Medicare - Medical Management Programs |
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. A listing of services and procedures that require pre-authorization is included later in this section.
Note: These pre-authorization requirements apply to VIP Prime Plans only.
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
• Five (5) business days in advance of any other services requiring pre-authorization.
A Clinical Review Pre-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 1-866-706-6929.
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.
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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 neces-sity determination.
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If requesting pre-authorization for services from a non-participating (out-of-plan) provider:
• ConnectiCare will give authorization only for services that are not available within ConnectiCare's VIP participating provider network.
• You must request pre-authorization - in advance and in writing - to obtain services from a non-participating provider. Such referrals should be made according to the plan and requested by the ConnectiCare referring physician of the like specialty. Send requests in writing via fax to 1-866-706-6929.
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’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 post-decision, peer-to-peer review process and/or choose to appeal the decision. See "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 appeal rights, if applicable, notice of the availability of the Medicare guideline referenced in the decision; and the name and phone number of the physician reviewer who made the decision.
• 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.
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 ConnectiCare or its designated vendor had been aware of the information, the treatment, service, or procedure would not have been authorized. This determination will be made using the same specific standards, guidelines or procedures as used during the pre-authorization review.
Services & Procedures Requiring Pre-Authorization
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Emergency services are not subject to pre-authorization.
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Admission to any facility, including:
• Hospital admissions that are elective or not the result of an emergency, including behavioral health services (mental health and alcohol or substance abuse services)
• Rehabilitation Facility admissions
• Skilled Nursing Facility admissions
• Sub-acute care admissions
Non-emergency Ambulance/Medical Transportation
Behavioral Health Program Services (mental health and alcohol or substance abuse services)
For pre-authorization of all behavioral health services call 1-800-349-5365.
Drugs, Physician Administered
Drugs administered by a health care professional outside of the hospital setting.
Drugs, Prescription
Pre-authorizations of prescription drugs are handled through the Pharmacy Program. For information call 1-877-224-8168.
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The listing of services and procedures that require pre-authorization is subject to change. ConnectiCare will notify you, in advance, of such changes.
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Durable Medical Equipment (DME):
• Electric hospital beds
• Insulin pumps
• Mechanical Stretching Devices
• Power-operated wheelchairs and scooters
• Oral appliance
• Osteogenic stimulators (including spinal, non-spinal and ultrasound)
• Subcutaneous Real Time Continuous Glucose Monitor
• Wound vacs
Prosthetics (arm & leg)
Elective Services & Procedures:
• Abdominoplasty, Panniculectomy
• Artificial Vertebral Disc
• Bariatric surgery
• Blepharoplasty
• Clinical trials (to validate that trial qualifies under Medicare Guidelines)
• Chondrocyte Implantation or Osteochondral Transplantation of the Knee
• Genetic testing
• Gynecomastia surgery
• Hyperbaric oxygen treatment
• Mammoplasty (breast augmentation or reduction)
• Mobile Outpatient Cardiac Telemetry or Ambulatory ECG Monitoring
• Septoplasty (surgery of the nose), except when requested by an Ear, Nose and Throat Specialist
• Sleep apnea surgery (e.g., UPPP, hyoid myotomy, mandibular advancement, osteotomy, tracheostomy)
• Stereotactic radiosurgery (e.g., gamma knife, cyberknife)
• Transplants (organ, stem cell or bone marrow)
• Vagus Nerve Stimulation
• Varicose vein surgery
Home Health Care
Nutritional Supplements
• Formula/enteral food
Out-of-Plan Services:
• All out-of-plan services (non-emergency)
Pulmonary Rehabilitation
Fax requests and clinical information to 1-866-706-6929.
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The ordering physician must seek pre-authorization of these radiological procedures by calling 1-877-607-2363.
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Radiological Services (except for inpatient or emergency services, or when such radiological services are done in conjunction with a biopsy or other surgical procedure):
• Bone Mineral Density exams ordered more frequently than every 23 months
• CT scans (all diagnostic exams)
• MRI/MRA (all examinations)
• Nuclear Cardiology
• PET scans
• Stress Echocardiograms (CPT code 93350)
For pre-authorization of these radiological services only, call 1-877-607-2363 or visit www.radmd.com. If authorization is not obtained, payment for the service may be denied.
Note: Services, supplies or drugs that are considered to be experimental or investigational will not be considered a covered benefit.
