Section 17a-453a-3 - Eligibility(a) In order to be eligible for covered behavioral health services under the GABHP, the individual shall: (1) Be determined eligible by DSS for medical services pursuant to section 17b-192 of the Connecticut General Statutes;(2) Be determined by DMHAS staff or the designated agent to need covered behavioral health services available through the GABHP established pursuant to section 17a-453a of the Connecticut General Statutes. Such determination shall be based upon an evaluation of medical necessity that includes, but is not limited to, evaluation of:(A) The individual's mental status;(B) Problems identified by the individual; and(C) The individual's history of behavioral health services; and(3) Meet the criteria for a diagnosis of one or more psychiatric disabilities, substance use disorders or both as specified in the following range of DSM-IV diagnostic codes: (A) 291.1 to 292.9, inclusive; or(B) 295.0 to 315.9, inclusive, except for diagnosis 307.89, Pain Disorder Associated with a Medical Condition.(b) An individual who receives a covered behavioral health service and who does not satisfy the requirements of subsection (a)(1) of this section at the time he or she receives the covered behavioral health service may be eligible under GABHP established pursuant to section 17a-453a of the Connecticut General Statutes, provided that: (1) The individual is subsequently determined by DSS to be eligible retroactively for medical services to a date that includes the date on which the covered behavioral health service was delivered;(2) A contracted provider requests prior authorization from the designated agent before delivering the covered behavioral health service; and(3) All other requirements of this section are met.Conn. Agencies Regs. § 17a-453a-3
Adopted effective December 7, 2009