Connecticut Administrative Code
Title 17a - Social and Human Services and Resources
453a - General Assistance Behavioral Health Program
Section 17a-453a-19 - Out-of-network providers
Current through March 14, 2024
(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:
(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:
(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.
