Commercial - Medical Management Programs
ConnectiCare directs its authorization efforts to selected
services and procedures where medical necessity determination has the potential
to make a discernable difference in utilization. The applicable services and
procedures are reviewed by ConnectiCare to determine eligibility, level of
benefits, and medical necessity. Pre-authorization of these services is required
even when ConnectiCare is the secondary payer. For a listing of services and
procedures that require pre-authorization, refer to the applicable state
appendix within this manual (Connecticut,
Physicians requesting pre-authorization must make their requests in writing and include all supporting clinical information. The pre-authorization requests must be provided to ConnectiCare at least:
- Five (5) business days in advance of all elective inpatient admissions (even when ConnectiCare is secondary payer), or
- Two (2) business days in advance of any other services requiring pre-authorization.
A Clinical Review Prior Authorization Request Form is available online to use when requesting authorization. Send requests and
supporting records to ConnectiCare, attention Clinical Review, or fax them to us at:
Fax: (860) 674-5893 or 1-800-923-2882
Other providers who are required to seek pre-authorization, are
asked to call at least five (5) business days in advance to allow time for a
response by the scheduled procedure date.
If requesting pre-authorization for services from a
non-participating (out-of-plan) provider:
• Services provided by a non-participating provider
are not covered unless specifically authorized in writing, in advance by
ConnectiCare, or if the member has a point-of-service or PPO
• ConnectiCare will give authorization only for services that are
not available within ConnectiCare's participating provider network, unless the
member has a point-of-service or PPO plan.
Note: Participating providers may not bill patients for denied
claims due to the provider’s failure to obtain pre-authorization. Not knowing
that a patient has benefit coverage through ConnectiCare is not considered a
valid reason for lack of pre-authorization.
What happens next?
ConnectiCare makes available to physicians a physician reviewer to
discuss determinations based on medical appropriateness. ConnectiCare will
provide you with the name and phone number of the physician reviewer in the
written notification of any denial, so that you may contact the reviewer to
discuss the medical necessity determination.
• ConnectiCare’s medical director will review the
request for authorization and make the determination.
• If the presented clinical information does not meet the
authorization criteria, additional information may be requested from the
• If the medical director does not approve the procedure or service
you will be notified in writing. You may utilize ConnectiCare’s reconsideration
process and/or choose to appeal the decision. See “Reconsideration Process” and/or “Provider Appeals”, found later in this section,
for additional information.
• The written notification will include: the reason
for the determination and clinical rationale, if any; instructions on how to
initiate an appeal of the decision; general information on external appeal
rights, if applicable, including how to initiate an external appeal; notice of
the availability of clinical review criteria referenced in the decision; and the
name and phone number of the physician reviewer who made the decision. Note:
external appeal may only be available after the internal appeal process has been
exhausted. Refer to the state-specific appendices within this Manual for
detailed information regarding appeals.
• Procedures not approved through this process or decisions not
overturned on appeal will not be covered by the health plan. The member should
not be billed, unless he/she agrees in advance, in writing to pay for
Reversal of a pre-authorization upon post-service review
ConnectiCare may reverse a pre-authorized treatment, service, or
procedure on post-service review when:
• Relevant medical information presented to
ConnectiCare, or its designated vendor, upon concurrent or post-service review
is materially different from the information that was presented during the
pre-authorization review; and
• The information existed at the time of the pre-authorization
review, but was withheld or not made available to ConnectiCare or its designated
• ConnectiCare, or its designated vendor, was not aware of the
existence of the information at the time of the pre-authorization review;
• Had the withheld information been made available to ConnectiCare
or its designated vendor, the treatment, service, or procedure would not have
been authorized. This determination will be made using the same specific
standards, criteria or procedures as used during the pre-authorization