Conn. Agencies Regs. § 17-134d-56 - Reimbursement of clinic outpatient services and clinic off-site medical services furnished by free-standing clinics

(a) Definitions

(1) "Free-Standing Clinic" means a facility providing medical or medically related clinic outpatient services or clinic off-site services by or under the direction of a physician or dentist and the facility is not part of, or related to, a hospital. Such facilities provide mental health, rehabilitation, dental and medical services and are subject to Sections 171 through 171.4 of the Department's Manual.

(2) In addition to the provisions set forth in the Department's Manual, Section 171B, "Clinic Outpatient Services" means services performed at the clinic, a satellite site, school, or community center.

(3) "Clinic Off-Site Services" means diagnostic, preventive, therapeutic, rehabilitative, or palliative items or services furnished by or under the direction of a physician or dentist employed by or under contract to a free-standing clinic to a Medicaid eligible recipient at a location which is not a part of the clinic. Such locations are the recipient's home, acute care hospital, skilled nursing facility, intermediate care facility, or intermediate care facility for the mentally retarded. Off-site services, as may be restricted by location in accordance with Section (b) of this regulation, include: Mental Health Services, Occupational Therapy Services, Physical Therapy Services, Speech Therapy Services, Audiological Services, Physician's Services, Respiratory Therapy Services, Primary Care Services, and Dental Services. Such services are subject to the provisions of the Department's Manual Sections 171 through 171.4 except as modified by this regulation.

(4) "By or under the direction of a physician or dentist" means a free-standing clinic's services may be provided by the clinic's allied health professionals (as defined in Sections 171.1.B through 171.4.B of the Department's Manual) whether or not a physician is physically present in the clinic at the time that services are provided. The physician:

(A) must assume professional responsibility for the services provided;

(B) assure that the services are medically appropriate, i.e., the services are intended to meet a medical or medically-related need, as opposed to needs which are social, recreational or educational;

(C) need not be on the premises, but must be readily available, meaning within fifteen (15) minutes.

(5) "Outpatient" means a patient of an organized medical facility, or distinct part of that facility who is expected by the facility to receive and who does receive professional services for less than a 24-hour period regardless of the hour of admission, whether or not a bed is used, or whether or not the patient remains in the facility past midnight.

(6) "Plan of Care" means a written individualized plan. Such plan shall contain the diagnosis, type, amount, frequency, and duration of services to be provided and the specific goals and objectives developed and based on an evaluation and diagnosis for the maximum reduction of physical or mental disability and restoration of a recipient to his best possible functional level.

(7) "Satellite Site" means a location separate from the primary clinic facility at which clinic outpatient services are furnished on an ongoing basis meaning with stated hours per day and days per week.

(8) "Home" means the recipient's place of residence which includes a boarding home or home for the aged. Home does not include a hospital, skilled nursing facility, intermediate care facility, or intermediate care facility for the mentally retarded.

(9) "Department's Manual" means the Department of Income Maintenance Medical Services Policy Manual. References to manual sections in this regulation shall mean those sections as they may be amended from time to time.

(10) "Medical or Medically-Related Service" means services which are required in the diagnosis, treatment, care, or prevention of some physical or emotional problem.

(11) "Eligible Person" means a person eligible for the Medical Assistance Program in accordance with Section 17-134b of the General Statutes of Connecticut and regulations promulgated pursuant to Section 17-134d of the General Statutes of Connecticut

(b) Service Limitations

In addition to the provisions set forth in the Department's Manual, Sections 171.1E, 171.2E, 171.3E, 171.4E which are incorporated by reference herein, the following limitations apply:

(1) Clinic outpatient services and clinic off-site services as defined in Section (a) of this regulation which are provided to a resident of a skilled nursing facility, intermediate care facility or intermediate care facility for the mentally retarded, and which are deemed routine services for such facilities are not covered for patients in such facilities. These services may include but are not limited to: occupational therapy services, physical therapy services, audiological services, speech services, respiratory therapy services, routine laboratory and routine radiologic services, consultation services, skilled nursing, other rehabilitative and personal care services;

(2) Reimbursement of a visit for a clinic patient is limited to one (1) per day for the same clinic provider to the same patient involving the same treatment modality, illness or injury regardless of the location at which the service is furnished. Encounters with more than one health professional and multiple encounters with the same health professional employed by or under contract to the same clinic provider that take place on the same day, regardless of the location, constitute a single visit, except when the patient, after the first encounter, suffers a new illness or injury requiring additional diagnosis or treatment.

(3) Clinic off-site services as defined in Section (a) of this regulation which are provided to hospital patients are covered only for services personally performed by clinic-based physicians and dentists who are not providing such services as salaried staff of the hospital.

(c) Need For Service

In addition to the provisions set forth in the Department's Manual, subsections 171.1F.I, 171.2F.I, 171.3F.I, and 171.4F.I, which are incorporated by reference herein, the following conditions apply to clinic outpatient and clinic off-site services:

(1) Such services are performed within the scope of the clinic's license or permit issued under State law; or, within the scope of the accreditation award; whichever applies;

(2) Such services are made a part of the eligible person's individual medical record;

(3) Such services are prescribed by a physician;

(4) Each recipient shall have an individual written plan of care.

(d) Documentation Requirements

(1) A record of each service performed must be on file in the recipient's individual medical record.

Such service record must include, but is not limited to:

(A) the specific services rendered;

(B) the date the services were rendered;

(C) for therapy services, the amount of time it took to complete the session on that date;

(D) the name and title of the person performing the services on that date;

(E) the location at which the services were rendered;

(F) for mental health and rehabilitation clinics, the recipient's individual medical record must contain at least a monthly summary documenting the progress made toward the goals and objectives in accordance with the recipient's plan of care;

(G) for medical and dental clinics the recipient's individual medical record must contain a progress note for each encounter.

(2) All documentation must be entered in ink and incorporated into the patient's permanent medical record in a complete, prompt, and accurate manner. All documentation shall be made available to authorized Department personnel upon request in accordance with Title 42 Section 431.107 of the Code of Federal Regulations. Failure to maintain documentation required in these regulations may result in disallowance of payment for any service for which documentation was not maintained.

(3) Documentation as required in these regulations must be maintained for a minimum of five (5) years.

(4) In the case of clinic off-site services, all individual medical records must be on file at the clinic in the manner prescribed in this subsection.

(e) Prior Authorization

The following services whether performed at the clinic, a satellite site, school, community center, or off-site require prior authorization from the Department as follows:

(1) Individual, group and family psychotherapy or counseling, and parent interviews, provided by mental health clinics in accordance with Section 171.1 of the Department's Manual, in excess of thirteen (13) visits in ninety (90) days or twenty-six (26) visits in six (6) months to the same recipient when performed at the clinic, a satellite site, school, community center, recipient's home, or hospital. The number of visits accumulate regardless of the location where the services are performed;

(2) Individual, group, or family psychotherapy or counseling performed in a skilled nursing facility, intermediate care facility, or intermediate care facility for the mentally retarded, from the date of first treatment;

(3) Individual, group, or family psychotherapy or counseling provided by a rehabilitation clinic, from the date of first treatment, regardless of the location;

(4) Individual, group, or family psychotherapy or counseling provided by mental health clinics to individuals whose etiology stems from alcohol or drug dependence, from the date of first treatment;

(5) Occupational therapy, physical therapy, speech, language, or hearing therapy, and respiratory therapy, from the date of first treatment, regardless of the location;

(6) Partial evaluations and medical check-ups provided by rehabilitation clinics in accordance with the provisions of Section 171.2F of the Department's Manual, regardless of the location;

(7) Complete evaluations, provided by rehabilitation clinics in accordance with the provisions of Section 171.2F of the Department's Manual, regardless of the location;

(8) Dental services in accordance with subsection 171.3 F.II of the Department's Manual;

(9) Day Treatment programs with the exception of Methadone Maintenance Treatment Programs;

(10) Respiratory Therapy.

(f) Other Requirements

(1) Clinics providing medical day treatment programs including, but not limited to: psychiatric; traumatic brain injury; early childhood; substance abuse; and other rehabilitative day programs; are required to furnish all services at the clinic except for a home visit for the purposes of evaluating the recipient's home environment if required by the recipient's plan of care.

(2) In addition to the provider enrollment eligibility provisions set forth in the Department's Manual, Section 120C, which are incorporated by reference herein, the following enrollment requirements pertain to clinics and satellite sites as defined in Section (a) of this regulation.

(A) All clinics and satellite sites operated by clinics established under Section 17-424 of the Connecticut State Statutes must comply with all Department of Children and Youth Services (DCYS) statutory, regulatory and preferred practice requirements and document to the Department DCYS approval of such sites.

(B) All satellite sites operated by clinics licensed by the Department of Health Services (DOHS) must also be approved by the DOHS to provide clinic services at such locations, and document to the Department DOHS approval of such sites.

(C) Rehabilitation clinics operating satellite sites must document to the Department that the clinic has applied for or received accreditation for services at such sites.

(D) All satellite sites operated by dental clinics must have received a permit from the Connecticut State Dental Commission to provide dental services at such locations and document to the Department the Commission's approval of such sites.

(E) All clinics must document to the Department the names and titles of satellite clinical staff and scheduled hours of operation (hours per day/days per week) and description of services provided at such sites.

(F) All such sites must otherwise comply with the provisions of Sections 171 throught 171.4 of the Department's Manual covering clinic services.

(G) In cases in which the clinic has a special arrangement to provide services in another organized facility, the clinic must submit to the Department a copy of a written agreement between the clinic and such facility stipulating the services to be provided at such facility.

(H) There must be adequate private office space in which to conduct direct patient care and treatment and administrative services.

(g) Payment

(1) Clinic outpatient services and clinic off-site services shall be paid in accordance with the provisions set forth in the Department's manual Sections 171.1I, 171.2I, 171.3I, and 171.4I which are incorporated by reference herein.

(2) Travel costs incurred by clinic staff in furnishing clinic outpatient and clinic off-site services as defined in Section (a) of this regulation, are considered to be included in the amount the Department shall pay for such services in accordance with Section 171.1I, 171.2I, 171.3I and 171.4I of the Department's Manual.

(3) All payments that are made utilizing the fee schedule shall be made in accordance with the fee schedule in effect on the date the service is furnished.

Notes

Conn. Agencies Regs. § 17-134d-56

Effective December 11, 1989