Conn. Agencies Regs. § 17a-453a-7 - Continued stay authorization review
(a) The continued
stay authorization review shall determine whether previously authorized covered
behavioral health services continue to be medically necessary. If a contracted
provider determines that additional care may be needed beyond that which has
been authorized for a potentially eligible or eligible recipient, the
contracted provider shall contact the designated agent by telephone not less
than four (4) hours prior to the expiration of the existing authorization for
acute care services and not more than forty-eight (48) hours prior to the
expiration of the existing authorization for other covered behavioral health
services in order to obtain a continued stay authorization.
(b) The contracted provider shall furnish all
information that may be requested by the designated agent for the purpose of
determining continued stay authorization of covered behavioral health services
requested for a potentially eligible or eligible recipient, including, but not
limited to, the following:
(1) Identifying
information;
(2) DSM-IV current
diagnosis or diagnoses;
(3) Level
of care requested;
(4) Clinical
presentation of the potentially eligible or eligible recipient and
justification for the requested covered behavioral health service, including
such factors as mental status, natural supports and strengths;
(5) Recovery plan objectives;
(6) Current symptoms of mental illness or
substance use disorders or both;
(7) Clinical risk assessment and relapse
potential;
(8) Medication(s)
used;
(9) Substance(s)
used;
(10) Whether the potentially
eligible or eligible recipient is voluntarily agreeing to treatment;
(11) Legal status of the potentially eligible
or eligible recipient, if known;
(12) Potentially eligible or eligible
recipient's preference for a covered behavioral health service and contracted
provider;
(13) Treatment
location;
(14) Provisional
discharge or aftercare plan or both;
(15) Projected date of discharge;
(16) Name of the potentially eligible or
eligible recipient's primary care physician, if any; and
(17) All other information that the
designated agent may require.
(c) The decision regarding continued stay
authorization shall be rendered by the designated agent not later than three
(3) hours after the receipt of all information that the designated agent
determines is necessary and sufficient to render a decision.
(d) Upon completion of the review, the
designated agent shall:
(1) Authorize the
requested covered behavioral health service for a specific number of days or
sessions of treatment over a specified time period;
(2) Authorize a different covered behavioral
health service than requested; or
(3) Deny authorization when the information
received by the designated agent does not demonstrate that the requested
covered behavioral health service is medically necessary.
(e) Continued stay authorization of a covered
behavioral health service is not a guarantee that DMHAS will pay a contracted
provider's claim for payment.
Notes
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