Sec.17a-453a-19 Out-of-network. providers

(a) An out-of-network provider is a provider who does not have an executed contract with DMHAS to participate in GABHP. An out-of-network provider only may deliver covered behavioral health services to eligible recipients, as specified in this section.

(b) Covered behavioral health services: Out-of-network providers are eligible for payment under GABHP for acute care services only.

(c) Service limitations, exclusions, and non-reimbursable services:

(1) Out-of-network providers shall be subject to all service limitations, exclusions and non-reimbursable services that apply to contracted providers as specified in section 17a-453a-5 of the Regulations of Connecticut State Agencies.

(2) DMHAS shall not pay an out-of-network provider for any covered behavioral health services except for a maximum of four (4) acute care services delivered to an eligible recipient in a calendar year.

(d) Prior authorization review: Out-of-network providers shall comply with all prior authorization review requirements that apply to contracted providers as specified in section 17a-453a-6 of the Regulations of Connecticut State Agencies.

(e) Continued stay authorization review: Out-of-network providers shall comply with all continued stay authorization review requirements that apply to contracted providers as specified in section 17a-453a-7 of the Regulations of Connecticut State Agencies.

(f) Recovery and Discharge Planning: Out-of-network providers shall comply with all recovery and discharge planning requirements that apply to contracted providers as specified in section 17a-453a-9 of the Regulations of Connecticut State Agencies.

(g) Quality management: Out-of-network providers shall comply with all quality management requirements that apply to contracted providers as specified in section 17a-453a-10 of the Regulations of Connecticut State Agencies.

(h) Provider Application Process: Out-of-network providers shall comply with all provider application process requirements that apply to contracted providers as specified in section 17a-453a-11 of the Regulations of Connecticut State Agencies.

(i) Credentialing process:

(1) An out-of-network provider shall only be credentialed to deliver acute care services.

(2) An out-of-network provider that delivers five (5) or more acute care services to an eligible recipient in a calendar year shall comply with the credentialing requirements for the levels of care delivered as specified in section 17a-453a-12 of the Regulations of Connecticut State Agencies; and

(3) An out-of-network provider who delivers acute care services to eligible recipients shall be licensed in the state in which the acute care service is delivered.

(j) Administration of out-of-network providers' claims for payment: An out-of-network provider who delivers more than four (4) acute care services to an eligible recipient without a contract with DMHAS shall not be paid under the GABHP. Out-of-network providers shall comply with all other claims administration requirements that apply to contracted providers as specified in section 17a-453a-14 of the Regulations of Connecticut State Agencies.

(k) Provider claim for payment grievance process: Out-of-network providers shall comply with all provider claim grievance requirements that apply to contracted providers as specified in section 17a-453a-15 of the Regulations of Connecticut State Agencies.

(l) Audit: Out-of-network providers shall comply with all audit requirements that apply to contracted providers as specified in section 17a-453a-16 of the Regulations of Connecticut State Agencies.

(m) Administrative hearing to appeal audit recovery or progressive sanctions: Out-of-network providers shall comply with all fair hearing regulations, when applicable, to appeal audit recovery or progressive sanctions requirements as specified in section 17a-453a-17 of the Regulations of Connecticut State Agencies.

(Adopted effective December 7, 2009)