Prior authorization

(a) Prior authorization, on forms and in the manner specified by the department, is required in order for payment to be available for the following provider services: (1) electrolysis epilation; (2) physical therapy services in excess of two visits per calendar week per client per provider; (3) physical therapy services in excess of nine visits per calendar year per client per provider, when the therapy being prescribed is for the treatment of: (A) all mental disorders, including diagnoses related to mental retardation and specific delays in development covered by the International Classification of Diseases (ICD), as amended from time to time; (B) musculoskeletal system disorders of the spine covered by the ICD, as amended from time to time; and (C) symptoms related to nutrition, metabolism, and development covered by the ICD, as amended from time to time; (4) reconstructive surgery, including breast reconstruction following mastectomy; (5) plastic surgery; (6) transplant procedures; and (7) Early and Periodic Screening, Diagnostic and Treatment services that are identified during a periodic screening as medically necessary and which are not payable pursuant to the existing physician fee schedule. (b) Prior authorization is required for payment of all hospital admissions as required and described in section 17-134d-80 of the Regulations of Connecticut State Agencies. (c) The department shall make payment available only if the procedure or course of treatment authorized shall be initiated not later than six months of the date of authorization. (d) The initial authorization period shall be for a period not to exceed six months. (e) If prior authorization is needed beyond the initial authorization period, requests for continued treatment beyond the initial authorization period shall be considered for up to an additional six-month period per request. (f) Except in emergency situations, prior authorization shall be received before services are rendered. (g) In an emergency situation that occurs after working hours or on a weekend or holiday, the provider shall secure verbal approval on the next working day for the services provided. This applies only to those services that normally require prior authorization. (h) In order to receive payment from the department a provider shall comply with all prior authorization requirements. The department in its sole discretion determines what information is necessary in order to approve a prior authorization request. Prior authorization does not, however, guarantee payment unless all other requirements for payment are met.