provider Name:
8. Member Name (Last, First):
3. Address:
9. Address:
4. City, State Zip:
10. City, State, Zip:
5a. Contact Name/Telephone Number:
11. Date of Birth (MM/DD/YYYY):
12. Sex: Male Female 5b. Contact Fax Number:
13. Primary Diagnosis Code:
6. Name, Address and Medicaid ID Number of Referring MD:
14. Estimated Delivery Date (DME ONLY) (MM/DD/YYYY):
15. Authorization Service Requested (Check only one from the list below):
Customized Wheelchair DME Genetic Testing/Lab Services Hearing Aids
Home Care Program for Elders Initial Re-Auth Home Health Initial Re-Auth Hospice Medical/Surgical Supplies Money Follows the Person (MFP) Occupational Therapy
Initial Re-Auth
Orthotic & Prosthetic
Devices Oxygen
Physical Therapy Initial Re-Auth Professional/Surgical Services Speech Therapy Initial Re-Auth Vision Care Services Independent Chiropractic Evaluation Initial Re-Auth
16. Dates of Service 17. Place of Service 18. Proc/RCC Code/List 19. Mod 1 20. Mod 2 21. Mod 3 22. Units 23. Total Cost Dollars Line Item Start Date (MM/DD/YYYY) End Date (MM/DD/YYYY) 1 2 3 4 5 6 7 8
24. Clinical Statement: Include a prognosis and rehabilitation potential in the space provided below. A current plan of treatment and progress notes as to the necessity, effectiveness and goals of service requested must be attached.
Signature of Clinical Practitioner:
Date:
25. Certification Statement:This is to certify that the requested service, equipment or supply is medically indicated and is reasonable and necessary for the treatment of this patient and that a prescribing practitioner signed order is on file (if applicable). This form and any statement on my letterhead attached hereto has been completed by me, or by my employee and reviewed by me. The foregoing information is true, accurate and complete, and I understand that any falsification, omission or concealment of material fact may be subject me to civil and criminal liability.
Signature of Billing Provider:
Date:
Field 18 Footnote for Outpatient Authorization request Form Instructions: !
11 Fairfield Blvd., Suite 1 • Wallingford, CT 06492 800.440.5071 • Fax 203.265.3994 • www.huskyhealth.com
PRIOR AUTHORIZATION REQUEST FORM INSTRUCTIONS
# Field Name Description
1 Medicaid Billing Number Enter the provider’s NPI number or the CMAP identification number (AVRS#) that has been issued to the provider upon enrollment in the Medicaid Program, if the provider is unable to obtain an NPI.
2 Billing Provider Name Enter the billing provider’s name. 3 Address Enter the billing provider’s street address. 4 City, State Zip Enter the billing provider’s city, state and zip code. 5a Contact Name/
Telephone Number
Enter the billing provider’s contact name and telephone with area code. 5b Contact Fax Number Enter the billing provider’s fax number with area code.
6 Name, Address and Medicaid ID Number of Referring MD
Enter the full name, address and CMAP identification number (AVRS#) of the Referring MD 7 Member ID Number Enter the member identification number as it appears on the member’s CONNECT Card or as
obtained from the Automated Eligibility Verification System (AEVS).
8 Member Last Name Enter the member’s name as it appears on the member’s CONNECT Card or from AEVS. 9 Address Enter the member’s address. If the member resides at a facility or institution, document that
information in this field.
10 City, State Zip Enter the member’s city, state and zip code. If the member resides at a facility or institution, enter that facility or institution’s city, state and zip code.
11 Date of Birth Enter the member’s date of birth in the MM/DD/YYYY format.
12 Sex Select the member’s gender.
13 Primary Diagnosis Code Enter the member’s primary diagnosis code.
14 Estimated Delivery Date Enter the estimated date of DME delivery in the MM/DD/YYYY format. 15 Authorization Service
Requested
Select the appropriate prior authorization type being requesting, checking only one. For outpatient therapy requests (occupational, physical and speech), be sure to indicate whether requested services are for initial or re-authorization. For Home Health and Home Care Program for Elders requests, be sure to indicate whether requested services or for initial, re-authorization or MFP requests. For independent chiropractic service requests please be sure to indicate whether requested services are for evaluation, initial or re-authorization.
16 Dates of Service Enter the requested start and end dates for the requested services in the MM/DD/YYYY format. 17 Place of Service Enter the place of service where the procedure or service will be provided; no code is needed just
a description of the place of service.
18 Proc/RCC Code/List Enter the code/list for the procedure/revenue center code (RCC) for the service.
Note for Home Health Providers, Independent Therapists, Physician Therapy Groups and Rehab Clinics
Please refer to following link for codes and instructions: Outpatient Authorization Request Form Instructions
(If you are on a PC, “ctrl + click” the link to download the instructions. If you are on a Mac, single click the link.)
Note for Genetic Testing In Line Item #1 enter the new 2012 Molecular Pathology CPT Code, e.g., 81200-81408, which will have 1 unit (Field #22). In Line Item 2-8 enter the “stacked” codes for the test being requested, e.g., 83890, 83891, etc., one code per line, the number of units for each code entered in Field #22. Where more than one 2012 CPT code in the range 81200-81408 is being requested, append an attachment providing code, the linked “stacked” codes, and units. If no new code, leave line #1 blank.
19-21 Mod 1, Mod 2, Mod 3 Enter first, second and third modifier code(s) for the procedure required, if applicable. 22 Units Enter the number of units requested.
23 Total Cost Dollars Enter the total amount, in dollars, for the units of service requested if applicable. 24 Clinical Statement/
Signature of Clinical Practitioner
The Clinical Practitioner should enter a comprehensive statement indicating the clinical necessity, the plan of treatment, and the desired outcome for the services requested. The Clinical Practitioner should sign and date the PA Request Form. Signature stamps are unacceptable.
For initial home health and therapy requests, this signature is optional. For general inpatient hospice requests beyond 5 days, explain why pain control or acute or chronic symptom management cannot be managed in other settings. For Medicaid members only: For hospice services that exceed a period of 12 months, explain why the continuation of the hospice benefit is clinically indicated for this patient given that hospice services are generally indicated for clients with a life expectancy of 6 months or less.
25 Certification Statement/ Signature of Billing Provider
Enter the full name signature for the billing provider and corresponding date. Signature stamps are unacceptable. A request form without original signature will be rejected.
Rehabilitation Clinic, Independent Therapy, Physician Therapy and Home Health Prior Authorization Instructions
Rehabilitation Clinics:
When requesting authorization for therapy services performed in a rehab clinic, please request authorization using code group number and number of units.
Example: If a physical therapist will be performing 97032 – 2 units and 97035 – 2 units, initial request would be made using Code Group “RCPTI” with 4 units. Claim would still be submitted with CPT Code(s), Modifier(s) and number of units.
Code Group Benefit CPT Codes/Modifiers
RCSTI ST Initial 92507, 92508, 92521, 92522, 92523, 92524, 92526 RCSTR ST
Re- authorization
RCPTI PT Initial 29125, 29126, 29131, 29260, 29280, 29540, 64550, 90901, 97001, 97002, 97010-97022, 97026, 97032-97035, 97110-97124, 97140-97535, 97542, 97597-97602, 97760-97762 (all with modifier GP or all with modifiers GP and 59 )
RCPTR PT
Re-authorization
RCOTI OT Initial 29125, 29126, 29131, 29260, 29280, 29540, 64550, 90901, 97003, 97004, 97010 – 97022, 97026, 97032-97035, 97110-97124, 97140-97535, 97542, 97597-97602, 97760-97762 (all with modifier GO or all with modifiers GO and 59)
RCOTR OT
Re-authorization
For services performed in a rehab clinic not included in the table above (HCPCS codes 94664, S5105,
S9446 and T1025), please request authorization using the applicable CPT or HCPCS code. If services described by CPT/HCPCS codes 92557 and V5010 are performed more than once per year by the same provider, prior authorization will be required. Submit requests using the applicable CPT or HCPCS code.
Audiology evaluations in excess of one per year will require prior authorization. Please submit
authorization requests using the applicable CPT codes as listed in the DSS Rehab Clinic Fee Schedule.
Independent Therapy Providers:
When requesting authorization for therapy services performed in an independent setting, please request authorization using code group number and number of units.
Example: If a physical therapist will be performing 97032 – 2 units and 97035 – 2 units, initial request would be made using Code Group “INPTI” with 4 units. Claim would still be submitted with CPT Code(s) and number of units.
Code Group Benefit CPT Codes
INSTI ST Initial 92507, 92508 INSTR ST
Re-authorization
INPTR PT
Re-authorization
INOTI OT Initial 97004, 97010-97150, 97530, 97542, 97760, 97761 INOTR OT
Re-authorization
Physician Therapy Providers:
When requesting authorization for therapy services performed by a physician group, please request authorization using code group number and number of units.
Example: If physician will be performing 97032 – 2 units and 97035 – 2 units, initial request would be made using Code Group “MDPTI” with 4 units. Claim would still be submitted with CPT Code(s) and number of units.
Code Group Benefit CPT Codes
MDPTI Physician Therapy Initial
97010-97530, 97533-97546 MDPTR Physician Therapy
Re-authorization
Home Health:
When requesting authorization for skilled home health services, please request authorization using code group letters and number of units:
Example: If a member is prescribed medication administration for 3 months, a typical request would include two skilled nursing visits and twice daily medication administration visits, request would be made using Code Groups SN - 2 units and MA - 180 units. Claim would still be submitted with HCPCS Code(s), Modifier(s) and number of units.
Code Group Benefit HCPCS Codes/Modifiers
SN Skilled Nursing S9123, S9124, S9123-TT, S9124-TT CN Complex Nursing S9123-TG, S9124-TG TE, S9123-TG TT,
S9124-TG TE TT
ON Obstetrical Nursing S9123-TH, S9124-TH, S9123-TH TT, S9124-TH TT MA Medication Administration T1502, T1502-TT, T1503, T1503-TT
**When requesting authorization for the services of a home health aid or services performed by physical therapists, occupational therapists and speech therapists in a home setting, please request authorization using code T1004 and number of units or revenue codes 421, 431 or 441 and number of units.
Inquiries Regarding Providers with questions regarding the PA process for services listed above
Service Requests should contact CHNCT provider services at (800) 440-5071.
Approval When a PA request is approved, an approval letter is sent to the referring
provider, the rendering provider and the client indicating the details of the prior authorized service.
Denial When a PA request is denied, a denial letter is sent to the referring provider, the
rendering provider and the client indicating the reason(s) for the denial. Correction Procedures If the form is not completed correctly, CHNCT returns the request for
authorization, and the provider is asked to resubmit a corrected, completed form. The provider must make the corrections indicated and resubmit all supporting documentation.
Once a PA letter is sent from CHNCT the provider should verify the information on the PA form to confirm the approval or reason for denial. If any information on the PA letter conflicts with information on the provider’s copy of the original PA form, the provider should contact CHNCT at 1.800.440.5071
Appeals If a PA request is denied, the client has the right to appeal the decision and
request a Fair Hearing within 60 days from the date of notice. A request for a Fair Hearing must be made in writing to the following address:
Department of Social Services Administrative Hearings and Appeals 25 Sigourney Street
Hartford, CT 06106-5033 Retroactive
Authorization Retroactive authorization may be granted for clients who have applied for HUSKY A, HUSKY B, HUSKY C, or HUSKY D eligibility after services are performed. The provider must complete and send a PA Request Form to CHNCT indicating "Pending on date of service" in the ’Clinical Statement’ field (field # 24).
Medicare and/or Third If a provider chooses to submit Prior Authorization paperwork for a HUSKY
Party Liability A, HUSKY B, HUSKY C, or HUSKY D client who also has Medicare or Third
Party coverage, the request will not be denied on the basis that Medicare or Third Party coverage determination has not been made prior to the submission of the request for Prior Authorization.
Instructions for Specific Professional or Miscellaneous Services or Provider Types Chiropractic Services
Medically necessary independent chiropractic services are available for HUSKY Health members under the age of 21 only as EPSDT special services, as well as for HUSKY B members with prior authorization. Prior authorization must be requested and approved before providing services under EPSDT special services or HUSKY B, otherwise the claim will deny.
When requesting prior authorization under EPSDT special services or HUSKY B the following must be submitted:
• An order provided by a physician licensed pursuant to Sec. 20-13 of the Connecticut General
Statutes, APRN, or PA who is enrolled with the CT Medical Assistance Program
• A description of the outcomes of any alternative measure tried;
• Any other documentation reasonably requested by the department or any designated agent of the
department which may be required to make a decision
Fax all requests, including the order from the licensed physician, APRN, or physician assistant to CHNCT at (203) 265-3994.
As outlined in PB 2003-24, for dually eligible HUSKY Health members, independently enrolled chiropractors may submit claims for the deductible or co-insurance as outlined in Chapter 5, Claims Submission - Section 5.7. Please note: if Medicare denies a chiropractic claim for a dually eligible member, these services will not be covered under the HUSKY Health program.
Durable Medical Equipment
Estimated Delivery Date Providers are required to include an estimated delivery date when submitting a Prior Authorization request for all durable medical equipment, allowing CHNCT up to twenty business days to process the request. CHNCT in turn, shares that estimate with the client so that expectations for service delivery can be clear.
FAX Requests Durable Medical Equipment providers may fax a PA Request Form to
CHNCT at (203) 265.3994 to facilitate the client’s discharge from an institution or to prevent hospitalization.
Durable Medical Equipment requiring prior authorization
For all Durable Medical Equipment (DME) that requires prior authorization, the following must be submitted with the request:
• Prior Authorization Request Form • Physician’s prescription
• The request meets the definition of Durable Medical Equipment (DME):
o can withstand repeated use;
o is primarily and customarily used to serve a medical purpose;
o generally is not useful to a person in the absence of an illness or injury; and
o is nondisposable
• The request is supported by a physician’s prescription.
• The DME provider submits a detailed product description and quotation
including manufacturer, model/part number, product description, HCPC code, unit(s), quantity, Medicaid allowable price, actual acquisition cost (AAC) and manufacturer’s suggested retail price (MSRP).
• The clinical documentation must include an explanation why the
requested DME is medically necessary for the client’s specific clinical situation includes establishing the severity of the individual's condition, the immediate and long-term need for the equipment, and the
therapeutic benefits that the client is expected to realize from its use. A claim of therapeutic effectiveness or benefit based on speculation or theory alone cannot be accepted, as indicated in the definition of medical necessity. When restoration of function or bodily function is cited as a reason for use of DME, the exact nature of the deformity or medical problem should be evident from the clinical evidence submitted and how the DME will restore or improve the clients bodily function. This documentation must validate that the client received an objective, onsite evaluation by a licensed health care profession, including the provision of actual DME trials and simulations and a comparison of various DME options
• If the request is for a replacement, the following information is required:
1) Specifications of current DME including manufacturer, model, and date of purchase; and 2) the reason for replacement; e.g., change in physiological/functional status; change in size where current DME cannot be modified; irreparable condition of the current DME.
• The DME request must meet the criteria for medical necessity: For
purposes of the administration of the medical assistance programs by the Department of Social Services, "medically necessary" and "medical necessity" mean those health services required to prevent, identify, diagnose, treat, rehabilitate or ameliorate an individual's medical condition, including mental illness, or its effects, in order to attain or maintain the individual's achievable health and independent functioning provided such services are: (1) Consistent with generally-accepted standards of medical practice that are defined as standards that are based on (A) credible scientific evidence published in peer-reviewed medical literature that is generally recognized by the relevant medical community, (B) recommendations of a physician-specialty society, (C) the views of physicians practicing in relevant clinical areas, and (D) any other relevant factors; (2) clinically appropriate in terms of type,
frequency, timing, site, extent and duration and considered effective for the individual's illness, injury or disease; (3) not primarily for the convenience of the individual, the individual's health care provider or other health care providers; (4) not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the individual's illness, injury or disease; and (5) based on an assessment of the individual and his or her medical condition. [Reference: CHAPTER 319vMEDICAL ASSISTANCE; Section 17b-259b re: definition of "medically necessary" and "medical necessity" of Connecticut State
Agencies] All final determinations of medically necessity must be based upon this statutory definition.
Orthotics Other than foot orthotics and FES Walkaide requests must submit the following: A documented comprehension evaluation by either
Connecticut licensed/certified orthotist (C.O), or licensed/certified prosthetist-orthotist (C.P.O.). This documentation must explain the medical necessity of each item requested and must include the client’s current use of orthotics and other DME, as relevant to the specify request. This explanation must be based on and related to the Client’s medical condition and their typical activities of daily living.
Foot Orthotics Prior authorization is required for foot orthotics including inserts, arch supports, and modifications to orthopedic shoes. Foot orthotics can be considered medically necessary for clients who meet the specific criteria and for whom other treatment methods have been ruled out prior to recommending foot orthotics, as documented in the “Foot Orthotics Clinical Guideline” located on the HUSKY Health Program website at www.huskyhealthct.org.
FES Walkaide Prior authorization is required for FES Walkaide requests. FES
Walkaide(s) can be considered medically necessary for clients who meet the specific criteria and for whom other treatment methods have been ruled out prior to evaluating for a FES Walkaide, as documented in the “FES Walkaide Clinical Guideline” located on the HUSKY Health Program website at
www.huskyhealthct.org.
Determinations of coverage of FES for the foot and ankle will be made in accordance with the DSS definition of Medical Necessity. Coverage determinations will be based upon a review of requested and/or submitted case-specific information to include evidence-based evaluations, both qualitative and quantitative, performed in the
individual’s customary environment(s) (including use on varied terrain). A two-week trial will be utilized to assess patient compliance prior to purchase.
Information Required for Initial Review:
1. Prescription/ signed letter of medical necessity;
2. Completed State of Connecticut, Department of Social Services Outpatient Prior Authorization Request Form;
3. Current list of ambulatory aids/orthotics with current skill level for each;
4. Patient’s self-assessment of current health status, functional abilities, level of activity and level of comfort;
5. Treatment history;
6. Clinical assessment to include:
• Primary diagnosis leading to foot drop
• Possible contraindications (e.g. seizures, pacemaker) • Current indications
• Current range of motion • Current muscle strength
• Observational gait assessment (swing and stance phase) • Gait speed (with and without FES device)
• Timed walk endurance evaluation (with and without FES
device) in all three evaluation sessions and 7. Other pertinent information as requested by CHNCT. Review Process:
1) Requests for the FES device will be reviewed by CHNCT in accordance with procedures in place for reviewing requests for DME.
2) If approved, a rental trial period will allow the member to use the device for 14 days within their customary environment(s). 3) After the 2 week period, the member will return to the DME
provider for an evaluation of the benefits/limitations of the trial and the level of compliance with the device. The resulting data will be compared to the data obtained during the initial evaluation session.
4) The DME provider may request a prior authorization for an additional 2-week rental, pending the functional results of the first 2 week trial.
5) CHNCT will review the results of the entire evaluation trial period after the rentals are complete to determine if the purchase of the FES device will be authorized. Determinations for medical necessity are based upon a comparison of the baseline data and two subsequent evaluations, given two 2-week trials within the member’s customary environment(s).
6) The rental fee for each two-week period is typically $250.00 per device. This fee will be deducted from the purchase price, if CHNCT approves the purchase.
Durable Medical Equipment - Customized Wheelchairs under Department of Social Services
Customized Wheelchair in Nursing Facilities regulation (Sec. 17-134d-46)
Authorization Prior Authorization requests for the purchase of a customized wheelchair
Requirements for patients in a Nursing Facility or ICF/MR must include:
• Prior Authorization Request Form
• Customized Wheelchair Prescription Form, W-628 completed by the
1) Patient’s attending physician, 2) A physician who is board certified in orthopedics or physiatry, 3) A Connecticut licensed physical therapist or a licensed registered occupational therapist, and 4) A representative of the professional nursing staff of the facility (R.N. or L.P.N.)
• Documented history and physical examination performed by the
attending physician within one (1) year prior to receipt of the request, and attending physician notes within ninety (90) days of receipt of the request, if necessary. (If history and physical examination are done within ninety (90) days of receipt of request, additional notes are not required).
• A documented examination by either an orthopedic physician or a
physiatrist. The examinations shall be part of the facility medical record as well as the submission to the Department and must have been completed within 3 months prior to the date of receipt of the request for a customized wheelchair. The examinations must document the results of
films and/or x-rays, as deemed appropriate by the attending physician and the physiatrist or orthopedic physician.
• A comprehensive rehabilitative assessment by either a physical
therapist or occupational therapist, as it relates to the custom wheelchair request. The examinations shall be part of the facility medical record as well as the submission to the Department and must have been
completed within 3 months prior to the date of receipt of the request for a customized wheelchair. Documentation by the evaluating occupational or physical therapist explaining the medical necessity of each item ordered on the W-628 form. The specification sheet for the wheelchair and each accessory/component must include an explanation of why the wheelchair and each custom accessory are necessary. This explanation must be based on and related to the Member’s medical condition.
• When/if the Member previously received a custom wheelchair under
Department of Social Services Customized Wheelchair in Nursing Facilities regulation (Sec. 17-134d-46) documentation of the current 24-hour positioning plan must be submitted with the new wheelchair request.
Additionally:
• Any modification with a price of $1000 or more requires the added
signature of the physiatrist or orthopedist in addition to a therapist, attending physician and nurse on the W-628 form. For other
modifications, signatures of a therapist, attending physician and nurse are sufficient.
• In situations where the original component is not usable by the client, the
Department requires the replacement item with the same procedure code to be swapped at no cost to the Department within 90 days of purchase. For example, if the initial headrest ordered is deemed to be inappropriate for the client, the replacement headrest should not be billed.
• In situations where the replacement component required necessitates
the use of a different procedure code, it is viewed as a modification of the original prior authorization (PA) and the Department should be billed for the net difference between the cost of the original and the
replacement components.
Please note that the nursing facility or ICF/MR, not the vendor, is responsible for: 1. identifying potential recipients who may require customized
wheelchairs;
2. initiating and conducting an interdisciplinary team (IDT) assessment, incorporating this assessment into the patient care plan and completing the W628 form;
3. upon completion of 1 and 2, contacting the wheelchair vendor and ordering the custom wheelchair as appropriate;
4. implementing a 24 hour positioning plan;
5. implementing a monitoring program that includes monthly nursing progress notes and quarterly therapy progress notes;
6. documenting the in-service training; and
The vendor should obtain quotes from manufacturers and submit a prior authorization (PA) request to CHNCT only after the prescribing practitioner has signed the prescription that details the specifications of the custom wheelchair. The DME provider submits a detailed product description and quotation including manufacturer, model/part number, product description, HCPC code, unit(s), quantity, Medicaid allowable price, AAC (actual acquisition cost) and MSRP.
PA requests must be faxed to CHNCT at (203) 265.3994.
Overview W-628 Form The Customized Wheelchair Prescription form, W-628 accompanies the
comprehensive patient assessment submitted by the Interdisciplinary Team (IDT). The provider may obtain the Customized Wheelchair Prescription form from the Department of Social Services. This one page prescription form is to be completed by the IDT and the provider, and submitted as described below.
How to Obtain The form and instructions are provided in this section of the Provider
Form W-628 Manual and can also be downloaded or printed from the Web site
www.ctdssmap.com under Information > Publications, and then accessing the W-628 form under the Forms section. Forms>Authorization/Certification Forms. Where to send the
Completed Form Providers may fax the completed Customized Wheelchair Prescription form, W-628 with the comprehensive patient assessment, other required documentation, and the Prior Authorization request form to CHNCT at (203) 265.3994.
Instructions for Completing the Form
The following page provides detailed instructions for completing the Customized Wheelchair Prescription form, W-628.
No Name Description
1. PATIENT NAME/ADDRESS Enter the client’s name (first name, middle initial,
last name), and full address.
2. PATIENT DIAGNOSIS Enter all diagnoses pertaining to the prescribed
equipment.
3. FACILITY NAME Enter the complete name of the facility where the
client resides.
4. PATIENT MEDICAL
I.D. NO. Enter the client’s 9-digit Connecticut Medical Assistance Program ID number exactly as it appears on the CONNECT Card or as communicated by the Automated Eligibility Verification System (AEVS).
5. D.O.B. Enter the patient’s date of birth using the
MM/DD/CCYY format.
6. LENGTH OF NEED Enter the length of time the wheelchair is needed.
7. WHEELCHAIR
DESCRIPTION IN DETAIL
Enter the full description of the wheelchair, including all individual components, and any specific changes or adaptive improvements that are necessary to meet the client’s needs.
8. DATED SIGNATURES OF ALL
IDT MEMBERS WITH APPROPRIATE TITLES ARE MANDATORY
Each Interdisciplinary Team (IDT) member must enter their printed name and title with signature and date on the corresponding line provided. Addresses of both signing physicians are also required.
9. WHEELCHAIR
PROVIDER NAME
This section to be completed by the wheelchair dealer.
Enter the name of the company supplying the wheelchair.
Durable Medical Equipment - Customized Wheelchairs for Clients living at home
Authorization Prior Authorization requests for the purchase of a customized wheelchair
Requirements for patients living at home must include:
• Prior Authorization Request Form
• A documented comprehensive rehabilitative examination by either
Connecticut licensed physical therapist or licensed occupational therapist, as it relates to the custom wheelchair request.
Documentation by the evaluating occupational or physical therapist explaining the medical necessity of each item requested. The specification sheet for the wheelchair and each
accessory/component must include an explanation of why the wheelchair and each custom accessory are necessary. This explanation must be based on and related to the Client’s medical condition and their typical mobility-related activities of daily living.
• A evaluation/assessment by the physical or occupational therapist
must accompany the request. The evaluation must include:
• Documentation that the wheelchair is able to be
maneuvered within the confines of the living space.
• Trial of the proposed wheelchair/similar wheelchair by
the Member and must demonstrate that the client has the cognitive ability to operate the proposed
wheelchair in the home.
• Documentation that comparability of various mobility
devices has been considered.
• The evaluation must be conducted within six (6)
months prior to the date of the request for a custom wheelchair for members who reside in the community.
• A physician’s prescription dated with 6 months of the
prior authorization request. Additionally:
• In situations where the replacement component required necessitates
the use of a different procedure code, it is viewed as a modification of the original prior authorization (PA) and the Department should be billed for the net difference between the cost of the original and the
replacement components.
• The vendor should obtain quotes from manufacturers and submit a prior authorization (PA) request to CHNCT only after the prescribing
practitioner has signed the prescription that details the specifications of the custom wheelchair. The DME provider submits a detailed product description and quotation including manufacturer, model/part number, product description, HCPC code, unit(s), quantity, Medicaid allowable price, AAC (actual acquisition cost) and MSRP.
PA requests must be faxed to CHNCT at (203) 265.3994.
Home Health Services
Home Health providers and Access Agencies must contact ValueOptions (VO) for services to Husky Health, including Waiver and Money Follows the Person (MFP), requiring PA when the primary diagnosis necessitating
treatment is between diagnosis codes 291-319. Providers may call the Connecticut Behavioral Health Partnership (CT BHP) at 1-877-552-8247 for additional information.
All Home Health Care requests for medical services (other than diagnoses 291-319) are authorized by CHNCT. The following information is related to Home Health Medical Services authorized by CHNCT:
Initial Authorization Home Health providers must fax a completed PA form to CHNCT at (203) 265.3994 to obtain authorization to begin home health services. Providers must be sure to use the updated PA form which can be obtained online at
www.huskyhealth.com to indicate that the PA request is an initial request in field 15 of the PA form and include supporting clinical documentation to support the requested service.
Home Care Prior authorization requests are submitted to CHNCT via either:
Clear Coverage secure web portal
Phone 1-800-440-5071 (Monday through Friday from 8 a.m. to 7 p.m.), or Fax at 1-203-265-3994 utilizing the Authorization Request Form, which can be found online at www.huskyhealth.com.
Extension of Treatment Home Health providers must complete the PA Request Form and fax that request to CHNCT at (203) 265-3994 when requesting an extension of treatment after the initial authorization. Providers must be sure to use the updated form to indicate that the PA request is a reauthorization request in field 15 of the PA form and include documentation to support the clinical statement. The PA Form must be submitted one month prior to the completion of the authorized service and may be granted for up to one year. Providers should review their PA online at www.ctdssmap.com using their secure provider ID and password to determine if their request has been approved, denied or modified. Providers will receive a written Notice of Action in response to their request.
Modification in Treatment To request an increase in services or a change in treatment during the current authorized time period, or to submit clinical documentation to support requests for an increase or change in home care services, the provider must fax their request/supporting documentation to (203) 265-3994. This must be done prior to the initiation of the modified plan. Providers DO NOT have to forward the paper PA Request Form to CHNCT.. A written Notice of Action will be sent to the provider confirming the approval or denial of the request.
Providers are reminded to review the status of their PA via their provider secure Web account to ensure all requests have been entered prior to claim submission.
Hospice Care
Authorization Prior Authorization is required for General Inpatient Care (GIP) beyond the fifth day of care and for hospice services for HUSKY A, HUSKY B and HUSKY D clients that exceed a period of twelve months.
Note: For Hospice Services for dually eligible clients that exceed a period of 12 months, providers must submit an extension for hospice care online transaction via the Hospice provider’s secure Web account. Detailed procedures can be found in Chapter 8.2 of the Hospice Provider Manual.
Written Notification All Hospice transactions for Husky Health clients must be submitted online via the Hospice provider’s secure Web account.
Fax Notification For extensions of General Inpatient Care which may be time sensitive in nature, providers must fax their PA requests to (203) 265-3994.
Instructions for Field 24 In field 24 on the PA form, for GIP beyond 5 days, explain why pain control for acute or chronic symptom management cannot be managed in other
settings. For hospice services for Husky Health clients that exceed a period of 12 months, explain why the continuation of the hospice benefit is clinically indicated for this patient given that hospice services are generally indicated for s with a life expectancy of 6 months or less. This explanation is in lieu of the customary clinical statement.
Medical/Surgical and MiscellaneousSupplies
Prescription Requirement Medical /Surgical and miscellaneous supplies in excess of the monthly quantity limits on the DSS fee schedule require Prior Authorization. All services provided continue to require a prescription from a prescribing practitioner, even if Prior Authorization is not required for provision of a product or service. A detailed prescription signed by a physician who specifies the need for that product or service must still be obtained by the MEDS provider before the product or service is provided. The Department may request a copy of the prescription at any time. Products or services provided to clients have been, and continue to be, subject to Department audit.
Prior authorization of diapers and incontinence supplies is required for Husky A, C and D members between the ages of 3-12 years. Prior authorization is required for clients 13 years of age and over for supplies which exceed the monthly quantity limits.
Diapers and incontinence supplies are not a covered benefit for children ages 0-2. Diapers and incontinence supplies are not covered for clients enrolled in the Husky B Program, regardless of age. All requests will be reviewed based on the DSS definition of medical necessity and must be in direct accordance with a signed prescription from the member’s ordering physician.
Supplies that are authorized by CHNCT must be purchased within six (6) months of the date of authorization.
Occupational, Physical, and Speech Services
Initial Authorization Occupational, Physical, and Speech Therapy providers should fax a completed PA form to CHNCT at (203) 265-3994 to obtain authorization to begin these therapy services. The PA request form must be signed by the individual completing the form or by the prescribing provider when there is no supporting clinical documentation with the signature of the prescribing provider. Initial Therapy PA requests are not accepted via telephone. Providers must be sure to indicate that the PA request is an Initial request. The PA may be granted for up to three months. Upon receiving prior authorization approval,providers will receive a written Notice of Action in response to their faxed request.
HUSKY B Clients HUSKY B clients are restricted to a 60 day plan of care. PA is required for all procedure codes.
Extension of Treatment Therapy providers must complete the PA Request Form and fax that request to CHNCT at (203) 265-3994 when requesting an extension of treatment after the initial authorization. Providers must indicate that the PA request is a
reauthorization request To support a PA request for authorization, clinical documentation with the physician’s signature along with the PA request form must be submitted 30 days prior to the end of the previous approved PA period. PAs for the extension of treatment may be granted for up to six months. Providers must also maintain clinical documentation with the physician’s signature.
Oxygen Therapy
Certificate of Medical In addition to completing the Prior Authorization Request Form the
Necessity physician must complete and submit a MedicareCertificate of Medical
Necessity form (CMN). The initial authorization period for oxygen therapy can be up to six (6) months. If the medical need continues beyond the initial
authorization period, a request for the extension of the authorization must be submitted to CHNCT by the attending physician prior to the expiration of the authorized period. The request for extension must document that the service continues to be medically necessary.
Hospital Services
Inpatient Hospital Prior
Authorization All prior authorization requests for HUSKY Health Program clients should now be submitted to CHNCT. Services Requiring Prior
Authorization All elective inpatient hospital admissions require prior authorization.
How to Obtain Prior Authorization
All requests from hospitals seeking PA for HUSKY Health Program non-behavioral inpatient services should be sent to CHNCT by either fax 1-203-265-3994 or phone 1-800-440-5071
How to Obtain Inpatient Providers can obtain the Prior Authorization Request Form downloading Prior Authorization Form the form from the web portal at www.huskyhealth.com click on For Providers, Provider Bulletins, Updates and Forms and then accessing the Inpatient Surgery PA Form, or by telephoning CHNCT Provider
Assistance Center at 1-800-440-5071 (in-state toll free) between the Hours of 8:00am-7:00pm Monday through Friday, excluding holidays.
Hospitals should contact the CT BHP ASO at 1-877-552-8247 to request authorization for inpatient behavioral health admissions.
Emergency Requests In an emergency situation when an in-state or border hospital must perform
inpatient services without a PA, the provider must telephone CHNCT within two business days of admission.
Department of Social Services defines an emergency as a medical condition (including labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the patient’s health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any body organ or part.
Approval If a PA request is approved, CHNCT mails a copy of the Pre-admission
Certification Form to the , the hospital patient accounts department, the hospital utilization review department, and the treating practitioner.
Correction Procedures If any information on the Pre-admission Certification Form is in conflict with the information agreed upon at the time of the telephone request, the provider should contact CHNCT.
Denial If the PA request is denied, the treating practitioner (dentist, physician, or
podiatrist) and the hospital receive a letter of denial from CHNCT explaining the reasons. For elective admissions, the client also receives a letter of denial. The treating practitioner and/or hospital may request reconsideration.
Provider Appeal Pre-admission Review Appeal
When CHNCT makes an adverse determination on a pre-admission or concurrent review, the provider is notified by telephone and in writing and is given the opportunity to request a second review. The second review to present additional information can be requested by telephone or in writing within ten (10) calendar days of the adverse determination, unless, for good cause, at the discretion of the Commissioner, the time for submission is extended. The provider sends the information to CHNCT. Following receipt of this additional information a final determination is made. The provider is notified by telephone and in writing.
Retrospective Review Appeal
When CHNCT makes an adverse determination on a retrospective review, the provider is sent a written summary of the findings. The provider is given an opportunity to request a second review and present additional information in writing, provided the request is submitted in writing to CHNCT within thirty (30) calendar days of the date of receipt of the notice of adverse
determination, unless, for good cause, at the discretion of the Commissioner, the time for submission is extended. The date of receipt is presumed to be five (5) days after the date on the notice, unless there is a reasonable showing to the contrary. The provider sends the information to CHNCT. Following receipt of this additional information a final determination is made and the provider is notified in writing.
Retroactive Authorization Retroactive authorization may be granted if Connecticut Medical Assistance Program eligibility is pending when services were performed. Providers should verify eligibility for the dates of service through the Secure Web Portal or by accessing the Automated Eligibility Verification System. Providers should retain the eligibility verification number once retroactive eligibility for HUSKY Health Program has been verified for the dates of services for the inpatient stay. The provider should submit the request for authorization to CHNCT along with a copy of the verification of eligibility (VOE) number within ten (10) days of the granting of the eligibility along with clinical information and documentation to substantiate the medical necessity of the admission. The documentation to support the request must include all clinical information with the medical record regarding the first five (5) days of admission. If the length of stay is less than five (5) days the complete medical record must be submitted. CHNCT will also accept a copy of the utilization review of the five (5) days of admission in lieu of the medical record.
CHNCT will process the request within five (5) days ** of receipt of all clinical and eligibility documentation. If a denial is issued a letter will be sent to allow the provider the opportunity to provide additional input and the standard reconsideration process is available. If CHNCT authorizes the admission, the provider will be notified. The initial notification will be followed by a notification letter and the provider may then submit the claim directly to HP.
** Effective July 1, 2014, the Department of Social Services is extending the time frame for processing these requests from five (5) calendar days to thirty (30) calendar days of receipt of all clinical and eligibility documentation.
Non-Behavioral Health Inpatient admission when the becomes eligible for dates of service after the admit date
Inpatient Admit Change from Medical to Psychiatric
If a HUSKY Health Program becomes eligible for dates of services during an inpatient stay, CHNCT will not authorize the inpatient claim. The inpatient claim for the eligible days needs to be submitted with only a cover letter and, if applicable, the spenddown amount to:
HP Written Correspondence PO Box 2991
Hartford, CT 06104
If the HUSKY Health Program is admitted with a primary medical diagnosis and then is subsequently admitted to a psychiatric unit, the initial
authorization from CHNCT will cover the entire inpatient admission. CT BHP will be requiring hospital psychiatric units to contact the CT BHP ASO, and notify the ASO of the transfer. This will allow the ASO to capture essential
Inpatient Admit Change from Psychiatric to Medical
CT BHP Claims
Inpatient Admit with a Primary Diagnosis of 291.0
Third Party Liability and/or Medicare
clinical information and assist with discharge planning.
If the HUSKY Health Program is admitted with a primary behavioral health diagnosis and then is subsequently admitted to a medical unit, a PA request must be submitted to CT BHP to process the authorization through discharge. If the inpatient admission for the HUSKY Health Program has a primary diagnosis of 291.0 (Alcohol withdrawal Delirium) with a RCC code other than 114, 116, 124, 126, 134, 136, 144, 146, 154, 156, or 204, the hospitals need to contact CHNCT to process the PA request.
For HUSKY Health Program who have other insurance, hospital providers must follow the same PA procedures as those who have no other insurance. If Medicare is the primary payer, a PA from CHNCT is not required.
UMHHE0024(0114*
11 Fairfield Blvd., Suite 1 • Wallingford, CT 06492 800.440.5071 • Fax 203.265.3994 • www.huskyhealth.com
INPATIENT SURGERY/PROCEDURE REQUEST FORM
Member’s Name: Member’s DOB: Member’s ID #:
Plan: HUSKY A B C D
Date of Surgery:
Hospital: Billing CMAP Group ID:
Surgeon: Billing CMAP Group ID:
Name of Contact: Phone:
Fax: Anticipated Number of days:
Name of Surgery:
Procedure Code: Diagnosis Code:
Clinical notes must be included to process request. Please fax request and clinical information to 203-265-3994.
**PLEASE ALLOW 5 BUSINESS DAYS FROM RECEIPT OF ALL CLINICAL INFORMATION TO PROCESS REQUEST**
Overview Services provided by a Chronic Disease Hospital must be prior authorized. All prior authorization requests for HUSKY Health Program clients should now be submitted to CHNCT.
Services Requiring Prior
Authorization Additional information about chronic disease hospital services that require
PA can be found in Chapter 7, Medical Services Policy, Chronic Disease Hospital Services Section.
How to Obtain Prior
Authorization All hospitals seeking PA for chronic disease hospital services must submit their request to CHNCT either by fax 1-203-265-3994 or phone 1-800-440-5071.
For additional questions regarding the prior authorization process, please call CHNCT at 1-800-440-5071.
Overview Effective July 1, 2012, requests for prior authorization for laboratory procedures, including genetic testing, are to be submitted through the medical administrative services organization (ASO), Community Health Network of CT (CHNCT).
How to Obtain Requests should be submitted to CHNCT via either: Prior Authorization
Phone 1-800-440-5071 (Monday through Friday from 8 a.m. to 7 p.m.), or Fax at (203) 265-3994 utilizing the Outpatient Prior Authorization Request Form, which can be found online at www.huskyhealth.com Click For Providers; Click Provider Bulletins and Updates; Click Outpatient Authorization Request Form. Services Requiring Please refer to the Department’s fee schedules for information on the procedure Prior Authorization codes that require prior authorization. Fee schedules can be accessed and
downloaded by going to the Connecticut Medical Assistance Website:
www.ctdssmap.com. From this Web page, go to “Provider”, then to “Provider Fee Schedule Download”. To access the CSV file press the control key while clicking the CSV link, then select “Open”.
Providers must request prior authorizations for all molecular pathology codes (e.g. 81200, 81201) supported by the codes previously billed as “stacked” codes (e.g. 83909, 83891) for the test being ordered, including the number of units of each of the stacked codes. Listing the stacked codes will enable the Department to price the request appropriately even though these stacked codes are no longer recognized by CMS. The Department will authorize one unit of the molecular pathology code. When possible, an appropriate price for a molecular pathology code will be established on the Consolidated Laboratory Fee schedule. When an appropriate price for the new code cannot be established the new code will be priced at the sum of reasonable fees for the stacked codes.
The Department has developed a form for requesting PA for molecular pathology codes. This form along with
detailed instructions for completion can be found on the HUSKY Website, www.huskyhealth.com. Click on “For
Providers” then on “Provider Bulletins, Updates & Forms.” Use the Outpatient Authorization Request Form.
Molecular pathology codes that do not require PA
Among the molecular pathology tests are specific codes used for cystic fibrosis screening which the American College of Obstetrician Gynecologists recommends for each first pregnancy. DSS is not requiring PA for these new codes if they are billed with a diagnosis of pregnancy. PA will be required for non-pregnant patients. Specifically, codes 81220-81224 (CFTR…gene analysis, common variants) will not require PA when the diagnosis is one of the following: V22.x, V23.x, 651.x3, 652.x3, 653.x3, 654.x3, 655.x3, 656.x3, 657.x3, 658.x3 or 659.x3.
Overview The Department of Social Services and their medical administrative service organization, Community Health Network of Connecticut, Inc. (CHNCT), manage outpatient advanced imaging and nuclear cardiology procedures for clients enrolled in the HUSKY Health Program, with assistance from Care to Care (CtC), a radiology benefit management company.
The HUSKY Health Program’s radiology management program includes the requirement of authorization for advanced imaging – CT, CTA, MRI, MRA, PET, PET/CT and nuclear cardiology studies – using comprehensive clinical criteria available upon request. Please note that while CtC criteria will be considered in making authorization decisions for these services, all final determinations will be made in accordance with the statutory definition of “medical necessity” in accordance with Conn. Gen. Stat. Section 17b-259b(a). Further, to the extent such criteria are used in denying a request for authorization, a copy must be made available to the in accordance with Connecticut General Statutes 17b-259b(c).
Services Requiring Prior
Authorization Prior authorization is required for all HUSKY A, HUSKY B, HUSKY C, HUSKY D and limited eligibility clients and must be obtained prior to the performance of any of the procedures requiring PA. Authorizations for advanced imaging and nuclear cardiology studies are valid for 30 days from the date of approval. Failure to obtain authorization will result in a denial of claims.
For providers billing on a professional claim form 837P/CMS 1500 (e.g. physician offices, independent radiology centers):
• Authorization is required for any of the CPT codes listed in the grids
below.
• Authorization will be requested for the desired study using the applicable CPT code, number of units and modifier(s) as appropriate.
• PA is not required if the provider is billing with modifier 26 (professional
component). As a reminder, a claim will deny if billed with modifier 26 and the place of service is “office” (FTC 11).
Bilateral procedures must be requested with the CPT code on two lines, one with modifier RT and one with modifier LT, one unit each.
For providers billing on an institutional claim form 837I/UB-04 (e.g. outpatient hospitals):
• Revenue Codes 35X, 404 and 61X will ALWAYS require prior
authorization.
• Revenue Code 34X, in combination with any of the CPT codes on the
grid under 34X, will ALWAYS require prior authorization.
• Revenue Code 34X, in combination with OTHER CPT codes will NOT
require prior authorization.
• Hospitals request PA for the CPT code only. The PA system will
automatically assign the appropriate RCC as mapped in the grids below. The PA file will reflect the CPT code only. The claim must be submitted with both the RCC and CPT and will pay based on the provider’s rate for the RCC.
• Authorization will be requested for the desired study using the applicable CPT code and number of units.
Advanced Imaging and Nuclear Cardiology Procedure Codes Requiring Prior Authorization:
Computed Tomography (CT) - Computed Tomographic Angiography (CTA) Revenue Code Series: 35X
70450 70460 70470 70480 70481 70482 70486 70487 70488 70490 70491 70492 70496 70498 71250 71260 71270 71275 72125 72126 72127 72128 72129 72130 72131 72132 72133 72191 72192 72193 72194 73200 73201 73202 73206 73700 73701 73702 73706 74150 74160 74170 74174 74175 74176 74177 74178 74261 74262 74263 75571 75572 75573 75574 75635 76380 77078
Magnetic Resonance Imaging (MRI) – Magnetic Resonance Angiography (MRA)
Revenue Code Series: 61X
70336 70540 70542 70543 70544 70545 70546 70547 70548 70549 70551 70552 70553 70554 70555 71550 71551 71552 71555 72141 72142 72146 72147 72148 72149 72156 72157 72158 72159 72195 72196 72197 72198 73218 73219 73220 73221 73222 73223 73225 73718 73719 73720 73721 73722 73723 73725 74181 74182 74183 74185 75557 75559 75561 75563 75565 76390 77058 77059 77084 Positron Emission Tomography (PET)
Revenue Code: 404
78459 78491 78492 78608 78609 78811 78812 78813 78814 78815 78816
Nuclear Cardiology Revenue Code Series: 34X
78451 78452 78453 78454 78466 78468
78469 78472 78473 78481 78483 78494
