Sec. 17b-262-531 - Payment limitations

ยง 17b-262-531. Payment limitations

Payment, by the department, to all providers shall be limited to medically appropriate and medically necessary goods or services furnished to Medical Assistance Program clients. The following payment limitations shall also apply:

(a) the department shall not make payment for any claim for Medical Assistance Program goods or services for persons not eligible for the Medical Assistance Program on the date the good or service is provided, except for those medical services required and requested by the department to determine a person's eligibility for the program;

(b) the department shall not make payment for any Medical Assistance Program goods or services which are not covered under, and furnished in accordance with federal and state statutes and regulations including 42 USC 1396b(f);

(c) the department shall not make an additional payment when a third party payment is equal to or greater than the department's schedule of payment for the same Medical Assistance Program good or service, except to meet the department's obligations as defined by federal and state laws and regulations;

(d) the department shall not make payment for Medical Assistance Program goods or services furnished by a provider after the date of termination of the provider, or during a period of suspension, from the Medical Assistance Program, except as may be determined by the commissioner;

(e) the department shall make payment only to a duly enrolled provider;

(f) the department shall not pay for goods or services that are furnished to providers or clients free of charge;

(g) the department shall not pay for any procedures, goods, or services of an unproven, educational, social, research, experimental, or cosmetic nature; for any diagnostic, therapeutic, or treatment goods or services in excess of those deemed medically necessary and medically appropriate by the department to treat the client's condition; or for services not directly related to the client's diagnosis, symptoms, or medical history;

(h) the department shall not pay for cancelled office visits and appointments not kept;

(i) the department shall make payment only to the provider to whom a client is locked-in, pursuant to section 17-134d-11 of the Regulations of Connecticut State Agencies, except in an emergency;

(j) a provider shall not charge an eligible Medical Assistance Program client, or any financially responsible relative or representative of that individual, for any portion of the cost of goods or services which are covered and payable under the Connecticut Medical Assistance Program. If a client or representative has paid for the goods or services and the client subsequently becomes eligible for the medical assistance program, payment made by or on behalf of the client shall be refunded by the provider to the payer. The provider then may bill the Medical Assistance Program for the goods or services provided. The provider shall obtain appropriate documentation that the payment was refunded prior to the submission of the claim and shall maintain said documentation;

(k) a provider shall not charge for medical goods or services for which a client would be entitled to have payment made, but for the provider's failure to comply with the requirements for payment established by these regulations;

(l) a provider shall only charge an eligible Medical Assistance Program client, or any financially responsible relative or representative of that individual, for goods or services which are not coverable under the Medical Assistance Program, when the client knowingly elects to receive the goods or services and enters into an agreement in writing for such goods or services prior to receiving them;

(m) Refunds by vendors to persons eligible for the medical assistance program shall be in acordance with section 17b-103 of the Connecticut General Statutes. The provider shall obtain and maintain appropriate documentation that the payment was refunded prior to submission of the claim;

(n) a provider shall charge a client a copayment for Medical Assistance Program goods or services only when the department specifically authorizes the provider to collect such copayment from the client;

(o) Any cost used to establish the amount to be reimbursed by the medical assistance program which was incurred by a provider through a related party transaction shall not include any amount in excess of the cost to the related party. Only the actual cost of the product or service to the related party may be used to establish reimbursement by the Medical Assistance Program. Such related party cost shall also meet all other requirements for reimbursement, including, but not limited to, being reasonable and directly related to patient care. For purposes of this section, "related party" is defined as persons or organizations related through an ability to control, ownership, family relationship or business association, and includes persons related through marriage; and

(p) The provider shall be prohibited from reassigning claims in accordance with 42 CFR 447.10.

(Adopted effective February 8, 1999; Amended April 1, 2003)

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