If claim is for ED admission – please submit ED clinical notes.

If claim is for MD consultation/office visit – please submit consultation/office visit notes.

If claim is for an inpatient admission – please submit admission notes and discharge summary.

If this is a professional claim that is part of an inpatient admission, please complete field 18 (Hospitalization Date: From and To Date) on the claim form.

Please submit all OOS inpatient & outpatient retrospective claims to Gainwell Technologies at PO Box 2991, Hartford CT 06104. Gainwell Technologies will scan all claims into their Contact Tracking Management System (CTMS) and forward appropriate claims electronically to the Connecticut Department of Social Services Medical and Clinical Consultants Team (MCCT) for review. Claims will be approved if services meet the necessary criteria for OOS services below:

• Medical emergency or
• Clients health would be endangered if required to travel to Connecticut for care or
• Needed medical services are not readily available in Connecticut or
• Child for whom the Department makes adoption assistance or foster care maintenance payments resides outside of Connecticut or
• General practice for clients in a particular locality of Connecticut to use medical resources of another state.

Please see the OOS Provider Enrollment and Re-enrollment information outlined in Chapters 2 & 3 of the provider manual on Web portal:
https://www.ctdssmap.com/CTPortal/Information/Publications

Once a determination is made, claims will be returned electronically to Gainwell Technologies. Gainwell Technologies will contact the provider if further action is required.

Please contact CHN CT at 1-800-440-5071, Option 2, for all OOS PA requests. CHN CT will give authorization if the requested service/s is medically necessary and meets the criteria outlined above. If request is authorized, CHN CT will notify provider and refer the provider to Gainwell Technologies, our claims contractor, to begin the enrollment process. If authorization is denied, CHN CT will notify both the provider and the member.