Payment limitations

(a) The fees listed in the department's fee schedule shall be payable only when the services are performed by or under the supervision of a provider. (b) The department shall pay the fee for an initial visit by a provider in an office, home, ICF/MR or nursing facility only once per client. Initial visits refer to the provider's first contact with the client and reflect higher fees for the additional time required for setting up records and developing past history. The only exception to this is when the provider-client relationship has been discontinued for three or more years and is then reinstated. (c) The department shall pay non-hospital based providers for evaluation and management services provided to the provider's private practice clients in the emergency room. (d) Payment for physician fees are available only when the opinions and advice of a physician consultant are requested by another physician or other appropriate source. The consultant's opinion and any services that were ordered or performed must be documented in the patient's medical record and communicated by written report to the requesting physician or other appropriate source. In a consultation, the referring provider carries out the plan of care. In a referral, a second provider provides direct service to the client. (e) If a client is referred to a provider for treatment of a condition that the referring provider does not usually treat, the department shall pay the treating provider the fee for an office visit rather than the fee for a consultation. (f) When the consultant provider assumes the continuing care of the client, any subsequent service shall be paid according to the fee listed for the procedure. (g) If a client's medical condition necessitates the concurrent services and skills of two or more providers, each provider shall be entitled to the listed fee for the service that he or she provides. (h) When a provider examines a Medicaid applicant for the purpose of substantiating whether a medical condition exists that would enable the department to determine eligibility for Medicaid disability, the department shall pay only for the tests required to establish eligibility as requested by the department. No other procedures shall be paid. (i) Surgery (1) When a claim is submitted by a provider for multiple surgical procedures performed on the same date of service, the department shall pay for the primary surgical procedure the full Medicaid allowed amount. the department shall pay for additional surgical procedures performed on that day at 50% of the Medicaid allowed amount. (2) When an assistant surgeon, in addition to staff provided by the general or chronic disease hospital, is required, the amount payable by the department to the assistant surgeon shall be 20% of the listed fee for surgery. (3) Fees for related evaluation and management encounters on the same day of surgery are not payable. (4) The listed fees for all surgical procedures include the surgery and typical postoperative follow-up care while in the general or chronic disease hospital. Followup visits after a client is discharged from the general or chronic disease hospital shall be payable as office visits. (5) The listed fees for surgery on the musculoskeletal system shall include payment for the application of the first cast or traction device. (j) Anesthesia (1) The listed fees for anesthesia services include pre- and post-operative visits, the administration of the anesthetic and the administration of fluids and blood incident to the anesthesia or surgery. (2) The listed fees for anesthesia services shall be used only when the anesthesia is administered by or under the supervision of a licensed provider who remains in constant attendance during the procedure for the sole purpose of rendering anesthesia services. (3) No payment shall be made for local infiltration or digital block administered by the operating surgeon. (k) Radiology (1) The listed fees for all diagnostic radiology procedures, including nuclear medicine, magnetic resonance imaging, computerized axial tomography and diagnostic ultrasound, shall include consultation and a written report to the referring provider. (2) The listed fees for all diagnostic radiology procedures shall apply only when the provider's own equipment is being used. If the equipment used to perform the procedure is owned directly or indirectly by the general or chronic disease hospital or a related entity, or if a hospital includes the operating expenses of the equipment in its cost reports, the provider shall not be paid for the technical component of the listed fee. (l) Radiotherapy (1) The provider fee for radiological treatment of malignancies shall include one-year follow-up care unless otherwise specified. (2) The provider fee for treatment of nonmalignant conditions shall include followup care ninety days from the end of treatment unless otherwise specified. (3) The provider fee for treatment shall include the concomitant office visits, but does not include surgical, radiological or laboratory procedures performed on the same day. (4) The fees listed for therapeutic procedures involving the use of radium and radioisotopes shall not include the radioactive drug used or preliminary and followup diagnostic tests. Radioactive drugs may be billed separately. (5) The fees listed for diagnostic procedures involving the use of radium and radioisotopes shall not include the radioactive drugs used. Radioactive drugs may be billed separately. (m) Laboratory (1) The following routine laboratory tests shall be included in the physician fee for an office visit and shall not be billed on the same date of service: urinalysis without microscopy, hemoglobin determination and urine glucose determination. (2) No payment shall be made for tests which are provided free of charge. (3) Payment shall be made for panel or profile tests according to the fees listed in the department's fee schedule for panel tests and not according to the fee for each separate test included in the panel or profile. (n) Drugs (1) The department shall pay the actual acquisition costs for oral medications incident to an office visit as billed by the provider. (2) The department shall pay for legend drugs and legend devices administered by the provider based on a fee schedule determined by the department. (3) No payment shall be made for drugs provided free of charge. (o) Newborn Care (1) The provider fee for routine care of a normal newborn infant in the general hospital includes history and examination of the infant, initiation of diagnostic and treatment programs, preparation of hospital records, history and physical examination of the baby and conferences with the parents. Subsequent hospital care for evaluation and management of a normal newborn is paid per day. (2) When a newborn requires other than routine care following delivery, the provider shall bill for the appropriate critical care. The department shall not pay both the critical care and the routine or subsequent newborn care for the same child. (3) Newborn resuscitation may be billed in addition to billing for routine care of a newborn or billing for critical care. (p) Payment for assessments and subsequent care for clients in a nursing facility, ICF/MR and chronic disease hospital (1) The department shall make payments available to providers for evaluation and management only when performed in the facility. (2) The annual assessment is limited to one per client per year. (q) Allergy Procedures Providers shall bill for follow-up visits which include intracutaneous tests only if subsequent visits require testing. If follow-up visits do not include testing, regular office visit codes for established clients shall be billed. (r) Admission to a General Hospital Payment for services provided by the admitting provider in a general hospital shall not be made available if it is determined by the department's utilization review program, either prospectively or retrospectively, that the admission did not fulfill the accepted professional criteria for medical necessity, medical appropriateness, appropriateness of setting or quality of care. Specific requirements are described in section 17-134d-80 of the Regulations of Connecticut State Agencies. (s) Family planning, abortion and hysterectomy (1) The department shall pay the provider for sterilization only if the client has given his or her informed consent in accordance with the requirements in 42 CFR 441.250 through 441.259, inclusive, as amended from time to time. (2) The department shall pay for hysterectomies and related laboratory and hospital services that are medically necessary and medically appropriate only if the physician or physician's representative has obtained: (A) a consent form in accordance with 42 CFR 441.251 through cfr 441.259 inclusive, as amended from time to time, or (B) a physician's certification in accordance with 42 CFR 441.255(d), as amended from time to time. (3) The department shall pay physicians for all abortions that a physician certifies as medically necessary and medically appropriate whether or not the woman's life would be endangered by carrying the fetus to term and whether or not the pregnancy is the result of rape or incest. For the purposes of abortion coverage and payment, a physician determines medical necessity. (4) the provider shall maintain all forms required by section 19a-116-1 of the Regulations of Connecticut State Agencies and section 19a-601 of the Connecticut General Statutes.