Pre-Authorization Requirements

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, Massachusetts, New York).

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:

1. Five (5) business days in advance of all elective inpatient admissions (even when ConnectiCare is secondary payer), or
2. 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 plan.
• 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.

• 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 practitioner.
• 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 non-approved procedures.

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 vendor; and
• ConnectiCare, or its designated vendor, was not aware of the existence of the information at the time of the pre-authorization review; and
• 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 review.