Sec.17a-453a-5. Limitations, exclusions and non-payment of behavioral health services

(a) Limitations: The following limitations shall apply:

(1) DMHAS payment for outpatient therapy shall be limited to one (1) session per contracted provider, per day, for each eligible recipient for each of the following therapies, unless additional behavioral health services are authorized in advance by the designated agent:

(A) Individual therapy;

(B) Group therapy; or

(C) Family therapy;

(2) Unless authorized in advance by the designated agent, medication management delivered by the same practitioner, on the same day, for the same eligible recipient and for the principal purpose of medication monitoring or management shall not be paid separately from individual or group therapy;

(3) Group therapy sessions shall be limited to a maximum of twelve (12) individuals per group session, excluding the supervising clinician(s); education groups shall be limited to a maximum of twenty-four (24) individuals per group session, excluding the supervising professional(s);

(4) DMHAS payment for the following shall be limited to one (1) each for each eligible recipient during a twelve (12) month period, if authorized in advance by the designated agent:

(A) Neuropsychological testing; or

(B) Psychological testing;

(5) Contracted providers of chemical maintenance treatment shall deliver behavioral health services at their licensed facility location, unless otherwise authorized in advance by DMHAS;

(6) DMHAS payment for laboratory services shall be limited to one (1) unit per allowable laboratory service per eligible recipient per day, unless authorized by the designated agent;

(7) DMHAS payment for initial intake evaluations conducted by contracted providers shall only be considered when:

(A) The individual is eligible for medical services pursuant to section 17b-192 of the Connecticut General Statutes at the time of the initial intake evaluation or is found to be eligible retroactively for such benefits on the date on which the initial intake evaluation occurred;

(B) The eligible recipient does not begin treatment in a level of care, other than outpatient-mental health or outpatient-substance use, with the same contracted provider not later than ten (10) calendar days after the date of his or her initial intake evaluation;

(C) The contracted provider registers the procedure not later than fifteen (15) calendar days after the date of the initial intake evaluation;

(D) The contracted provider has not received payment for an initial intake evaluation for the same eligible recipient within the previous six (6) months; and

(E) The contracted provider has neither sought nor received payment for emergency room behavioral health services on the same day as the date of the initial intake evaluation.

(b) Excluded services: The following shall be excluded under the GABHP:

(1) Any behavioral health services delivered to an eligible recipient with a primary diagnosis which is outside the range of DSM-IV diagnostic codes of 291.1 to 292.9, inclusive; 295 to 307.88, inclusive or 307.90 to 315.9, inclusive;

(2) Behavioral health services that DMHAS determines to be experimental in nature;

(3) Behavioral health services that the designated agent determines are not medically necessary;

(4) Behavioral health services which the designated agent determines to be similar or identical that are delivered to the same eligible recipient;

(5) Behavioral health services, consultation or information delivered over the telephone;

(6) Activities that DMHAS determines are primarily for vocational or educational guidance that relate solely to a specific employment opportunity, job skill, work setting or development of an academic skill;

(7) Therapies, treatments or procedures that relate to transsexual or gender-change medical or surgical procedures; and

(8) Activities, treatment or items delivered to an eligible recipient for which the contracted provider does not usually charge others.

(c) DMHAS shall not pay a contracted provider of inpatient or residential services for the following:

(1) The day of discharge or transfer, unless the eligible recipient is discharged or transferred on the same day as he or she is admitted;

(2) A leave of absence or pass from an inpatient or residential facility that occurs without staff permission or against staff advice;

(3) A leave of absence or pass from an inpatient or residential facility with staff permission, if the absence is longer than 24 hours, unless authorized in advance by the designated agent; and

(4) Emergency room behavioral health services delivered on the same day as an acute psychiatric hospital admission or a medically managed inpatient detoxification admission to the same facility.

(d) DMHAS shall not pay a contracted provider for the following:

(1) Electroconvulsive therapy, unless delivered by a licensed psychiatrist and pre-authorized by the designated agent;

(2) Hypnosis, unless delivered by a licensed psychiatrist or psychologist and pre-authorized by the designated agent;

(3) Psychological or intelligence testing, unless delivered by a licensed psychologist and pre-authorized by the designated agent;

(4) Neuropsychological testing, unless delivered by a licensed psychologist and preauthorized by the designated agent;

(5) Behavioral health services delivered by a staff member who is not a licensed behavioral health professional or who is not a Connecticut certified alcohol and drug counselor, unless the following conditions are met:

(A) The individual is employed by or under contract with a licensed facility whose medical director or clinical supervisor has determined that the staff member is qualified to deliver behavioral health services to eligible recipients;

(B) For acute psychiatric hospitalization, intensive outpatient-mental health, observation bed-mental health, outpatient-mental health and partial hospitalization-mental health only, the individual is actively pursuing behavioral health licensure and is under the direct supervision of licensed behavioral health professional with at least two (2) years of experience in the delivery of behavioral health treatment services; and

(C) The supervising clinician has signed the eligible recipient's recovery plan;

(6) Behavioral health services delivered by staff of a licensed facility at a location other than that which is specified on the facility's license;

(7) Any laboratory service delivered by a laboratory that is not in compliance with the federal Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 CFR 493; and

(8) Individual laboratory tests, where it is determined by DMHAS that a panel or profile test should be conducted instead.

(Adopted effective December 7, 2009)