Precertification and Prior Approval Requirements (Connecticut Local Plan, FEP)
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Defines when members or providers must obtain precertification or prior approval for inpatient and outpatient services, behavioral health, ABA, transplants, surgeries, and specific high-cost services under the FEP (Connecticut) Local Plan.
No material clinical or coverage changes in this revision.
Coverage and Prior-Approval Criteria by Service
Coverage criteria by service
Coverage and prior approval criteria by service type and contract (Standard, Basic, Blue Focus).
ALL of the following
Examples that require prior approval under Standard & Basic
- Air ambulance transport (non-emergent).
- Applied behavior analysis (ABA).
- Artificial heart implantation.
- BRCA/LGR genetic testing.
- Clinical trials for certain blood or marrow stem cell transplants.
- Gender reassignment surgery.
- Gene therapy and cellular immunotherapy (e.g., CAR T and T-cell receptor therapy).
- Hospice care.
- Organ/tissue transplants (prior approval does not apply for kidney or cornea transplants per outpatient list).
- Outpatient IMRT for specified cancers (exceptions noted for head/neck, breast, prostate; brain cancer requires prior approval).
- Outpatient surgery for morbid obesity and surgery to treat morbid obesity.
ALL of the following
- Under the Blue Focus contract, specific outpatient/professional services require prior approval. When prior approval is not obtained, a $100 penalty will be applied to professional and outpatient facility claims once services have been approved (note: $100 penalty does not apply to prescription drugs).
ALL of the following
- All admissions for mental health and substance abuse to an inpatient treatment facility require prior approval based on the Service Benefit Plan medical necessity criteria.
- Residential Treatment Centers (RTC): Precertification must be obtained prior to admission or the entire admission is denied as non-covered.
- FEP members must be enrolled and participating in case management prior to RTC admission and remain in case management through post-discharge; facility must provide preliminary treatment and discharge plans; care must be medically necessary and RTC must be licensed and accredited.
- FEP Blue Focus: Coverage up to a combined total of 30 days (medical and mental health) of inpatient care provided and billed by an RTC when member is enrolled and participating in case management and care is medically necessary.
ALL of the following
- Prior approval is required for all ABA therapy; clinical review is required for medical necessity determination; parents/guardians must be engaged in the treatment plan.
- Coverage is limited to autism spectrum disorder; ABA and related services are excluded when provided for any condition other than an autism spectrum disorder, or when services are provided as part of an educational program/in a school setting or as a replacement for services that are the responsibility of the educational system.
ALL of the following
- Prior approval is required for transplants.
- Exceptions: kidney and cornea transplants do not require prior approval when listed in outpatient section.
Coding and Code-Related Notes
| No codes listed |
Precertification, Prior Approval, and Provider Notification Rules
Precertification and prior‑approval contact rules
Members and providers must contact the Local Plan for precertification prior to a planned inpatient admission. For emergency inpatient admissions, the Local Plan must be notified no later than two business days after admission. Precertification for outpatient services is handled as prior-approval.
- Phone: 800-860-2156 (8AM - 7PM ET) Monday-Friday
- FAX: 800-732-8318
All inpatient admissions require prior approval
Prior approval is required for all inpatient admissions, including long term acute rehabilitation, obstetric stays beyond the federal minimum length of stay (including newborn stays beyond the mother's stay), emergency admissions (notification within 2 business days), and all solid organ and bone marrow/stem cell transplants.
- Includes LTAC and OB stays beyond federal minimum LOS (including newborn stays beyond mother’s stay)
- Emergency admissions require Plan notification no later than 2 business days after admission
- Includes all solid organ and bone marrow/stem cell transplants (including kidney)
Outpatient prior approval; $100 Blue Focus penalty for missing approvals
Numerous outpatient services require prior approval under Standard/Basic and under Blue Focus contracts (examples include air ambulance non‑emergent, ABA, gene/cellular therapies, certain surgeries, hospice, and outpatient IMRT as specified). Under Blue Focus, when prior approval is not obtained for applicable outpatient/professional services, a $100 penalty will be applied to professional and outpatient facility claims once services are approved.
- Examples requiring prior approval: air ambulance (non‑emergent), ABA, gene therapy/cellular immunotherapy, selected surgical services, hospice, outpatient IMRT (per criteria)
- Blue Focus: $100 penalty applies to professional and outpatient facility claims if prior approval is not obtained (penalty does not apply to drugs)
Behavioral health inpatient prior approval and RTC precertification
All inpatient mental health and substance abuse admissions require prior approval based on the Service Benefit Plan medical necessity criteria. For Residential Treatment Centers (RTC), members must be enrolled and participating in case management prior to admission, the facility must provide preliminary treatment and discharge plans, care must be medically necessary, and precertification must be obtained prior to admission or the entire admission is denied as non‑covered.
- All inpatient mental health and substance abuse admissions: prior approval based on Medical Necessity
- RTC requirements: enrollment in case management prior to admission and continued participation; facility must supply preliminary treatment and discharge plans; precertification required prior to admission or admission denied as non‑covered
- FEP Blue Focus RTC limit: combined total of 30 days (medical and mental health) when enrolled and participating in case management
ABA requires prior approval and medical‑necessity review
Prior approval is required for all Applied Behavior Analysis (ABA) therapy. Clinical review for medical‑necessity determination is required, and parents/guardians must be engaged in the treatment plan.
- Prior approval required for all ABA therapy
- Clinical review required to determine medical necessity
- Parents/guardians must be engaged in the treatment plan
Key Definitions and Benefit Scope
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