Sec. 17b-262-532 - Payment for out-of-state goods or services

ยง 17b-262-532. Payment for out-of-state goods or services

(a) Pursuant to 42 CFR 431.52, payment for Medical Assistance Program goods or services furnished to clients while they are out-of-state shall be made by the department to the same extent as payment is made to in-state providers, unless otherwise specified in state statutes or regulations which govern the provider's assigned type and specialty, only when any of the following conditions is met:

(1) Medical Assistance Program goods or services are needed by a client because a medical emergency occurred while the client was outside of the state;

(2) Medical Assistance Program goods or services are needed because a client's health would be endangered if required to travel to Connecticut;

(3) the department determines that the Medical Assistance Program goods or services are[more readily] available only in another state and prior authorization was granted to the provider; or

(4) it is general practice for clients in a particular locality of Connecticut to use the medical resources in a bordering state. The department shall allow providers, who are designated by the department to be border providers, to be treated in the same manner as in-state providers.

(b) In addition, payment for Medical Assistance Program goods or services furnished to clients while they are out-of-state shall be made to the same extent as payment is made to in-state providers when:

(1) enrollment is for copayment or deductible of a Medicare claim; and

(2) a child for whom the department makes adoption assistance or foster care maintenance payment resides outside of Connecticut, or an individual approved to attend school out-of-state resides in Connecticut.

(c) In order to be paid for goods or services, out-of-state providers shall enroll in the Connecticut Medical Assistance Program.

(d) Out-of-state pharmacies rendering services in-state to clients shall:

(1) participate in on-line point of sale and prospective drug use review claims processing; and

(2) pursuant to section 20-627 of the Connecticut General Statutes, out-of-state pharmacy providers shall, when doing business in Connecticut, receive a certificate of registration from the Department of Consumer Protection, upon approval of the Commission of Pharmacy, and provide a toll-free telephone number disclosed on labels for drugs dispensed in Connecticut.

(e) For payment for emergency services, providers shall be required to submit a claim and applicable medical emergency room reports, discharge summaries, or other documentation as determined by the department which confirms the emergency.

(f) In most cases, enrollment shall be for dates of service or provision of goods only. An exception to this rule may apply to providers of goods or services to children for whom the department makes adoption assistance or foster care maintenance payments who reside outside of Connecticut, or individuals approved to attend school out-of-state who reside in Connecticut. In these situations, a provider shall not be required to submit a claim to initiate the enrollment process. The provider shall indicate the name of the child or individual for whom it shall be providing services at the time of enrollment.

(g) Timely filing requirement shall be the same for out-of-state providers as for in-state providers except that the date of first contact with the department's fiscal agent to become enrolled in the Medical Assistance Program or to submit a claim shall be within twelve months of the date of provision of the service or delivery of the good.

(h) Pursuing other third party liabilities shall be the same for out-of-state providers as for in-state providers.

(i) Out-of-state independent laboratories, border hospitals, and physician groups having admitting privileges in a border hospital shall be exempt from the out-of-state criteria delineated in subsection (a) of section 17b-262-532 of the Regulations of Connecticut State Agencies. All other border providers shall be considered for enrollment in the Medical Assistance Program on a case-by-case basis.

(j) The Medical Assistance Program shall not cover out-of-state long-term care services unless such services are not available in the state of Connecticut and receive prior authorization from the department.

(k) Out-of-state providers shall, upon request of authorized department representatives, make available fiscal and medical records as required by applicable Medical Assistance Program regulations and the provider agreement. Such records shall be made available for review by authorized department representatives at a location within the State of Connecticut.

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

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