Conn. Agencies Regs. § 17a-453a-13 - Provider contract

(a) DMHAS, in its sole discretion, may extend an offer to contract with a provider who has been credentialed for covered behavioral health services under the GABHP.

(1) A provider who has been credentialed for a covered behavioral health service may not participate in the GABHP unless the provider has executed a contract with DMHAS to deliver a covered behavioral health service to eligible recipients. The contract shall specify the terms and conditions that shall govern the GABHP and to which the contracted provider must adhere in order to participate in the GABHP.

(2) DMHAS shall not pay for covered behavioral health services that are delivered to eligible recipients in the absence of a fully executed contract with DMHAS, unless covered behavioral health services were delivered by an out-of-network provider as specified in section 17a-453a-19 of the Regulations of Connecticut State Agencies.

(b) DMHAS may terminate a contract with a contracted provider after giving the contracted provider a thirty (30) calendar days written notification or such notice as otherwise required by law and regulation. The commissioner, in his or her sole discretion, may terminate the contracted provider's contract for reasons that include, but are not limited to, the following:

(1) Loss, revocation, suspension, surrender or non-renewal of any credential required by section 17a-453a-12 of the Regulations of Connecticut State Agencies, such as the contracted provider's facility license or any other credential required as a condition of eligibility;

(2) The contracted provider has a diminished ability to provide covered behavioral health services legally, including disciplinary action by a governmental agency or licensing board that impairs the contracted provider's ability to practice;

(3) Loss of Drug Enforcement Administration (DEA) certification;

(4) Failure to comply with DMHAS credentialing and re-credentialing requirements and criteria as specified in section 17a-453a-12 of the Regulations of Connecticut State Agencies;

(5) Failure to notify DMHAS of any event that would affect or modify the information contained in the contracted provider's application for participation in the GABHP;

(6) Disciplinary action by any other state, governmental agency or licensing board; and

(7) Termination of, or failure to maintain, adequate malpractice insurance coverage.

(d) Termination reconsideration process:

(1) A provider terminated from participation in the GABHP may request reconsideration of such termination. Such request shall be submitted in writing to the commissioner not more than ten (10) calendar days after the date of receipt of such termination notice;

(2) The commissioner, in his or her sole discretion, shall determine whether to reinstate a provider;

(3) The commissioner may reinstate a provider to participate in the GABHP. Such participation may be subject to conditions and limitations as determined by DMHAS.

(4) Following a decision to terminate a contracted provider's participation or upon the expiration of the ten (10) calendar day period for the provider to request reconsideration of termination, the commissioner shall publish a notice of termination in the Connecticut Law Journal. The commissioner may take any steps necessary to inform the public of the provider's termination from the GABHP.

(e) The commissioner may seek to terminate a contracted provider's contract after giving the contracted provider thirty (30) calendar days' written notice, based upon any of the following circumstances:

(1) Fraud, such as, the contracted provider:

(A) Presents a false claim for payment;

(B) Accepts payment for goods or services delivered that exceeds the amount due for the goods or covered behavioral health services delivered to eligible recipients;

(C) Solicits to deliver or delivers covered behavioral health services for any eligible recipient, knowing that such eligible recipient is not in need of such covered behavioral health services;

(D) Accepts from any person or source other than the GABHP any additional compensation in excess of the amount authorized as specified in section 17a-453a-14 of the Regulations of Connecticut State Agencies; or

(E) Presents a claim for payment to DMHAS or its designated agent for covered behavioral health services that were not delivered to an eligible recipient;

(2) Failure to comply with the terms and conditions established in the contract;

(3) Failure to comply with DMHAS quality management and utilization review, as specified in section 17a-453a-10 of the Regulations of Connecticut State Agencies;

(4) Failure to deliver covered behavioral health services to eligible recipients in an ethical manner;

(5) Neglect of or failure to perform contracted provider duties as specified in the contract with DMHAS;

(6) Failure to implement corrective action required by DMHAS as the result of an audit as specified in section 17a-453a-16 of the Regulations of Connecticut State Agencies; and

(7) Any other breach of the contracted provider's GABHP contract that is not corrected by the contracted provider not later than thirty (30) calendar days after receipt of notice from DMHAS or its designated agent.

(f) If the commissioner seeks to terminate a contracted provider's contract for any reason as specified in subsection (e) of this section, the contracted provider may request an administrative hearing as specified in section 17a-453a-17 of the Regulations of Connecticut State Agencies.

(g) The contract is effective through the date specified in the contract and, if not renewed, it is considered expired without prejudice to the provider.

Notes

Conn. Agencies Regs. § 17a-453a-13

Adopted effective December 7, 2009