Sec.17a-453a-14. Administration of contracted providers' claims for payment

(a) Contracted providers shall only be paid for covered behavioral health services that:

(1) Are delivered to eligible recipients; and

(2) The contracted provider received all applicable prior authorization, continued stay authorization and alternative authorization as specified in sections17a-453a-6 through 17a-453a-8 of the Regulations of State Agencies, concerning the delivery of covered behavioral health services to eligible recipients.

(b) Contracted providers' claims for payment shall only be considered for covered behavioral health services that:

(1) Are delivered during time period in which the individual was determined eligible by DSS for medical services pursuant to section 17b-192 of the Connecticut General Statutes; or

(2) Are delivered during the time period in which the individual was determined retroactively eligible by DSS for medical services pursuant to section 17b-192 of the Connecticut General Statutes.

(c) The contracted provider shall verify that DSS has determined the individual eligible for medical services pursuant to section 17b-192 of the Connecticut General Statutes, unless the contracted provider is submitting a claim for payment as specified in (b)(2) of this section.

(d) Each claim for payment shall contain evidence that the contracted provider complied with all applicable prior authorization, continued stay authorization and alternative authorization requirements as specified in sections 17a-453a-6 through 17a-453a-8 of the Regulations of the Connecticut State Agencies.

(e) The contracted provider shall file claims for payment not later than 180 calendar days after the date on which the covered behavioral health services were delivered, unless there is a delay due to the need for coordination of benefits or DMHAS finds other good cause. If the contracted provider is unable to file a timely claim for payment because DSS has not determined an individual's eligibility for medical services pursuant section 17b-192 of the Connecticut General Statutes, then the contracted provider shall file a claim for payment not later than 365 calendar days after the date on which the covered behavioral health services were delivered.

(f) Acceptance of a contracted provider's claim for payment shall not be a guarantee of payment.

(g) The designated agent shall accept any claims forms approved by DMHAS, including but not limited to, the CMS-1500 (formerly HCFA-1500) and the UB-92 forms.

(h) Contracted providers shall submit claims for payment that contain all information necessary to match the invoice with the covered behavioral health services delivered and, if applicable, authorization data including, but not limited to, the following:

(1) Individual's name and address;

(2) Individual's EMS-ID number or Social Security number;

(3) Individual's DSM-IV diagnosis;

(4) Date(s) of covered behavioral health service;

(5) Type of covered behavioral health service delivered to the individual;

(6) Contracted provider's name and address;

(7) Contracted provider's I.D. number; and

(8) Covered behavioral health service authorization number, if applicable.

(i) Payment of contracted providers' claims:

(1) Contracted providers' claims shall be paid in accordance with rates as specified by DMHAS;

(2) DMHAS may establish rates for the payment of covered behavioral health services by using rate setting methods including, but not limited to, the following:

(A) A per-session, per-diem, per-unit of time (hour, minute) or per-episode rate;

(B) A negotiated rate with a specific contracted provider for a particular covered behavioral health service or level of care;

(C) An established per capita rate;

(D) Rates for eligible recipients in related diagnostic groups; and

(E) Bundled rates for a defined group of covered behavioral health services.

(3) In order to participate in the GABHP, the contracted provider shall agree to accept the rates set by DMHAS;

(4) The contracted provider shall be paid at the rate established by DMHAS for each covered behavioral health service or at the billed rate, whichever is lower;

(5) The contracted provider shall not be paid for excluded or unauthorized behavioral health services; and

(6) The contracted provider shall not bill the eligible recipient for covered behavioral health services.

(j) DMHAS shall not make payments to a contracted provider for appointments missed by an eligible recipient. A contracted provider shall not bill an eligible recipient for missed appointments.

(k) Coordination of Benefits:

(1) Coordination of benefits shall be the responsibility of each contracted provider.

If the contracted provider identifies that an eligible recipient has other medical coverage for covered behavioral health services, the contracted provider shall seek payment first from the other medical coverage. The contracted provider shall submit documentation to the designated agent, substantiating either the amount of payment that was made by the other medical coverage or that payment was denied due to exclusion of coverage. When the other medical coverage is lower than the full DMHAS payment for the covered behavioral health service, DMHAS shall pay the difference between the other medical coverage and the DMHAS rate for the covered behavioral health services;

(2) Any payment made by DMHAS to a contracted provider for covered behavioral health services delivered to an eligible recipient who has been or is subsequently found to be eligible for any other medical coverage shall be subject to recovery by DMHAS for payments made for behavioral health services that are covered by the other medical coverage. Upon determination that an eligible recipient has other medical coverage, any payment made by DMHAS for the behavioral health service shall, at the department's discretion, either be withheld from any payment due the contracted provider or refunded to DMHAS by the contracted provider. If the other medical coverage payment is lower than the DMHAS payment, the contracted provider may retain the portion of the DMHAS payment that represents the difference between the full DMHAS payment and the payment made by the other medical coverage, upon submission of appropriate documentation to the designated agent; and

(3) Any payment made to a contracted provider by DMHAS for covered behavioral health services delivered to an eligible recipient who is or is subsequently found to be ineligible for the GABHP as a result of a determination of eligibility for Medicaid shall be subject to recovery by DMHAS to the extent that the eligible recipient's Medicaid eligibility overlaps with the period for which covered behavioral health services were delivered and to the extent that the covered behavioral health services are reimbursable under the Medicaid program. Upon determination of an individual's Medicaid eligibility, any payment made by DMHAS for the covered behavioral health service shall, at the discretion of DMHAS, either be withheld from any payment due the contracted provider or refunded to DMHAS by the contracted provider.

(Adopted effective December 7, 2009)