Prior authorization (PA) is required for certain services. The PA requirement is spelled out in each section of other Chapters of this Manual whenever it applies to a covered service. In addition, management of high cost member services and/or supplies may require PA by the Department or its Authorized Entity.
1.14-1In-State ServicesA. The dated and signed request for PA must be made by the member's provider in writing and sent to the MaineCare Prior Authorization Unit, or as appropriate, to the Department's Authorized Entity or any other office as required by the Department and provided in other sections of this Manual. For PA, contact information and where to send completed PA forms, visit the MaineCare Services website at: https://mainecare.maine.gov.
A request for prior authorization must be signed by the provider and must include:
1. Member's name and MaineCare identification number;2. Diagnosis for which the request is being made;3. The procedure(s) requested and its/their corresponding code(s); 4 Date(s) of the scheduled procedure, if known;5. The billing provider ID number of the physician and/or physicians practice or other authorized provider that will render the requested service(s), if known;6. All clinical records to support the requested service (describing diagnostic studies and treatment completed to date along with results, and clinical records upon which the request has been made); and 7. Additional information as determined by the Department or its Authorized Entity.B. PA may be effective for up to twelve (12) months as determined by medical criteria and documentation of ongoing necessity. In some cases, for covered health care expenditures that require PA, financial eligibility for medical services may be determined retroactively. MaineCare will provide reimbursement for these services if it can be shown that all Departmental requirements were met at the time the services were performed.C. For enrolled MaineCare members, the provider must verify the need for PA with the Department and subsequently, ensure that authorization has been obtained when applicable. This must be done priorto provision of services, except in cases of medical emergency, or as described in Section 1.14-2(B). D. Notwithstanding any other provision herein, MaineCare Services or its Authorized Entity shall act on requests for PA with reasonable promptness and shall adjust the time periods specified herein as circumstances require. In circumstances that do not require an immediate decision, MaineCare Services or its Authorized Entity will make a decision to authorize or deny the request for PA within thirty (30) days of the receipt of the completed request, or thirty (30) days after the date the application is determined to be complete following a decision in an administrative hearing as provided herein, or services will be considered authorized. MaineCare Services will notify the provider and member of the decision.E. The thirty (30) day provision regarding the treatment of complete requests shall not apply in the case of an emergency. In the case of an emergency, the PA decision will be made expeditiously to address the emergency, including notifying the provider of an incomplete request.F. Providers that submit an incomplete request for authorization of services will be notified within thirty (30) days of receipt of the incomplete request. MaineCare Services or its Authorized Entity will defer the request until the specific additional information necessary to complete the request is received. Such notice shall be sent to the provider and member, within thirty (30) days of receipt of the incomplete request and shall clearly identify the following: 1. The information necessary to complete the request;2. Specific citation of the regulations requiring the information; and 3. The name and telephone number of the person in MaineCare Services or its Authorized Entity, who should be contacted should the provider and/or member have questions regarding the deferral.G. The member's provider shall make a reasonable effort to submit to MaineCare or its Authorized Entity the information requested within thirty (30) days from the date that notice is received that it is incomplete, failing which the application may be considered abandoned and may be denied for that reason. Any notice that an application is incomplete, sent out by MaineCare or its Authorized Entity, more than thirty (30) days from the date the original application was filed with MaineCare, shall be considered an adverse action by MaineCare. Such notice shall be accompanied with a statement advising the applicant of an opportunity for an administrative hearing to challenge the determination that the application is incomplete.
In the case of a notice of incompleteness given more than sixty (60) days from the date the original application was filed, the statement shall advise the applicant of an opportunity for an administrative hearing to determine not only whether the application is complete, but, in the event that it is deemed so, whether MaineCare Services should be ordered to take final action on the application within ten (10) days. Any such order by the administrative hearing officer shall provide that the request shall be considered authorized if a decision is not made within such ten (10) day period.
H. Once approval has been given, if the provider originally requesting PA is unable or unwilling to provide the service requested within a reasonable time, the member may choose another provider. The second provider is responsible for notifying MaineCare Services of his/her intention to provide the service subject to the initial approval. MaineCare Services, upon request, will assist the member in attempting to locate a provider when the member is unable to do so.I. If the request for prior authorization is denied, MaineCare or its Authorized Entity will clearly explain the denial reasons in the denial notice. This explanation shall include any facts, circumstances, calculations, and other data that were used as a basis for making the denial and shall specify any additional information that could be supplied, by the provider or member, to permit the request to be approved. This explanation shall be set forth clearly and conspicuously and shall be phrased, to the extent possible, in simple terms easily understandable by a layperson.J. MaineCare will not deny a request for services without examining the nature of the request to determine whether any portion of the services requested or reasonable alternative services thereto might be covered by MaineCare. A notice of denial shall be given when the services requested are denied in whole or in part. If a portion of the request is covered under MaineCare and a portion is not, MaineCare or its Authorized Entity shall give notice of a denial of only those services not covered and shall give approval of those services that are covered.
K. MaineCare Services or its Authorized Entity shall promptly refer requests for PA for mental health services not covered (or for the portion of services not covered for partially denied services) by MaineCare to DHHS, Adult Mental Health Services or Children's Behavioral Health Services. Such referrals will be made within three (3) business days of the determination that mental health services requested are not covered by MaineCare and shall be made to the appropriate regional office of DHHS by telephone or electronic mail or other method to ensure that the referral is received as soon as practicable. Any denial of requested services, in whole or in part, shall be accompanied by a statement advising the applicant of a right to an administrative hearing. If an applicant chooses to request a hearing, the request shall be made no later than thirty (30) days from the date of receipt of the notice and, if requested, MaineCare Services or its Authorized Entity, shall forward the request to the DHHS Division of Administrative Hearings (DAH) within twenty-four (24) regular business hours (that is, by the next day if not a holiday or weekend) and a hearing shall be held within seven (7) working days thereafter. (See Sections 1.23 & 1.24).
L. When a participating provider furnishes a service or equipment and has either failed to request PA or has been notified that PA has been refused, that provider is liable for the costs of those services and that provider may not bill either the Department or the member for such care or services, except in the following situation: Prior to the provision of the services the member shall acknowledge in writing that he or she is aware that PA has not been granted and, therefore, MaineCare will not pay for the services and that he or she accepts financial liability to pay for the services. In addition, if and when a member chooses not to utilize the PA process, the service is considered non-covered by MaineCare if the member acknowledged in writing that he or she understood that he or she would assume financial responsibility for the service.
1.14-2Out-Of-State ServicesUnless otherwise allowed in Chapter II of this Manual, medical care that is covered under MaineCare that is only available outside the State of Maine requires prior authorization. MaineCare will not guarantee payment for services received out-of-state unless PA has been granted pursuant to the procedure outlined in Section 1.14-2(A).
The provider is responsible for verifying the need for PA and subsequently, that authorization has been obtained from the Department or its Authorized Entity when applicable. This needs to be done priorto provision of services, except in cases of medical emergency, or as described in Section 1.14-2(B).
PA for services will be granted to out-of-state providers for covered services described in this Manual, only when a member's continuity of care must be preserved for medical reasons and only after it is determined that the needs of the member cannot be met in the State of Maine.
Notwithstanding any other provision herein, MaineCare Services or its Authorized
Entity shall act on applications for PA for out-of-state services with reasonable promptness and shall adjust the time periods specified herein as circumstances require.
If the request for PA is denied, MaineCare or its Authorized Entity will clearly explain the reasons for denial in the denial notice. This explanation shall include any facts, circumstances, calculations, and other data that were used as a basis for making the denial and shall specify any additional information that could be supplied, by the provider or member, to permit the request to be approved. This explanation shall be set forth clearly and conspicuously and shall be phrased, to the extent possible, in simple terms easily understandable by a layperson.
A. Procedure and Requirements for Out-Of-State Services The procedure to request prior authorization is as follows:
1. Each member must be currently under the care of a licensed professional providing physician services, or a recognized primary care provider acting within the scope of his/her license, and practicing in the State of Maine, or within fifteen (15) miles of the Maine/New Hampshire border.2. The request for PA must be made by the Maine physician for services provided out-of-state. Criteria for PA of out-of-state services shall be as set forth in this Chapter and in the specific section of this Manual covering those services. PA contact information and prior authorization forms can be found at http://www.maine.gov/dhhs/oms/provider_index.html.3. The request must be made at least thirty (30) calendar days prior to the date medical care/services are to be provided in another state. The only exception would be for medical or behavioral health emergency cases. In cases involving such an emergency, the PA decision will be made as soon as necessary to relieve the emergency. Emergency cases will be given special consideration and should be so identified by the physician or provider requesting approval.
Telephone requests, which must be followed by written materials, will be accepted only in emergency situations. Faxed requests are allowed.
4. The provider's request for PA must include:b. Member's MaineCare identification number;c. Diagnosis (describe diagnostic studies and treatment completed to date along with results, and clinical records upon which the request for out-of-state referral has been made). Send clinical records to support diagnosis and referral;d. Names of physicians and/or facilities that the member has previously been referred in Maine for diagnosis and/or treatment. Include second opinion documentation;e. Physicians consulted by attending physician relative to availability of diagnosis and/or recommended treatment in Maine. Send second opinion documentation supporting out-of-state referral;f. Recommended treatment or further diagnostic work;g. Reasons why medical care cannot be provided in Maine or the next closest location outside the State;h. Names of physicians and facility outside of Maine to provide services and date of appointment(s) if known, and i. Additional information if specified in applicable Chapters of this Manual. 5. If additional information is needed or it appears that the service may be available within the State, the Department or its Authorized Entity reserves the right to require that the patient seek consultation and/or treatment from providers of the service within the State.6. The reviewing Department or its Authorized Entity will notify the provider and member of approval or disapproval. If approved, a letter will be sent to the member and the out-of-state provider(s) authorizing medical care. The out-of-state provider must enroll as a MaineCare provider for the State of Maine and must accept MaineCare reimbursement as payment in full for the covered services authorized. The Department reserves the right to set rates for services. If disapproved, an explanation will be given, and notice of the member's right to request an administrative hearing will be given.7. The procedures for granting, denying and processing requests for in state services, as set forth in Section 1.14-1, shall apply to requests for out-of-state services.8. Once approval has been given, if the provider originally requesting prior authorization is unable or unwilling to provide the service requested within a reasonable time, the member may choose another provider. The second provider is responsible for notifying the applicable Department of his or her intention to provide the service subject to the initial approval and conditions set forth above. The applicable Department, upon request, will assist the member in attempting to locate a provider when he or she is unable to do so.9. The attending physician in the State of Maine is expected to perform follow up for medical procedures provided out-of-state, unless medical necessity requires return to the out-of-state provider. Therefore, it is expected that the referring physician will receive medical reports of services provided by the out-of-state provider and follow the above procedures for any required out-of-state follow up.B.Exceptions MaineCare will evaluate claims for MaineCare services rendered to eligible members out-of-state without prior authorization only under the following circumstances.
1. Emergency medical services rendered to members who are temporarily absent from the State, and for which they cannot reasonably be expected to return to Maine or because the member's health would be endangered if required to travel back to the State of Maine. Out of state emergency medical services will be reviewed for medical appropriateness. Providers must notify the Department, or its Authorized Entity, within one (1) business day of an emergency admission for a MaineCare member. For inpatient emergency services, the provider must seek and receive approval for an appropriate length of stay, determined by the Department or its Authorized Entity, based on the evidence of medical necessity provided in the member's medical documentation. In order to be reimbursed by MaineCare for emergency inpatient services, the provider must submit an authorization number on the claim form submitted to the Department. In cases where the provider is unable to confirm proof of MaineCare coverage (e.g. member is unconscious, or the member does not have MaineCare card readily available), the provider may exceed the one-day requirement by providing a sufficient explanation of the case.2. MaineCare covered services rendered to eligible members who intend to remain out-of-state. The Office of for Family Independence will determine when MaineCare coverage will terminate.3. MaineCare covered services rendered to eligible members by qualified providers within fifteen (15) miles of the Maine/New Hampshire border.4. MaineCare covered services rendered to persons prior to their date of application, when eligibility is determined retroactively to cover the time period in which the services were provided.5. MaineCare covered services received by qualified Medicare beneficiaries out-of-state when the providers have accepted Medicare assignment and only the deductible and coinsurance are to be billed.6. MaineCare covered services provided through out-of-state, culturally appropriate, alcohol treatment and substance abuse services, that are fully reimbursed (100%) by Indian Health Service funds, and provided by enrolled MaineCare providers. These services are subject to post payment review by the Division of Program Integrity. C. Specific Requirements for Behavioral Health Emergencies and Mental Health Services for Children Requests involving behavioral health emergencies are in a unique group that does not require PA.
1. The definition of a behavioral health emergency is as follows: The member displays significant, prolonged, escalation of volatile or suicidal behaviors to the point that the parent, guardian, or service provider is unable to reasonably assure the safety of the member and/or others. There must be clinical documentation of professional inability to secure safety, as well as inability to obtain the necessary behavioral health emergency services in the State of Maine.
1.14-3Early and Periodic Screening, Diagnosis and Treatment ServicesMaineCare Services shall take reasonable and necessary steps to ensure that all requests for PA of services for MaineCare members under age twenty-one (21) are not denied without first taking reasonable steps to determine if the services can under the MBM, Section 94, Early and Periodic Screening, Diagnosis and Treatment Services. Reasonable steps may include, but are not limited to, contacting the provider to inform the provider of the EPSDT for these treatment services. Such services include those medically necessary treatment/diagnostic services and other measures provided to correct or ameliorate conditions discovered during a screening performed under the EPSDT benefit and are described in a member's comprehensive plan of care.
These MaineCare covered services are furnished in accordance with the Omnibus Budget Reconciliation Act (OBRA) of 1989 and are covered under federal regulations.