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Out of State (OOS) Claims Submission information for Retrospective Services
 
If claim is for ED admission – please submit ED clinical note.
If claim is for MD consultation/office visit – please submit consultation/office visit notes.
If claim is for an inpatient admission – please submit admission note 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 Hewlett Packard Enterprise at PO Box 2991, Hartford CT 06102. DXC Technology 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/tabid/40/Default.aspx
Once a determination is made, claims will be returned electronically to DXC Technology. DXC Technology will contact the provider if further action is required.

 
Request for Prior Authorization (PA) for Out of State (OOS) Prospective Services
 
Please contact CHN CT at 1-800-440-5071, Option 2, for all inpatient OOS PA requests. CHN 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 DXC Technology, our claims contractor, to begin the enrollment process. If authorization is denied, CHN CT will notify both the provider and the member.
Please contact the Connecticut Department of Social Services Medical and Clinical Consultants Team (MCCT) for all OOS outpatient services PA request at (860) 424-5192. The team will approve the request based on medical necessity and the criteria outlined above. Once verbal approval is given, the provider will be referred to our claims contractor (DXC Technology) to begin the enrollment process. If the request is denied, both provider and member will be notified.

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