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Clinical Information
Guidance and Support
- Commercial
- Medicare
Mental health and substance abuse treatment is covered, when medically necessary, through ConnectiCare’s Behavioral Health Program for most members. Treatment for these services requires preauthorization by the Behavioral Health Program. If you are coordinating mental health/substance abuse services on behalf of a ConnectiCare member, please contact the program at the number below:
ConnectiCare’s Behavioral Health Program
- This number may vary for some Customized (self-funded) plans.
PPM/10.16
Bone marrow and organ transplants are covered when established criteria for medical necessity are met. Covered organ transplants may include, but are not limited to cornea, heart, heart-lung, kidney, liver, lung, pancreas, pancreas-kidney and bone marrow transplants, depending on the member’s benefit plan. All requests for organ transplants, except corneal transplants, require pre-authorization prior to any referral. Request preauthorization bone marrow or organ transplant services with ConnectiCare as soon as the patient’s needs are known, prior to any evaluative services.
Services are available at participating facilities, including contracted centers of excellence. To obtain a listing of participating transplant facilities, call 860-674-5860 or 800-562-6833.
Exception: Members covered under a ConnectiCare of Massachusetts, Inc. plans may have access to out of network facilities.
Enter a preauthorization request on our provider portal along with supporting medical documentation.
Next steps:
- The utilization manager will request clinical documentation. Upon receipt, the utilization manager will review the documentation with ConnectiCare’s medical director to determine medical necessity and benefit coverage.
- The utilization manager or medical director may discuss the determination with you by phone and will follow up with a written determination.
JP 65073 5/24
Maternity preauthorization
Maternity coverage may vary by product. You can check member eligibility and benefits on the provider portal. You can also contact Member Services at 800-251-7722 for determination of coverage.
Doctors should preauthorize patients with ConnectiCare on the provider portal before 16 weeks of gestation or as soon as possible after 16 weeks of gestation. To arrange for post-delivery services use the provider portal.
Post-discharge services:
- Preauthorization is required.
- Labor support doulas are a benefit exclusion. Refer to member's plan document.
Lactation Consultant: Provide a lactation consult is for members who are experiencing difficulties breast feeding.
- Lactation Consultant must be certified by the International Board of Lactation Consultants (IBLC).
- Preauthorization is not required.
- Coverage consists of one home visit and must be used within two months of delivery regardless of vaginal/cesarean delivery or duration of hospital stay.
- Member is required to pay for services and then submit a claim to ConnectiCare for reimbursement (covered at 100%).
Type of Delivery |
Mandated benefit: |
Optional Early Discharge Program: Vaginal delivery with less than 48 hours length of stay after delivery. |
Value Added : Vaginal delivery - inpatient stay after delivery is 1 night or less. |
Vaginal Delivery |
• 1 skilled nursing visit by a maternal child health nurse from a Home Health Agency (requires pre-authorization from ConnectiCare). |
• 2 skilled nursing visits by a maternal child health nurse from a home health agency within two weeks of the delivery (requires Preauthorization from ConnectiCare). |
• 2 skilled nursing visits by a maternal child health nurse |
Cesarean Delivery |
• No skilled nursing visits unless medically indicated |
• 1 lactation consultant visit at home up to 2 months postpartum. |
• 2 skilled nursing visits by a maternal child health nurse. • 1 lactation consultant visit at home up to 2 months postpartum. |
JP 65073 5/24
ConnectiCare participates in a kidney stone testing and prevention program offered by Litholink Corp. Litholink is a metabolic testing laboratory focused exclusively on prevention of recurrent kidney stones. ConnectiCare encourages members who have had two or more acute episodes of renal stones in the past two years to participate. ConnectiCare also encourages physicians to refer patients to the program. To enroll a patient in the Litholink Program, or learn more, call Litholink at 800-338-4333.
PPM/10.16
The Transplant Case Management Program is designed to provide ConnectiCare members and their families with education, support, and advocacy during the pre-intra- and post-transplant period (for up to one year after organ or bone marrow transplantation). A registered nurse with experience in transplant management conducts telephonic outreach to these members to aid them in obtaining and coordinating necessary health care services, while helping to maximize health care benefits. The nurses are a resource regarding transplants, cost issues, community resources, and care options.
PPM/10.16
Provider appeals are those where the provider, rather than the member, will be financially liable for the services rendered. Providers may submit their appeals of a denial orally, electronically, by facsimile, or in writing to ConnectiCare's Provider Appeals Department or Member Appeals Department. The appeal must be made as soon as possible after the denial, but no later than 180 days after the provider was notified of the denial. There are two types of provider appeals:
Administrative Appeals
(i.e., denials that are based on failure to follow a ConnectiCare administrative requirement)
Administrative appeals will be reviewed, and a decision will be given within 90 calendar days of the appeal request. Send provider administrative appeals to:
ConnectiCare Provider Appeals
175 Scott Swamp Road
Farmington, CT 06032
Phone: 800-828-3407
Fax: 860-674-7035
Medical Appeals
(i.e., those where the denial of payment is based on medical necessity criteria)
| Providers may also appeal a medical necessity decision on behalf of a member. Details about how to appeal on behalf of a member are provided with the initial notification of denial. |
Provider medical appeals will be decided within 30 calendar days of receipt unless additional information is required. In such cases, you will be notified of the need for additional information within 7 calendar days, and a decision will be made within 30 calendar days of our receipt of complete information, but no later than 45 business days from receipt of the appeal.
For provider medical appeals, a physician of the appropriate specialty, who was not previously involved in the case, will review the appeal and render the final determination. Provider appeals receive only one level of review. Send provider medical appeals to:
Provider Appeals
P.O. Box 4061
Farmington, CT 06034-4061
Phone: 800-828-3407
Fax: 860-674-2866 or 800-313-0089
If the denial is upheld on appeal, the final adverse determination notice shall include the reason for the determination, clinical rationale, and general information on the external appeal process (if applicable), including instructions on how to initiate an external appeal.
PPM/10.16
When a member who is discharged from a hospital is readmitted to the same hospital or same hospital network within thirty (30) days, a ConnectiCare utilization manager will review the case to determine if the readmission is related to the original inpatient stay.
Please view for our complete Hospital Readmission Policy
Please Note: Elective admissions require preauthorization.
PPM/10.16
Kidney Resource Services (KRS) helps ConnectiCare members manage their kidney disease, providing telephonic case management services by specialized renal-trained registered nurse consultants. Members with a diagnosis of chronic kidney disease (CKD) or end stage renal disease (ESRD) or who are receiving dialysis at a dialysis facility or at home qualify for the Kidney Resource Case Management Program. Members can be co-managed with the transplant program. To enroll a patient in the Kidney Resource Program or learn more, call 866-897-1038.
PPM/10/16
Peer-to-peer process for all ConnectiCare plans in Connecticut (including plans sold through Access Health CT, the state insurance exchange)
ConnectiCare offers participating practitioners a peer-to-peer process when an adverse medical determination has been issued. Providers may request a peer-to-peer conference within a two-week period following the date of the notice of adverse determination provided that an appeal has not been initiated. The peer-to-peer shall occur between the practitioner requesting approval of the service and the clinical peer reviewer who made the initial adverse determination. If the adverse determination is not reversed after the peer-to-peer process, providers or members may pursue the provider appeals process. Please note, the peer-to-peer process is not a prerequisite to the appeals process. Requests for peer-to-peer that are initiated more than two weeks after the initial notification of adverse determination will be processed as appeals.
Reconsideration process for all ConnectiCare plans in Massachusetts
ConnectiCare offers providers a reconsideration process when an adverse determination has been issued during a clinical peer review, whether such adverse determination was given during an initial or a concurrent review. That reconsideration process shall take place within one (1) working day after ConnectiCare receives the provider’s request. The reconsideration process shall involve the provider rendering the service and the clinical peer reviewer who made the initial adverse determination or, if the reviewer is not available, the reviewer’s clinical peer designee. If the adverse determination is upheld, the member, or the provider on behalf of the member, may then follow the grievance process through the formal provider appeals process. Please note, the reconsideration process is not a prerequisite to the formal internal grievance process or expedited appeal.
What happens next after the peer-to-peer process or the reconsideration process?
- ConnectiCare’s medical director will review the request and make the determination.
- If ConnectiCare upholds the initial adverse determination, providers will be notified verbally. Providers may then use the appeals process as outlined in the provider appeals process. However, members may not be billed for services denied under this process.
- For determinations that were upheld, the initial adverse determination letter to the provider serves as notification and will include: the reason for the determination and clinical rationale, if any; instructions on how to initiate an appeal of the decision; general information on external appeal rights, if applicable, including how to initiate an external appeal; notice of the availability of clinical review criteria referenced in the decision, and the name and phone number of the physician reviewer who made the decision.
PPM/06.18
Clinical Practice Guidelines
Information and practice standards for treating some of the more common chronic conditions.
Preauthorization Lists
A complete listing of services and procedures that require preauthorization.
Pharmacy and Prescribing Information
Find information on ConnectiCare’s pharmacy programs and more.
Special Programs
Learn about radiation oncology preauthorization and benefit management services.
Quality Improvement
Our Quality Improvement programs and information are developed, implemented, and evaluated to promote and preserve clinical excellence that fosters the safety and well-being of our members.
New: Submitting Clinical Information
Preauthorization and Emergent Inpatient Admission Notification Enhancements
We recently added the ability to request a modification to an existing preauthorization request or emergent inpatient admission notification.
In the fall, we will begin to require clinical information to be submitted with preauthorization requests and emergent inpatient admission notifications. We will allow drafts of the requests and notices to be saved for 96-hours. This will give you time to collect the clinical information or hand off the case to someone else with the expertise to address the clinical criteria and supporting documentation.
Transplant Case Management Program
The Transplant Case Management Program is designed to provide ConnectiCare members and their families with education, support, and advocacy during the pre-intra- and post-transplant period (for up to one year after organ or bone marrow transplantation). A registered nurse with experience in transplant management conducts telephonic outreach to these members to aid them in obtaining and coordinating necessary health care services, while helping to maximize health care benefits. The nurses are a resource regarding transplants, cost issues, community resources, and care options. For additional information call 800-508-6157.
Medicare Case Management Program
Through this program we identify members with special needs who would most benefit from direct intervention in their case, before their health condition or living situation deteriorates. The primary focus is on assessment, triage, and follow up. This is accomplished through comprehensive telephonic assessment of the member's medical and functional status and development of a care plan to include health coaching and care coordination. For additional information, call 1-800-509-3181.
MEDICARE PPM/3.11
Free In-Home Screening Kits for Eligible Plan Medicaid and Medicare Members
EmblemHealth and ConnectiCare have partnered with Quest Diagnostics to provide in-home colorectal cancer and diabetes screening test kits to our eligible Medicaid and Medicare members. This program aims to increase the screening adherence of eligible members and improve health outcomes,
- Eligible EmblemHealth Medicaid and Medicare members can receive:
- A fecal occult blood test (FOBT) to screen for colorectal cancer, free of charge.
- Eligible ConnectiCare Medicare members can receive:
- FOBT for colorectal cancer and/or
- The A1C test for diabetes, free of charge.
FOBT kit eligibility:
Medicare and Medicaid members who were identified with a gap in care for colorectal cancer screening and who meet certain other criteria (e.g., utilization of an FOBT or FIT DNA test in the past and members who have never had a screening for colorectal cancer). Medicare members who have registered for EmblemHealth’s Medicare member rewards program are also eligible.
Members may receive a kit mailed directly to them with instructions and a pre-paid postage envelope to return the kit, or a letter with instructions on how they can order a test kit directly from Quest.
Please direct any questions about your patients’ test results to Quest by calling 855-623-9355.
If you have any additional questions concerning this program, please email Quality_Providerengagement@emblemhealth.com.
Free In-Home Screening Kits for Eligible Plan Medicaid and Medicare Members
EmblemHealth and ConnectiCare have partnered with Quest Diagnostics to provide in-home colorectal cancer and diabetes screening test kits to our eligible Medicaid and Medicare members. This program aims to increase the screening adherence of eligible members and improve health outcomes,
- Eligible EmblemHealth Medicaid and Medicare members can receive:
- A fecal occult blood test (FOBT) to screen for colorectal cancer, free of charge.
- Eligible ConnectiCare Medicare members can receive:
- FOBT for colorectal cancer and/or
- The A1C test for diabetes, free of charge.
A1c test kit eligibility:
ConnectiCare Medicare members who have been identified as diabetic and as having a gap in care for HbA1c testing will receive an A1c test kit with instructions and a pre-paid postage envelope to return the kit.
If you have patients that receive and complete one or both in-home screening kits, please be aware:
- Test results within the normal range will be mailed to the member’s attributed primary care provider to add to their medical record and provide any necessary follow-up.
- Abnormal test results will be mailed via certified letter to the member’s attributed primary care provider.
- The member can receive negative results through the Quest portal and mail (letter). For positive results, Quest will attempt to reach the member via telephone three times. If they are unable to reach the member, they will mail a certified letter.
Please direct any questions about your patients’ test results to Quest by calling 855-623-9355.
If you have any additional questions concerning this program, please email Quality_Providerengagement@emblemhealth.com.
Mental health and substance abuse treatment is covered, when medically necessary, through ConnectiCare’s Behavioral Health Program for most members. Treatment for these services require preauthorization by the Behavioral Health Program. If you are coordinating mental health/substance abuse services on behalf of a ConnectiCare member, please contact the program at the number below:
ConnectiCare’s Behavioral Health Program
800-349-5365
Medicare PPM/2.10
Bone marrow and organ transplants are covered when Medicare guidelines for medical necessity and the appropriateness of the patient are met.
All requests for organ transplants, except corneal transplants, require pre-authorization prior to any referral for patient appropriateness determination.
Request preauthorization for bone marrow or organ transplant services with ConnectiCare as soon as the patient’s needs are known, prior to any evaluative services.
Services are available at Medicare-approved transplant facilities. To obtain a listing of participating transplant facilities or to pre-authorize a transplant, call 800-508-6157.
What happens next?
- The case manager will request clinical documentation. Upon receipt, the case manager will review the documentation with ConnectiCare’s medical director to determine medical necessity and benefit coverage.
- The case manager or medical director may discuss the determination with you by phone and will follow up with a written determination.
Medicare PPM/3.11
Maternity preauthorization
Maternity coverage may vary by product. You can check member eligibility and benefits on the provider portal.
Doctors should preauthorize patients with ConnectiCare on the provider portal before 16 weeks of gestation or as soon as possible after 16 weeks of gestation. To arrange for post-delivery services use the provider portal.
Note: As a courtesy to our members, doctors should also notify ConnectiCare of pregnancy loss. This will help prevent us from inappropriately contacting the member for case management purposes and sending additional pregnancy-related information.
JP 65073 5/24
Provider appeals are those where the provider will be financially liable for the services rendered. Providers may submit their appeals of a denial orally, electronically, by facsimile, or in writing to ConnectiCare's Provider Appeals Department or Member Appeals Department. The appeal must be made as soon as possible after the denial, but no later than 180 days after the provider was notified of the denial. There are two types of provider appeals:
Administrative appeals
(i.e., denials based on failure to follow a ConnectiCare administrative requirement)
Administrative appeals will be reviewed, and a decision will be given within 90 calendar days of the appeal request. Send provider administrative appeals to:
Provider Appeals Department
ConnectiCare
175 Scott Swamp Road
Farmington, CT 06032-3124
Medical appeals
(i.e., those where the denial of payment is based on medical necessity criteria)
Medical appeals will be decided within 30 calendar days of receipt, unless additional information is required. In such cases, you will be notified of the need for additional information within 7 calendar days, and a decision will be made within 30 calendar days of our receipt of complete information, but no later than 45 business days from receipt of the appeal.
For provider medical appeals, a physician of the appropriate specialty who was not previously involved in the case, will review the appeal and will render the final determination. Provider appeals receive only one level of review. Send provider medical appeals to:
ConnectiCare
P.O. Box 4061
Farmington, CT 06034-4061
If the denial is upheld on appeal, the final adverse determination notice shall include the reason for the determination, clinical rationale, and notice of availability of clinical review criteria referenced in the decision.
Providers may also appeal a medical necessity decision on behalf of a member. Details about how to appeal on behalf of a member are provided with the notice of adverse determination, delivered to the member.
MEDICARE PPM/2.10
Clinical Practice Guidelines
Information and practice standards for treating some of the more common chronic conditions.
Preauthorization Lists
A complete listing of services and procedures that require preauthorization.
Special Programs
Learn about radiation oncology preauthorization and benefit management services.
Pharmacy and Prescribing Information
Find information on ConnectiCare’s pharmacy programs and more.
Quality Improvement
Our Quality Improvement programs and information are developed, implemented, and evaluated to promote and preserve clinical excellence that fosters the safety and well-being of our members.
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Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.
Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.