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Clinical Information
Guidance and Support
- Commercial
- Medicare
Mental health and substance abuse treatment is covered, when medically necessary, through ConnectiCare’s Behavioral Health Program for most members. Treatment for these services must be pre-authorized by the Behavioral Health Program. If you are coordinating mental health/substance abuse services on behalf of a ConnectiCare member, please contact the program at the number below:
ConnectiCare’s Behavioral Health Program
- This number may vary for some Customized (self-funded) plans.
PPM/10.16
Bone marrow and organ transplants are covered when established criteria for medical necessity are met. Covered organ transplants may include, but are not limited to cornea, heart, heart-lung, kidney, liver, lung, pancreas, pancreas-kidney and bone marrow transplants, depending on the member’s benefit plan. All requests for organ transplants, except corneal transplants, require pre-authorization prior to any referral. Pre-authorize bone marrow or organ transplant services with ConnectiCare as soon as the patient’s needs are known, prior to any evaluative services.
Services are available at participating facilities, including contracted centers of excellence. To obtain a listing of participating transplant facilities, call 1-860-674-5860 or 1-800-562-6833.
Exception: Members covered under a ConnectiCare of Massachusetts, Inc. plans may have access to out–of–network facilities.
Request services in writing from ConnectiCare’s Medical Operations Department by faxing us at: 1-860-674-5893 or 1-800-923-2882.
Next steps:
- The utilization manager will request clinical documentation. Upon receipt, the utilization manager will review the documentation with ConnectiCare’s medical director to determine medical necessity and benefit coverage.
- The utilization manager or medical director may discuss the determination with you by phone and will follow up with a written determination
PPM/10.16
Maternity pre-certification
Maternity coverage may vary by product. Refer to Member Services at 1-800-251-7722 for determination of coverage. |
Physicians should pre-certify patients with ConnectiCare before 16 weeks of gestation or as soon as possible after 16 weeks of gestation. Please use the Maternity Pre-Certification Form to pre-certify for delivery.
ConnectiCare clinical review
- Fax the pre-certification form to 1-860-674-5893 or 1-800-923-2882
or, call Clinical Review at 1-800-562-6833.
To arrange for post-delivery services, please call (following delivery or the next business day following delivery):
- ConnectiCare Baby Line
1-888-935-2229
Post-discharge services:
- Preauthorization is required.
- Labor support doulas are a benefit exclusion. Refer to member's plan document.
Lactation Consultant: Lactation consult is for members who are experiencing difficulties breast feeding.
- Lactation Consultant must be certified by the International Board of Lactation Consultants (IBLC)
- Pre-authorization is not required.
- Coverage consists of ome home visit and must be used within two months of delivery regardless of vaginal/cesarean delivery or duration of hospital stay.
- Member is required to pay for services and then submit a claim to ConnectiCare for reimbursement. (covered at 100%).
Type of delivery |
Mandated benefit: |
Optional Early Discharge Program: Vaginal delivery with less than 48 hours length of stay after delivery. |
Value Added : Vaginal inpatient stay after delivery is 1 night or less. |
Vaginal delivery |
• 1 skilled nursing visit by a maternal child health nurse from a Home Health Agency (requires pre-authorization from ConnectiCare) |
• 2 skilled nursing visits by a maternal child health nurse from a home health agency within two weeks of the delivery (requires Preauthorization from ConnectiCare) |
• 2 skilled nursing visits by a maternal child health nurse |
Cesarean delivery |
• No skilled nursing visits unless medically indicated |
• 1 lactation consultant visit at home up to 2 months postpartum |
• 2 skilled nursing visits by a maternal child health nurse • 1 lactation consultant visit at home up to 2 months post partum |
PPM/07.18
ConnectiCare participates in a kidney stone testing and prevention program offered by Litholink Corp. Litholink is a metabolic testing laboratory focused exclusively on prevention of recurrent kidney stones. ConnectiCare encourages members who have had two or more acute episodes of renal stones in the past two years to participate. ConnectiCare also encourages physicians to refer patients to the program. To enroll a patient in the Litholink Program, or to find out more information, call them at 1-800-338-4333.
PPM/10.16
The Transplant Case Management Program is designed to provide ConnectiCare members and their families with education, support and advocacy during the pre-intra- and post-transplant period (for up to one year after organ or bone marrow transplantation). A registered nurse with experience in transplant management conducts telephonic outreach to these members to aid them in obtaining and coordinating necessary health care services, while helping to maximize health care benefits. The nurses are a resource regarding transplants, cost issues, community resources, and care options.
PPM/10.16
Provider appeals are those where the provider, rather than the member, will be financially liable for the services rendered. Providers may submit their appeals of a denial orally, electronically, by facsimile, or in writing to ConnectiCare's Provider Appeals Department or Member Appeals Department. The appeal must be made as soon as possible after the denial, but no later than 180 days after the provider was notified of the denial. There are two types of provider appeals:
Administrative Appeals
(i.e., denials that are based on failure to follow a ConnectiCare administrative requirement)
Administrative appeals will be reviewed and a decision will be given within 90 calendar days of the appeal request. Send provider administrative appeals to:
ConnectiCare Provider Appeals
175 Scott Swamp Road
Farmington, CT 06032
Phone: 1-800-828-3407
Fax: 1-860-674-7035
Medical Appeals
(i.e., those where the denial of payment is based on medical necessity criteria)
| Providers may also appeal a medical necessity decision on behalf of a member. Details about how to appeal on behalf of a member are provided with the initial notification of denial. |
Provider medical appeals will be decided within 30 calendar days of receipt, unless additional information is required. In such cases, you will be notified of the need for additional information within 7 calendar days, and a decision will be made within 30 calendar days of our receipt of complete information, but no later than 45 business days from receipt of the appeal.
For provider medical appeals, a physician of the appropriate specialty, who was not previously involved in the case, will review the appeal and will render the final determination. Provider appeals receive only one level of review. Send provider medical appeals to:
Provider Appeals
P.O. Box 4061
Farmington, CT 06034-4061
Phone: 1-800-828-3407
Fax: 1-860-674-2866 or 1-800-313-0089
If the denial is upheld on appeal, the final adverse determination notice shall include the reason for the determination and clinical rationale; general information on the external appeal process (if applicable), including instructions on how to initiate an external appeal.
PPM/10.16
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.
Please click here for our complete Hospital Readmission Policy
Pleaes note, elective admissions require preauthorization.
PPM/10.16
Kidney Resource Services (KRS) helps ConnectiCare members manage their kidney disease by providing them with telephonic case management services by specialized renal-trained registered nurse consultants. Members with a diagnosis of chronic kidney disease (CKD), end stage renal disease (ESRD), or are receiving dialysis at a dialysis facility or at home qualify for the Kidney Resource Case Management Program. Members can be co-managed with the transplant program. To enroll a patient in the Kidney Resource Program, or to find out more information, call them at 1-866-897-1038.
PPM/10/16
Peer-to-peer process for all ConnectiCare plans in Connecticut (including plans sold through Access Health CT, the state insurance exchange)
ConnectiCare offers participating practitioners a peer-to-peer process when an adverse medical determination has been issued. Providers may request a peer-to-peer conference within a two-week period following the date of the notice of adverse determination provided that an appeal has not been initiated. The peer-to-peer shall occur between the practitioner requesting approval of the service and the clinical peer reviewer who made the initial adverse determination. If the adverse determination is not reversed after the peer-to-peer process, providers or members may pursue the provider appeals process. Please note, the peer-to-peer process is not a prerequisite to the appeals process. Requests for peer-to-peer that are initiated more than two-weeks after the initial notification of adverse determination will be processed as appeals.
Reconsideration process for all ConnectiCare plans in Massachusetts
ConnectiCare offers providers a reconsideration process when an adverse determination has been issued during a clinical peer review, whether such adverse determination was given during an initial or a concurrent review. That reconsideration process shall take place within one (1) working day after ConnectiCare receives the provider’s request. The reconsideration process shall involve the provider rendering the service and the clinical peer reviewer who made the initial adverse determination or, if the reviewer is not available, the reviewer’s clinical peer designee. If the adverse determination is upheld, the member, or the provider on behalf of the member, may then follow the grievance process through the formal provider appeals process. Please note, the reconsideration process is not a prerequisite to the formal internal grievance process or expedited appeal.
What happens next after the peer-to-peer process or the reconsideration process?
- ConnectiCare’s medical director will review the request and make the determination.
- If ConnectiCare upholds the initial adverse determination, providers will be notified verbally. Providers then may use the appeals process as outlined in the provider appeals process. However, members may not be billed for services denied under this process.
- For determinations that were upheld, the initial adverse determination letter to the provider serves as notification and 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.
PPM/06.18
Clinical Practice Guidelines
Information and practice standards for treating some of the more common chronic conditions.
Preauthorization Lists
A complete listing of services and procedures that require preauthorization.
Pharmacy and Prescribing Information
Find information on ConnectiCare’s pharmacy programs and more.
Special Programs
Learn about radiation oncology preauthorization and benefit management services.
Transplant Case Management Program
The Transplant Case Management Program is designed to provide ConnectiCare members and their families with education, support and advocacy during the pre-intra- and post-transplant period (for up to one year after organ or bone marrow transplantation). A registered nurse with experience in transplant management conducts telephonic outreach to these members to aid them in obtaining and coordinating necessary health care services, while helping to maximize health care benefits. The nurses are a resource regarding transplants, cost issues, community resources, and care options. For additional information call 1-800-508-6157.
Medicare Case Management Program
Through this program we identify members with special needs who would most benefit from direct intervention in their case, before their health condition or living situation deteriorates. The primary focus is on assessment, triage, and follow up. This is accomplished through comprehensive telephonic assessment of the member's medical and functional status and development of a plan of care to include health coaching and care coordination. For additional information, call 1-800-509-3181.
MEDICARE PPM/3.11
Mental health and substance abuse treatment is covered, when medically necessary, through ConnectiCare’s Behavioral Health Program for most members. Treatment for these services must be pre-authorized by the Behavioral Health Program. If you are coordinating mental health/substance abuse services on behalf of a ConnectiCare member, please contact the program at the number below:
ConnectiCare’s Behavioral Health Program
1-800-349-5365
Medicare PPM/2.10
Bone marrow and organ transplants are covered when Medicare guidelines for medical necessity and the appropriateness of the patient are met.
All requests for organ transplants, except corneal transplants, require pre-authorization prior to any referral for patient appropriateness determination.
Pre-authorize bone marrow or organ transplant services with ConnectiCare as soon as the patient’s needs are known, prior to any evaluative services.
Services are available at Medicare-approved transplant facilities. To obtain a listing of participating transplant facilities or to pre-authorize a transplant, call 1-800-508-6157.
What happens next?
- The case manager will request clinical documentation. Upon receipt, the case manager will review the documentation with ConnectiCare’s medical director to determine medical necessity and benefit coverage.
- The case manager or medical director may discuss the determination with you by phone and will follow up with a written determination.
Medicare PPM/3.11
Maternity pre-certification
Physicians should pre-certify patients with ConnectiCare before sixteen (16) weeks of gestation or as soon as possible after sixteen (16) weeks of gestation. To pre-certify for delivery and arrange for post-delivery services:
Call the ConnectiCare Utilization Management at 1-800-508-6157
or, fax the pre-certification form to 1-866-706-6929.
Note: As a courtesy to our members, physicians should also notify ConnectiCare of pregnancy loss. This will help prevent us from inappropriately contacting the member for case management purposes and sending additional pregnancy-related information.
Medicare PPM/8.12
Provider appeals are those where the provider will be financially liable for the services rendered. Providers may submit their appeals of a denial orally, electronically, by facsimile, or in writing to ConnectiCare's Provider Appeals Department or Member Appeals Department. The appeal must be made as soon as possible after the denial, but no later than 180 days after the provider was notified of the denial. There are two types of provider appeals:
Administrative appeals
(i.e., denials based on failure to follow a ConnectiCare administrative requirement)
Administrative appeals will be reviewed and a decision will be given within 90 calendar days of the appeal request. Send provider administrative appeals to:
Provider Appeals Department
ConnectiCare
175 Scott Swamp Road
Farmington, CT 06032-3124
Medical appeals
(i.e., those where the denial of payment is based on medical necessity criteria)
Medical appeals will be decided within 30 calendar days of receipt, unless additional information is required. In such cases, you will be notified of the need for additional information within 7 calendar days, and a decision will be made within 30 calendar days of our receipt of complete information, but no later than 45 business days from receipt of the appeal.
For provider medical appeals, a physician of the appropriate specialty, who was not previously involved in the case, will review the appeal and will render the final determination. Provider appeals receive only one level of review. Send provider medical appeals to:
ConnectiCare
P.O. Box 4061
Farmington, CT 06034-4061
If the denial is upheld on appeal, the final adverse determination notice shall include the reason for the determination and clinical rationale, and notice of availability of clinical review criteria referenced in the decision.
Providers may also appeal a medical necessity decision on behalf of a member. Details about how to appeal on behalf of a member are provided with the notice of adverse determination, delivered to the member.
MEDICARE PPM/2.10
Clinical Practice Guidelines
Information and practice standards for treating some of the more common chronic conditions.
Preauthorization Lists
A complete listing of services and procedures that require preauthorization.
Special Programs
Learn about radiation oncology preauthorization and benefit management services.
Pharmacy and Prescribing Information
Find information on ConnectiCare’s pharmacy programs and more.
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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.