Conn. Agencies Regs. § 17a-453a-6

Current through November 7, 2024

Section 17a-453a-6 - Prior authorization review

(a) The prior authorization review shall determine whether covered behavioral health services are medically necessary and determine the appropriate level of care. Contracted providers shall obtain prior authorization from the designated agent by contacting the designated agent by telephone before admitting a potentially eligible or eligible recipient to a covered behavioral health service, except that contracted providers shall obtain authorization for covered outpatient services as specified in section 17a-453a-8 of the Regulations of Connecticut State Agencies.

(b) The contracted provider shall provide the designated agent with the following information for the purpose of prior authorization review of covered behavioral health services requested for a potentially eligible or eligible recipient:

(1) Identifying information;

(2) DSM-IV provisional or admitting diagnosis or diagnoses;

(3) Level of care requested;

(4) Clinical presentation of the potentially eligible or eligible recipient and justification for the requested covered behavioral health service, including such factors as mental status, natural supports and strengths;

(5) Recovery plan objectives;

(6) Current symptoms of a psychiatric disability, a substance use disorder or both;

(7) Clinical risk assessment and relapse potential;

(8) Medication(s) used;

(9) Substance(s) used;

(10) Whether the potentially eligible or eligible recipient is voluntarily agreeing to treatment;

(11) Legal status of the potentially eligible or eligible recipient, if known;

(12) Potentially eligible or eligible recipient's preference for a covered behavioral health service and contracted provider;

(13) Treatment location;

(14) Provisional discharge or aftercare plan or both;

(15) Projected date of discharge;

(16) Name of the potentially eligible or eligible recipient's primary care physician, if any; and

(17) All other information that the designated agent may require.

(c) The designated agent may require a DMHAS designated mobile crisis team or another organization identified by DMHAS to collect information necessary for prior authorization of acute psychiatric hospitalization, following a face-to-face evaluation of the potentially eligible or eligible recipient.

(d) The decision regarding prior authorization shall be rendered by the designated agent not later than three (3) hours after the receipt of all information that the designated agent determines is necessary and sufficient to render a decision.

(e) Upon completion of the review, the designated agent shall:

(1) Authorize the requested covered behavioral health service for a specific number of days or sessions of treatment over a specified time period;

(2) Authorize a different covered behavioral health service than requested; or

(3) Deny authorization, when the information received by the designated agent does not demonstrate that the requested covered behavioral health service is medically necessary.

(f) Prior authorization of a covered behavioral health service is not a guarantee that DMHAS will pay a contracted provider's claim for payment.

Conn. Agencies Regs. § 17a-453a-6

Adopted effective December 7, 2009