C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-101, subsec. 144-101-II-101.06

Current through 2024-51, December 18, 2024

Subsection 144-101-II-101.06 - POLICIES AND PROCEDURES

101.06-1 Medical Imaging Services

The professional, administrative and technical components of a medical imaging procedure are covered when medically necessary and provided by, or provided under the supervision of a physician practicing within the scope of his or her profession as defined by state or provincial law. All imaging procedures must be performed with appropriately licensed equipment operated by appropriately licensed or certified staff. It is the responsibility of the imaging provider to assure compliance with all current federal, state or provincial guidelines and regulations, maintain appropriate records and provide documentation upon request.

Additionally, any mammography services (including but not limited to, breast cancer screening or diagnosis through mammography) must be provided in accordance with the MQSA, Public Law 102-539 and any applicable regulations of the FDA. A mammography facility must possess a current certificate issued by an accredited body and maintain compliance with State of Maine radiation regulations or those of the province in which services are provided. It is the responsibility of the mammography facility to provide the MaineCare Program with current, as well as any updated Certificate(s). Certificate renewals must be provided to MaineCare before expiration of the previous certificate.

The professional component includes the following services:

1. determining the presenting problems, by interviewing the member, obtaining member history and making appropriate physical examination to decide upon the method of performing the medical imaging procedure; and

a. performing the procedure, including instructing technologists or other assistants; and/or

b. performing diagnostic, therapeutic, or screening procedures personally; and

2. if necessary, checking radiographs or checking preliminary readings in radioisotope studies; and

3. studying and evaluating results of diagnostic or therapeutic procedures, interpreting radiographs or radioisotope data, or estimating results of treatment; and

4. dictating report of examination or treatment; and

5. consulting with the referring physician regarding the results of the diagnostic or therapeutic procedures.

The professional component as a separate service is a covered service only when provided by a qualified physician.

The administrative and technical components include services associated with technologists, clerical staff, films, opaques, radioactive materials, chemicals, drugs or other materials, purchase, rental use or maintenance of space, equipment, telephone service or other facilities or supplies.

101.06-2 The Division of Program Integrity

See the MaineCare Benefits Manual (MBM), Chapter I for the Division of Program Integrity procedures.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-101, subsec. 144-101-II-101.06