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Coverage guidelines

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Coverage guidelines

Commercial
Medicare

Health care management decisions

Health care treatments, drugs and supplies that are not part of the member’s benefit plan or are not medically necessary are not covered. We determine if a treatment, drug or supply is medically necessary and, therefore, covered. Additionally, if health services can be provided in more than one medically appropriate setting, ConnectiCare may determine which setting is eligible for benefit coverage and the health services must be provided in that setting in order for the member to be eligible for benefit coverage. These benefit determinations are made through various health care management procedures, including pre-service review, concurrent review, inpatient hospital readmission review, post-service review, and a reconsideration process.

Note: ConnectiCare reserves the right to use third-party vendors to administer benefits, including utilization management services.

Pre-service review (before services are rendered)

Pre-admission certification for elective hospitalization
Preauthorization for medical necessity of selected elective surgical procedures inpatient and outpatient
Preauthorization for elective care from out-of-network providers (excluding Point-of-Service plans)
Preauthorization for non-acute facility admissions (sub-acute, skilled nursing facility, hospice, etc.), home health care, durable medical equipment (DME)
Preauthorization for prescriptions and injectable medications

Note: Admission to a skilled nursing facility for rehabilitation, in the absence of a preceding hospitalization or acute episode of illness or injury, requires preauthorization and is subject to medical necessity review.

Concurrent review (while services are being rendered)

Evaluation of discharge readiness based on utilizing nationally recognized criteria received during an inpatient admission
Assessment of appropriateness of site for care; including the medical necessity of emergency/urgent admissions
Facilitation of care delivery throughout the continuum of care

Inpatient hospital readmission review

Review resulting from a member who is discharged from a hospital and is then readmitted to the same hospital or same hospital network within View our complete Hospital Readmission Policy

Post-service review (after services are rendered)

Review of clinical information for medical necessity and appropriateness of service

Peer to peer process (upon an adverse medical determination)

Review by the clinical peer reviewer who made the initial adverse determination, only upon request by the physician who originally requested approval of the services

Decision-making check financial incentives policy

When health care management decisions are made, they are based on the member’s benefit plan and the appropriateness of the proposed health care treatments, drugs and supplies for that member. We do not reward practitioners or other individuals conducting utilization review for issuing denials of coverage for health care treatments, drugs, and supplies. We offer no incentives to promote decision making that would result in inappropriate denials of services.

We will make non urgent pre-service determinations within 15 business days from receipt of the request. ConnectiCare will notify the member and the attending physician of the decision in writing. For questions about preauthorization of procedures, 1-800-562-6833.

When an adverse determination has been issued, providers have the right to the following:

• Provider Appeals Process

Note: Utilization managers are also available for other Utilization Management questions from 8 a.m. to 5 p.m., Monday – Friday at 1-800-562-6833. After hours, please leave a voicemail message.

PPM/10.16

Preauthorization 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. Preauthorization of these services is required even when ConnectiCare is the secondary payer. For a listing of services and procedures that require preauthorization, refer to this preauthorization list.

Physicians requesting preauthorization must make 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 and any services requiring preauthorization (even when ConnectiCare is secondary payer)

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 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-network) 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
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

PPO plans do not require any preauthorization

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. The provider may utilize ConnectiCare’s Peer to Peer process and/or choose to appeal the decision. See Peer to Peer Process and/or 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 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 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 materially different from the information that was presented during the pre-authorization 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 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 preauthorization review.

PPM/10.16

Pre-service review

Pre-service review: Inpatient admissions

The following information pertains to admitting members to both participating (in-network) and non-participating (out-of-network) inpatient facilities.

If admitting to a PARTICIPATING (in-network) 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 during normal business hours.
The hospital should verify that the preauthorization has been obtained by calling Provider Services at 1-800-828-3407.
Physicians, hospitals, or other Health Delivery Organizations (HDOs) should notify ConnectiCare within twenty-four (24) hours for any emergency or urgent admission. Call ConnectiCare’s Notification Line at 1-800-562-6833.

Note: Failure to obtain prior authorization 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-network) facility:

Elective admissions to non-participating hospitals are not covered, unless specifically authorized in writing, in advance by ConnectiCare, or, if the member has a Point-of-Service or PPO Plan. You must submit your request for an out-of-network 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, unless the member has a Point-of-Service or PPO Plan.

Exception: If they choose, members with a Point-of-Service, PPO, or FlexPOS benefit design may exercise their option to access out-of-plan hospitals without preauthorization. This subjects the member to both out-of-network benefit levels and additional benefit reduction. In addition, the member is responsible for obtaining any necessary preauthorization approvals. Member ID cards clearly identify the Point-of-Service product. Ask members to call Member Services at 1-860-674-5757 or 1-800-251-7722 if they have any questions about their benefits.

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

If you admit a member to a skilled nursing facility (SNF) on a weekend or holiday, ConnectiCare will automatically authorize payment from the day of admission through the next business day. However, ConnectiCare will not automatically pay for admission to a SNF for rehabilitation in the absence of a hospitalization or acute episode of illness or injury. These admissions require pre-authorization during regular business hours and are subject to medical necessity review.
You must call ConnectiCare’s Notification Line at 1-800-562-6833 to advise us of the admission. This line is available twenty-four (24) hours/day, seven (7) days/week. If you do not inform ConnectiCare according to these guidelines, the SNF may not receive payment for any additional days of the member’s stay.
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?

As appropriate, ConnectiCare’s medical director may review the proposed admission and make the determination.
If the admission meets accepted criteria for medical necessity and place of service, and the request is approved, a case number is assigned.
If the admission does not meet established criteria, 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; instructions on how to initiate an appeal of the decision; notice of the availability of clinical review criteria referenced in the decision; general information on external appeal rights, including how to initiate an external 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. Refer to the Provider Appeals process for detailed information regarding appeals.

Note: External appeal may only be available only after the internal appeal process has been exhausted.

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 ConnectiCare’s Notification Line at 1-800-562-6833 to leave applicable information.
The hospital or other HDO must notify ConnectiCare in the event of a member signing out against medical advice.

Note: Providers are expected to provide inpatient reviews upon request, even when ConnectiCare is the secondary carrier for the member.

PPM/10.16

Concurrent review

ConnectiCare approves a length of stay based upon medical necessity on a concurrent review basis. Inpatient care and home care services are subject to concurrent review, which is conducted by a ConnectiCare case manager or designee over the telephone or through direct medical chart review. ConnectiCare uses nationally recognized medical necessity criteria for medical surgical/acute care admissions, skilled nursing/sub-acute admissions, home health care services, and observation level of care.

If you have any questions or would like a copy of the criteria specific to a member’s condition, please contact the utilization manager with whom you are working, or call 1-800-562-6833.

Although concurrent review activity involves the facility or agency utilization review departments, physicians are frequently contacted for information and assistance in developing a discharge plan that facilitates the delivery of services in the most appropriate setting. The attending physician is contacted for more information when it appears that the member’s condition does not meet continued stay criteria. If the intensity of services or severity of illness of the member does not support a continued stay at the current level of care a ConnectiCare medical director will review the case. If the authorized length of stay has expired before a continuance is approved, the member may not be held responsible for the fees associated with such services, unless the member was otherwise notified in writing by ConnectiCare in advance.

Note: Practitioners and other providers are expected to comply with inpatient reviews upon request, even when ConnectiCare is the secondary carrier for the member.

Per federal Department of Labor and NCQA timeliness standards, ConnectiCare will issue a decision for a concurrent review within twenty-four (24) hours of the request. If ConnectiCare makes an attempt to obtain the needed clinical information in this twenty-four (24) hour period and the information is not provided, ConnectiCare is still required to issue a determination. In this case, ConnectiCare will issue a determination based on the information already made available. If clinical information is requested by ConnectiCare and it is not provided within one business day of request, ConnectiCare may issue an administrative denial due to lack of information for date of service requested.

In addition, circumstances may occur during a hospital/facility admission in which the patient’s care or treatment is delayed by scheduling problems, delays in getting needed evaluations or consultations, delays in discharge planning, the unavailability of hospital/facility services over the weekend or on holidays, or other administrative delays. These cases will also be reviewed by a ConnectiCare medical director for determination of authorization of payment.

If the delay in discharge results from a facility’s delay in providing needed services, attending physicians will be compensated for their services during this time.

However, if the delay in discharge is due to a decision or lack of action by the attending physician, that physician will not be compensated for days not authorized.

What happens next?

ConnectiCare’s medical director will review the request for continued stay and make the determination.
If the decision results in extending coverage, the notification will include the number of extended services approved, the new total of approved services, the date of onset of the services, and the next review date.
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. In addition, the services must be provided in that setting in order for the member to be eligible for benefit coverage.
If the medical director determines that continued payment for the facility stay cannot be authorized, the attending physician will be notified by phone or fax and will also receive written confirmation. If upon review of clinical documentation the medical director does not approve the day(s), you may utilize their Peer to Peer process and/or appeal the decision. See "Provider Appeals Process" for additional information attached with the letter 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.

Medicare PPM/10.16

Post-service review

ConnectiCare’s Medical Operations Department conducts post-service reviews on unauthorized elective admissions and emergency admissions of which ConnectiCare was not notified or services that required preauthorization where none was obtained. If a claim is submitted without preauthorization or deemed not to be a true emergency, ConnectiCare may issue an administrative denial for failure to meet the plan’s administrative requirements related to notification.

PPM/10.16

Medical management program

Health care management decisions

Health care treatments, drugs and supplies that are not part of the member’s benefit plan or are not reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve function are not covered. We determine if a treatment, drug or supply is medically necessary and, therefore, covered. Additionally, if health services can be provided in more than one medically appropriate setting, ConnectiCare may determine which setting is eligible for benefit coverage and the health services must be provided in that setting in order for the member to be eligible for benefit coverage. These benefit determinations are made through various health care management procedures, including pre-service review, concurrent review, inpatient hospital readmission review, and post-service review.

All providers must cooperate with the decisions, rules and regulations established by ConnectiCare's Quality Improvement and Utilization Management Programs. ConnectiCare works with an independent quality improvement organization to develop quality improvement and utilization management programs to ensure compliance with federal standards.

Note: ConnectiCare reserves the right to use third-party vendors to administer benefits, including utilization management services.

Pre-service review (before services are rendered)

Pre-admission certification for elective hospitalization
Preauthorization for medical necessity of select elective surgical procedures
Preauthorization for elective care from out-of-plan providers
Preauthorization for non-acute facility admissions (sub-acute, skilled nursing facility, hospice, etc.), home health care, Durable Medical Equipment (DME)

Note: Admission to a skilled nursing facility (SNF) for rehabilitation, in the absence of a preceding hospitalization or acute episode of illness or injury, requires preauthorization and is subject to medical necessity review.

Concurrent review (while services are being rendered)

Evaluation of discharge readiness based on severity of illness and intensity of services received during an inpatient admission
Assessment of appropriateness of site for care, including the medical necessity of emergency/urgent admissions
Facilitation of care delivery throughout the continuum

Inpatient hospital readmission review

When a member who is discharged from a hospital is readmitted to the same hospital or same hospital network within thirty (30) days, a ConnectiCare utilization manager will review the case to determine if the readmission is related to the original inpatient stay.

View our complete Hospital Readmission Policy

Post-service review (after services are rendered)

Review of clinical information for medical necessity and appropriateness of service

Decision-making
When health care management decisions are made, they are based on the member’s benefit plan and the appropriateness of the proposed health care treatments, drugs and supplies for that member. We do not reward practitioners or other individuals conducting utilization review for issuing denials of coverage for health care treatments, drugs, and supplies. We offer no incentives to promote decision making that would result in inappropriate denials of services.

We will make preauthorization and pre-service determinations in a timeframe that is compliant with Centers for Medicare & Medicaid Services (CMS) regulations. ConnectiCare will notify the member and the attending physician of the decision in writing. For questions about preauthorization of procedures, call 1-800-508-6157.

When an adverse determination has been issued, providers have the right to the following:

Provider appeals process

Note: Case managers are also available for other Utilization Management questions from 8 a.m. to 5 p.m., Monday through Friday at 1-800-508-6157. After hours, please leave a voicemail message.

Medicare PPM/2.12

Preauthorization requirements

Preauthorization 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. 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.

A Clinical Review Preauthorization 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 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 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 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 & 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 1-800-349-5365.

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 1-877-224-8168.

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

Fax requests and clinical information to 1-866-706-6929.

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 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.

Medicare PPM/7.15

Pre-service review

Pre-service review: 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 during normal business hours.
The hospital should verify that the pre-authorization has been obtained by calling Provider Services at 1-877-224-8230.
Physicians, hospitals, or other Health Delivery Organizations (HDOs) should notify ConnectiCare within twenty-four (24) hours for any emergency or urgent admission at 1-800-508-6157.

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 1-860-409-8951 or 1-800-451-7784 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 1-800-508-6157 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 1-800-451-7784.

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 1-860-674–5893. If you are unable to provide the notice at least two days prior to the discontinuation of services – you must contact ConnectiCare at 1-800-451-7784.

Medicare PPM/8.14

Concurrent review

Concurrent review

ConnectiCare approves a length of stay based upon medical necessity on a concurrent review basis. Inpatient care and home care services are subject to concurrent review, which is conducted by a ConnectiCare case manager or designee over the telephone or through direct medical chart review. ConnectiCare uses Medicare guidelines for medical surgical/acute care admissions, skilled nursing/sub-acute admissions, home health care services, and observation level of care.

If you have any questions or would like a copy of the guideline specific to a member’s condition, please contact the case manager with whom you are working, or call 1-800-508-6157.

Although concurrent review activity involves the facility or agency utilization review departments, physicians are frequently contacted for information and assistance in developing a discharge plan that facilitates the delivery of services in the most appropriate setting. The attending physician is contacted for more information when it appears that the member’s condition does not meet continued stay criteria. If the intensity of services or severity of illness of the member does not support a continued stay at the current level of care, the applicable physician organization’s medical director or a ConnectiCare medical director will review the case. If the authorized length of stay has expired before a continuance is approved, the member may not be held responsible for the fees associated with such services, unless the member was otherwise notified in writing by ConnectiCare in advance.

Note: Practitioners and other providers are expected to comply with inpatient reviews upon request, even when ConnectiCare is the secondary carrier for the member.

ConnectiCare will issue a decision in a timeframe consistent with federal regulation for a concurrent review. If ConnectiCare makes an attempt to obtain the needed clinical information in this timeframe and the information is not provided, ConnectiCare is still required to issue a determination. In this case, ConnectiCare will issue a determination based on the information already made available. An administrative denial may be issued if information was requested but not submitted within this twenty-four (24) hour period.

In addition, circumstances may occur during a hospital/facility admission in which the patient’s care or treatment is delayed by scheduling problems, delays in getting needed evaluations or consultations, delays in discharge planning, the unavailability of hospital/facility services over the weekend or on holidays, or other administrative delays. These cases will also be reviewed by the applicable physician organization medical director or a ConnectiCare medical director for determination of authorization of payment to the hospital/facility and physician.

If the delay in discharge results from a facility’s delay in providing needed services, attending physicians will be compensated for their services during this time.

However, if the delay in discharge is due to a decision or lack of action by the attending physician, that physician will not be compensated for days not authorized.

What happens next?

ConnectiCare’s medical director will review the request for continued stay and make the determination.
If the decision results in extending coverage, the notification will include the number of extended services approved, the new total of approved services, the date of onset of the services, and the next review date.
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. In addition, the services must be provided in that setting in order for the member to be eligible for benefit coverage.
If the medical director determines that continued payment for the facility stay cannot be authorized, the attending physician will be notified by phone or fax and will also receive written confirmation. If upon review of clinical documentation the medical director does not approve the day(s), you may utilize the reconsideration process and/or 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 external appeal rights, if applicable; 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.

Medicare PPM/1.12

Inpatient hospital readmission review

Inpatient hospital readmission review

Medicare PPM/10.18

Post-service review

Post-service review

ConnectiCare's Medical Operations Department conducts post-service reviews on unauthorized elective admissions and emergency admissions of which ConnectiCare was not notified or services that required preauthorization where none was obtained. If a claim is submitted without preauthorization, ConnectiCare may issue an administrative denial for failure to meet the plan’s administrative requirements related to prior approval or notification.

Medicare PPM/2.10

provider

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Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.