Prior Authorization Frequently Asked Questions

Choose the area you have questions in to find out more information. If you are unable to find the answers to your questions, feel free to contact us directly using the information on our "Contact Us" page.

Repair of Medical Equipment and Devices:

Q: How do I bill for repairs and modifications to items which show a fee of “List - 15” on the DSS MEDS Fee Schedules?

A: There is no change to the billing process for these services; the change is to the maximum that will be reimbursed without prior authorization. Repairs and modifications to items which show a fee of “List - 15” on the DSS MEDS Fee Schedule must be billed at the lesser of list minus 15% based on the Manufacturer’s Suggested Retail Price (MSRP), usual and customary, the amount authorized by DSS or the lowest Medicare price if available (see Section 17b - 262 - 679 of the Regulations of Connecticut State Agencies). Reimbursement is capped at 60% of the DSS allowed amount for a new piece of equipment. (See below) The HCPCS code for the item must be appended with the “RB” modifier indicating a repair or modification to an existing piece of DME.

Q: How do I bill for repairs and modifications to items which have a listed fee on the DSS MEDS Fee Schedules?

A: There is no change to the billing process for these services. Reimbursement is capped at the amount indicated on the fee schedule. Repairs or modifications priced greater than the "Maximum Fee" amount listed on the fee schedule require prior authorization. When billing, the HCPCS code for the item would be appended with the "RB" modifier.

Q: How do I bill for repairs and modifications where the cost to repair the item is more than 60% of the DSS fee schedule allowed amount for a new piece of equipment?

A: There is no change to the current billing practice. However, if the cost to repair the items is greater than 60% of the DSS fee schedule allowed amount for a new piece of equipment, the item must be prior authorized. With the PA request, the vendor must provide documentation indicating that the repair exceeds 60% of the purchase price along with pricing information. When billing, the HCPCS code for the item would be appended with the “RB” modifier.

In some instances, when the cost to repair the item is more than 60% of the DSS fee schedule amount for a new piece of equipment, it is more cost effective to replace the item versus repair the item. A prior authorization request must be submitted along with (1) comparative documentation validating why it is more costly to repair the item than to provide a replacement, and (2) warranty information. When billing, the HCPCS code for the item would be appended with the “NU” modifier.

Q: How do I bill for repairs to a custom wheelchair?

A: The DSS Fee Schedule should be referenced. If a repair is needed to a specific part of the wheelchair, then the specific HCPC code should be used. The DSS Fee Schedule identifies which codes require prior authorization for a repair, using the appropriate RB modifier.

Code K0108 RB will require prior authorization if the total dollar amount is greater than $1,000.00.

Q: When is it appropriate to use the "RB" modifier when billing for a DME component/item?

A: The "RB" modifier should be used for repairs only. If the equipment needs to be fully replaced, it is considered a new purchase and a prior authorization request must be submitted.

Additional billing guidelines may be found in Chapter 8 of the MEDS Provider Manual, on the DSS website, From the home page, select "Information" and then "Publications."

Home Care & Outpatient Therapies

Q: Which outpatient request form should be used?

A: Here is the most recent form for outpatient authorization requests.

Q: If a request is made for two different modalities, can they be billed on one claim?

A: Yes. Providers can submit all modalities for the member on one claim form.

Q: What type of clinical information should be submitted with the prior authorization request?

A: Please continue to submit the same clinical information that has been submitted previously for all requests.

Q: What is the difference between an initial and a reauthorization request?

A: For members who have never been serviced by your agency before under Medicaid, the request submitted will be an INITIAL request. For members who have been serviced by your agency under Medicaid, the request will be for REAUTHORIZATION, no matter what the modality. The first submission for prior authorization of a service is considered an initial request. Also, any new requests for authorization of an initial care plan will be submitted as an initial request. Reauthorization requests are any subsequent, continued reviews of a care plan after an initial request is submitted.

Q: Once I have submitted my request, may I update the request via Clear Coverage?

A: Additional clinical information may be included once the request via Clear Coverage is submitted, if the status of the authorization has not moved from pending to another status. Additional updates such as additional modalities or extensions of services must be sent via fax or phone to the Prior Authorization Department.

Inpatient Admissions

Q: Should a request for authorization be submitted for members placed in Observation?

A: No, authorization is not required for observation stays.

Q: Should reviews be submitted for Observation admissions?

A: If an observation stay changes to an admission, an authorization is required.

Q: What admission date should be entered into Clear Coverage when a patient coverts from Ambulatory/Observation stay to an inpatient admission?

A: The admission date entered should be the day of the inpatient order.

Q: If one user initially entered the authorization request, can additional information be submitted or attached in Clear Coverage by another user?

A: Yes, any registered Clear Coverage user within the facility may edit, cancel, or submit additional information to an authorization record.

Q: If the admitting department initially enters an authorization request, can someone else from the facility attach additional information?

A: Yes, additional information or clinical review may be attached by another registered user.

Q: Can the fax cover sheet be printed at the time of initial admission notification?

A: The fax cover sheet cannot be printed until the initial authorization request has been submitted. Please remember each fax cover sheet may be used one time only and will attach the faxed information to the member authorization record. You will need to print a new fax cover sheet with each submission of clinical information.

Q: Will a prior authorization be required for members with Medicaid as a secondary payer?

A: Authorization for inpatient admission is required for members with other insurance. Authorization for members with Medicare as their primary insurance is only required when they have exhausted their Medicare Part A benefit or have Medicare Part B coverage only.

Q: Is authorization required for admission for members with Medicare Part B only?

A: Yes, an authorization is required.

Q: If a member is admitted for routine delivery and does not deliver until the following day, is an authorization required?

A: No, an authorization is not required. However, a notification of delivery should be submitted to CHNCT via fax.

Q: How is a request for authorization submitted for a member admitted for detoxification on a medical unit?

A: Admissions for which the primary focus of treatment is related to detoxification or treatment of withdrawal from alcohol, opiates, anxiolytics or sedative hypnotics, or other conditions related to alcohol use, abuse or dependence must be submitted to CT BHP for prior authorization, with the exception of medically necessary admissions to an Intensive Care Unit (ICU). Admissions to an ICU should be submitted to Community Health Network of Connecticut, Inc. (CHNCT).

Q: Is a second authorization required when a member is admitted to a medical unit and is then transferred to a behavioral health unit?

A: When CHNCT is the authorizing entity upon admission, a second authorization would be required by CT BHP when transferring a member to a behavioral health unit.

Q: If a patient comes in as a self-pay and later obtains Connecticut Medicaid, do we need to send the $100.00 check?

A: No, the $100 fee is for special retrospective reviews resulting from untimely notification of an admission. Retrospective reviews that result from retroactive eligibility must be submitted within 90 days of eligibility being granted. They are submitted with the Verification of Eligibility (VOE) and clinical information. In this case, the $100 fee is not necessary. These are faxed in and not entered through the Medical Authorization Portal (Clear Coverage).

Quick Tips

Q: For questions on status of authorization or clinical questions about an authorization, who do I contact?

A: For questions on status of authorization or clinical questions about an authorization, please contact CHNCT Utilization Management at 1.800.440.5071, option #2 (for authorizations).

Q: What should I do if I can’t find the requesting (ordering) clinician in the Medical Authorization Portal (Clear Coverage)?

A: Please select Default Provider, Provider as the requesting clinician. However, the user must also provide the name of the ordering provider in a note on Tab six. Only providers who are registered with the State of Connecticut as a CMAP provider may request services.

Q: Can I enter additional information after the authorization request has been submitted?

A: Yes, only notes and attachments may be entered once the authorization request has been submitted. All other changes, for example a change to the admission date, must be called in or faxed to CHNCT.

Q: Can I change the answers to the medical questions after I submit the authorization?

A: No, after an authorization has been submitted, you cannot edit the answers to questions previously answered. You can, however, add notes or attach additional information.

Q: Can I cut and paste documentation from another clinical system?

A: Yes, you may cut and paste information into the notes section in Clear Coverage. There is a 3,970 character limit but, additional information may be submitted as an attachment (up to 5 MB) at this time.

Q: Is there a specific format that needs to be followed with regard to the notes section?

A: No, but for inpatient notifications the following information should be included: the Medical Record number, campus where the member is being admitted and contact information.

Q: If I am responsible for obtaining authorizations for multiple organizations, will I be able to request authorizations for more than one organization?

A: Yes, you will have one user ID that will allow you to access all organizations that you are a registered user for.

Q: What timeframe does the Medical Authorization Portal (Clear Coverage) allow users to enter authorization requests for?

A: Authorization requests and notifications must be submitted within 2 business days of the service or admission. Clear Coverage will allow a user to enter for admission notifications 5 days in the past to account for long holiday weekends.

Q: What data elements are required to search for a member when requesting a new authorization?

A: To perform a search, criteria must be entered for: Medicaid ID and Date of Birth.

Q: If the eligibility lookup in the Medical Authorization Portal (Clear Coverage) does not match the DSS Automated Eligibility Verification System (AEVS), what should I do?

A: The eligibility lookup does not replace the DSS AEVS; please continue to use the DSS AEVS if a record of the transaction is required. If the member does not display and the DSS AEVS shows the member as eligible, please fax the request for services to 203.265.3994.

Q: How should authorization requests be submitted?

A: CMAP providers can submit requests for authorizations for inpatient admissions, home healthcare services, durable medical equipment and outpatient therapies via Clear Coverage, or by phone at 1.800.440.5071, option #2 (for authorizations), or via fax at 203.265.3994. Use this form for authorization requests submitted via fax.

Q: Can I reuse fax coversheets generated via Clear Coverage?

A: No, please do not reuse the fax coversheet as it is unique to each authorization request. Print off a new fax coversheet for additional new information for the authorization request that is being faxed.

Q: Why do I see multiple lines on my home page when I have only submitted one request for a member?

A: Clear Coverage creates a line for each service requested.

Q: Why is the submit button grayed out (i.e. can’t submit the authorization request)?

A: If you are unable to submit the authorization request, place your mouse over the grayed out submit button. The system will display a message advising the user what is missing.

Q: Where will the authorization dates display?

A: Authorization dates are posted in Clear Coverage in the notes section when a determination is made regarding the request.

Technical Support

Q: How do I request a username and password for the Medical Authorization Portal (Clear Coverage)?

A: Please contact the Clear Coverage Help Desk via phone at 1.877.606.5172 or 203.626.7105 and select the Clear Coverage prompt #3. You can also email the Clear Coverage Help Desk.

Q: How do I log into the Medical Authorization Portal (Clear Coverage)?

A: Step 1: The link can be accessed by going to Select “For Providers” in the left menu.
Step 2: The Prior Authorization Main page will have a Medical Authorization Portal button. Clicking the button will display the Clear Coverage Login Screen.
Step 3: To Register for Clear Coverage, users must complete the request for access form. CHNCT will provide the username and password that will be required to sign into Clear Coverage via a secure email. Upon the first log on, Clear Coverage will prompt the user to create a new password.

Q: Who can register to use the the Medical Authorization Portal (Clear Coverage) to submit a prior authorization or an admission notification?

A: Effective May 1, 2012, staff associated with inpatient admission notifications, home care and outpatient hospital-based therapy only, may request access to Clear Coverage. There is no limit to the number of users within an organization that can register as a user for Clear Coverage.

Q: Who should I contact if I am unable to log into the Medical Authorization Portal (Clear Coverage) or have technical issues?

A: For any Technical Issues, please contact the CHNCT Help Desk at 1.877.606.5172. Please press prompt #3 for Clear Coverage Technical Support regarding login or technical issues. Standard hours of operation are Monday - Friday 9:00 a.m. – 4:00 p.m.

Q: What version of Adobe Reader is needed?

A: Version 9.X or later.

Q: Why can’t I log into Clear Coverage from my iPad?

A: Clear Coverage is a flash-based application and is not compatible with the iPad.

Q: What is the timeframe for password expiration?

A: Passwords are good for 60 days. After that time, you will be prompted to change your password.

Q: Is there a session time out on the application?

A: After 15 minutes of inactivity, the system will log you out and return you to the login page.

Q: If an employee with a user login has left the practice, how do I cancel the login?

A: Please contact the CHNCT Help Desk at 1.877.606.5172 or email the Clear Coverage Help Desk and they will deactivate the user.

This portion of the HUSKY Health website is managed by Community Health Network of Connecticut, Inc., the State of Connecticut’s Medical Administrative Services Organization for the HUSKY Health Program. For the general HUSKY website gateway, please visit HUSKY Health includes Medicaid and the Children’s Health Insurance Program, and is administered by the Connecticut Department of Social Services.