Subsection 144-101-II-15.03 - ELIGIBILITY FOR SERVICESA. Individuals must meet the financial, residency and eligibility criteria as set forth in the MaineCare Eligibility Manual in order to be eligible for chiropractic services under this Section. Some members may have restrictions on the type and amount of services they are eligible to receive. It is the responsibility of the primary care provider or prescribing provider (MD,DO, PA, or APRN) who is licensed and acting within the scope of his or her license to verify a member's eligibility for MaineCare, as described in Chapter I, Section I of the "MBM", prior to the provision of chiropractic services.B. If the Centers for Medicare and Medicaid Services (CMS) approves, covered chiropractic services for members of all ages must be medically necessary for the diagnosis and treatment of a spinal condition, as determined in an initial evaluation by the chiropractor or his or her primary care provider or prescribing provider (MD, DO, PA, or APRN). The Department or its authorized agent has the right to perform eligibility determination and/or utilization review to determine if services provided were medically necessary.C. A member age twenty-one (21) and over must obtain a referral by his or her primary care provider or prescribing provider (MD, DO, PA, or APRN), who is licensed and acting within the scope of his or her license that documents the member's rehabilitation potential. The provider's documentation of rehabilitation potential must include the reasons used to support this expectation. New rehabilitation potential documentation must be re-authorized per episode of unrelated conditions. This referral requirement does not apply to members with Medicare coverage or other third party health insurance while meeting adeductible. This referral requirement will also not apply to members with Medicare coverage or other third party health insurance until the coverage for chiropractic services by the other payer has been exhausted.
D. If for any reason a course of treatment is discontinued for a period longer than one (1) year, the primary care provider or prescribing provider (MD, DO, PA, APRN) must re-evaluate the member following the guidelines specified in Section 15.03. C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-15, subsec. 144-101-II-15.03