C.M.R. 10, 144, ch. 101, ch. I, § 144-101-I-1, subsec. 144-101-I-1.17
The Department or its Authorized Entity is responsible for carrying out a series of safeguarding measures. These measures safeguard against excessive payments, unnecessary or inappropriate utilization of care and services, and assess the quality of services available under MaineCare. The Department may use consultants and peer reviewers with expertise appropriate to the medical care or services to be reviewed.
Delegation of any utilization review activities pertaining to length of stay in acute care hospitals will be carried out in accordance with the hospital's utilization review program/plan.
The Department has the authority to request medical records and other records as necessary to support utilization review, utilization management, concurrent review, or other service review activities. Providers must respond to the requests in a timely manner and at no charge to the Department.
The Department uses a behavioral health managed care system for all members receiving selected behavioral health services that are covered by MaineCare to ensure access to appropriate care and improve member outcomes.
The Department's Administrative Services Organization (Authorized Entity) is used for eligibility verification, utilization management, and for examination of clinical appropriateness for selected services as identified in the behavioral health services sections of the MBM. The Authorized Entity performs the following duties: facilitates referrals to appropriate service providers; prior authorizes selected services; expedites delivery of services to members in need of treatment; tracks the service status of members enrolled in the system; and gathers data that will inform the Department of resource development needs. The Department's goal is to promote early intervention of services provided to avoid unnecessary reliance on emergency and inpatient services. All providers must submit notification of their intent to initiate behavioral health services identified in the MBM prior to the start of services for all members. The Department's Authorized Entity must have prior notification of services for utilization review purposes to assess the medical necessity, efficiency, appropriateness of services and treatment plans on a prospective, concurrent or retrospective basis.
Please refer to the appropriate Sections of the MBM for additional requirements and information on behavioral health managed care.
C.M.R. 10, 144, ch. 101, ch. I, § 144-101-I-1, subsec. 144-101-I-1.17