Sec.17a-453a-8. Alternative authorization review

(a) Web-based registration or outpatient treatment review (OTR) submission shall be the alternative methods to prior authorization review and continued stay review. The web-based registration and OTR submission shall be in the format as determined by DMHAS or its designated agent.

(b) The alternative authorization review shall be designed to determine whether the following covered behavioral health services are medically necessary:

(1) Outpatient-substance use;

(2) Outpatient-mental health; and

(3) Chemical maintenance treatment.

(c) The contracted provider shall furnish such information as may be requested by the designated agent for the purpose of alternative authorization review of the designated 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 psychiatric disability 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.

(d) The decision regarding alternative authorization shall be rendered by the designated agent not later than five (5) business days after the date of receipt of all information that the designated agent determines is necessary and sufficient to render a decision.

(e) Upon completion of the alternative authorization 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.

(f) A contracted provider shall submit a written request to the designated agent to obtain authorization for an initial intake evaluation, not more than fifteen (15) calendar days following the initial evaluation, and only if the potentially eligible or eligible recipient does not begin treatment with the contracted provider not later than ten (10) calendar days after the date of his or her initial intake evaluation.

(g) Alternative authorization of a covered behavioral health service specified in this section will not guarantee that DMHAS will pay providers' claims for payment.

(Adopted effective December 7, 2009)