C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-17, subsec. 144-101-II-17.09

Current through 2024-51, December 18, 2024

Subsection 144-101-II-17.09 - PROGRAM INTEGRITY AND QUALITY ASSURANCE

17.09-1Role of Department of Health and Human Services. DHHS or an Authorized Entity is responsible for Program Integrity, Quality Assurance and Utilization Review. Please refer to Chapter I of the MaineCare Benefits Manual for more information. DHHS is responsible for establishing, supporting, and maintaining quality assurance policies, licensing standards, and criteria and procedures for authorizing continuation of services in accordance with Section 17.04.

17.09-2Waiver Criteria. In certain circumstances, DHHS may authorize waivers of Section 17.09-3 Specific Requirements (eligibility), Section 17.04 Covered Services (authorization of the continuation of services or concurrent services), Section 17.05 Limitations (the limitations on certain services), and 17.07-2 Other Qualified Individuals (supervision of other qualified individuals) beyond the criteria set forth in this Section. All waiver requests must be submitted to the Authorized Entity.

A.Eligibility

Any request for a waiver of specific eligibility, as defined in Section 17.02-3, must explain why the member does not meet eligibility criteria and why the member is in need of services. The clinician must document that without the requested treatment, the member would likely deteriorate clinically to a point where the criteria in Section 17.02 will be met; or demonstrate that without the requested continuation of services, the member would be unstable or deteriorate further; and, there is a reasonable expectation that the defined service(s) will reduce the current symptoms of the member's mental illness.

B.Continuing or Concurrent Services

Any request for a waiver for continuing services or concurrent services as defined in Sections 17.04-4, 17.04-5, or 17.04 -6 must include documentation that the member has improved with the current service, the anticipated goals of the future services, the skills development methods to be used, and a summary of the member's progress to date. Any approval for future services will be of limited duration.

C.Limitations

Any request for a waiver of limits as defined in Section 17.05 including 17.05-2 "Multiple Providers", 17.05-3 "Concurrent Services", and 17.05-5 "Private Non-Medical Institutions", must include documented demonstration that without the requested services, the member would be unstable or deteriorate further. There must be clinical evidence that the defined service(s) will reduce the current symptoms of the member's mental illness and that the needed service(s) cannot be provided in a manner that does not require a waiver.

D.Supervision

Any request for a waiver of the supervision requirements as defined in Section 17.07-2 for Other Qualified Individuals must meet DHHS's licensing standards and approval. Documented approval from DHHS's Division of Licensing and Regulatory Services must be kept in the Other Qualified Individual's personnel file.

All approvals for waivers described above must follow the prior authorization timelines and requirements in Chapter I, Section 1.17 of the MaineCare Benefits Manual.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-17, subsec. 144-101-II-17.09