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. Preauthorization of these services is required even when ConnectiCare is the secondary payer. Here’s a listing services and procedures that require preauthorization.
Note: These preauthorization requirements apply to ConnectiCare Medicare Advantage plans only.
Physicians requesting preauthorization must submit their requests in writing and include all supporting clinical information. The preauthorization 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 preauthorization.
Send requests and supporting records to ConnectiCare using the provider portal.
Other providers who are required to seek preauthorization 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 preauthorization for services from a non-participating (out-of-plan) provider:
- ConnectiCare will give authorization only for services that are not available within ConnectiCare's Medicare Advantage participating provider network.
- You must request preauthorization – 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 using the provider portal.
Note: Participating providers may not bill patients for denied claims due to the provider’s failure to obtain preauthorization. Not knowing that a patient has benefit coverage through ConnectiCare is not considered a valid reason for lack of preauthorization.
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 choose to appeal the decision. See "Provider Appeals" 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 preauthorization upon post-service review
ConnectiCare may reverse a preauthorized 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 different from the information that was presented during the preauthorization review; and
- The information existed at the time of the preauthorization 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 preauthorization 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 preauthorization review.
Services and procedures requiring preauthorization
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 preauthorization of all behavioral health services call 800-349-5365.
Drugs, physician administered
Drugs administered by a health care professional outside of the hospital setting.
Drugs, prescription
Preauthorization reviews of prescription drugs are handled through the Pharmacy Program. For information call 877-224-8168.
Durable medical equipment (DME):
- Power mobility devices and scooters
- Oral appliance for the treatment of sleep apnea
- Osteogenic bone growth stimulators (including spinal, non-spinal and ultrasound)
- Ventricular Assist Device
Elective services & procedures:
- Clinical trials (to validate that trial qualifies under Medicare Guidelines)
- Mammoplasty (breast augmentation or reduction)
- Mobile Outpatient Cardiac Telemetry or Ambulatory ECG Monitoring
- Transplants (organ, stem cell or bone marrow)
Genetic testing
With the exception of the list below, all genetic tests require preauthorization.
Preauthorization is not required for:
- Genetic counseling
- FISH testing for lymphoma or leukemia
- Chromosomal Microarray except for prenatal/fetal diagnosis
- Screening for Cystic Fibrosis, Prothrombin, Factor V Leiden, Fragile X and Hereditary hemochromatosis
Home health care
Out-of-plan services:
- All out-of-plan services (non-emergency)
Pulmonary rehabilitation
Use the provider portal to submit clinical information.
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
- Radiation Therapy for the following cancer diagnoses: breast, prostate, lung, colon and rectal cancer
- Stress Echocardiograms (CPT code 93350)
- Stereotactic Radiosurgery
For preauthorization of these radiological services only, call 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.
Preauthorization for inpatient admissions
The following information pertains to admitting members to both participating (in-plan) and non-participating (out-of-plan) inpatient facilities.
If admitting to a PARTICIPATING (in-plan) facility:
- The physician must obtain preauthorization of all elective inpatient admissions at least five (5) business days in advance. (Preauthorization is required even when ConnectiCare is secondary payer.)
- All elective preauthorizations must be requested using the provider portal.
- The hospital should verify that the preauthorization has been obtained by using the provider portal or calling Provider Services at 877-224-8230.
- Physicians, hospitals, or other Health Delivery Organizations (HDOs) should notify ConnectiCare within 24 hours for any emergency or urgent admission. Use the provider portal or call ConnectiCare’s Notification Line at 800-562-6833.
Note: Failure to obtain preauthorization for elective admissions or elective procedures may result in a denial of payment to the participating practitioner and/or provider. The member may not be billed for a claim denied for failure to obtain prior authorization.
If admitting to a NON-PARTICIPATING (out-of-plan) facility:
- Elective admissions to non-participating hospitals are not covered, unless specifically authorized in writing, in advance by ConnectiCare. You must submit your request for an out-of-plan authorization at least five (5) business days in advance of the anticipated admission date.
- ConnectiCare will give authorization only for services that are not available within ConnectiCare’s participating provider network.
Required information for elective inpatient preauthorization
- Member’s name and date of birth
- Member’s address and telephone number
- Member ID number
- Scheduled admission date or estimated date of delivery if obstetrical patient
- Name of hospital/facility
- Admitting provider’s name and ConnectiCare provider ID number
- Primary and secondary diagnoses, using ICD-10 codes
- Reason for hospitalization, using CPT-4 codes, if applicable
Skilled nursing facility admissions
All skilled nursing facility (SNF) admissions for skilled care require preauthorization. You must call 860-409-8951 or 800-451-7784 extension 8951 to request preauthorization. If you are admitting a member for custodial care only, you must still notify ConnectiCare prior to admission. ConnectiCare is required to provide the member with proper notification under the requirements of the Centers for Medicare & Medicaid Services (CMS).
In addition, ConnectiCare will deny admissions to a SNF that is under Denial of Payment of New Admissions (DOPNA) status by CMS or the State of Connecticut. If a member is already in a facility when it goes on a DOPNA status, then we will offer the member the option to transfer to a different SNF.
Providers:
- Must obtain preauthorization for admission to a SNF for rehabilitation in the absence of a hospitalization or acute episode of illness or injury. This admission is subject to medical necessity review.
- Do not have to obtain preauthorization for land ambulance/medical transport from an in-network hospital to an in-network SNF.
What happens next?
- ConnectiCare’s medical director will review the proposed admission and make the determination.
- If the admission meets Medicare guidelines and the request is approved, an authorization number is assigned, and the provider receives a phone call with the authorization number.
- If the admission does not meet Medicare guidelines, you may be asked to advise ConnectiCare of additional indications in support of the admission.
- When a request for authorization is denied, ConnectiCare will notify the member and physician in writing, including: the reason for the determination and clinical rationale, if any; notice of the availability of Medicare guidelines referenced in the decision; information about appeal rights, including how to initiate an appeal, if applicable; notification of the appeals process if the provider and/or member choose to appeal the decision, and the name and phone number of the physician reviewer who made the decision.
- If health services can be provided in more than one medically appropriate setting, it is within ConnectiCare’s discretion to choose the setting for the provision of those services for benefit purposes. In addition, the services must be provided in that setting in order for the member to be eligible for benefit coverage.
- The hospital or other Health Delivery Organization (HDO) must notify ConnectiCare to confirm that a patient who has been preauthorized for an elective inpatient stay has been admitted. Call 800-508-6157 to leave applicable information.
- The hospital or other HDO must notify ConnectiCare in the event of a member signing out against medical advice.
Notice of Medicare Non-Coverage with Appeal Rights
Skilled nursing facilities: Once the last date of covered services is determined, ConnectiCare will fax you the Notice of Medicare Non-Coverage with Appeal Rights at least two days prior to the services not being covered. You are responsible for providing the Notice with Appeal Rights to the member (or legal representative) and obtaining a signature with the date signed. A copy of the signed and dated notice must be faxed to ConnectiCare at 860-674-2831. If you are unable to deliver the notice at least two days prior to the last date of covered services – you must contact ConnectiCare at 800-451-7784.
Home care agencies and comprehensive outpatient rehabilitation facilities: The Notice of Medicare Non-Coverage with Appeal Rights must be provided to the member (or legal representative) at least two days prior to the discontinuation of services. If there is more than a two-day span between services, the notice should be issued the next to last time the services are provided. A copy of the signed and dated notice must be faxed to ConnectiCare at 860-674–5893. If you are unable to provide the notice at least two days prior to the discontinuation of services – you must contact ConnectiCare at 800-451-7784.
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