C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-45, subsec. 144-101-II-45.06
Accommodations in a private room will not be reimbursable unless they meet conditions spelled out in Section 45.05-5 above. Hospitals may not bill a MaineCare member for the difference between a private room rate and a semi-private room rate unless the member requests a private room and signs a written statement acknowledging that he or she is to be billed the difference.
Routine physician visits are not reimbursable for members awaiting placement in a NF or in swing beds.
MaineCare will not reimburse for a hospital admission that is not certified by a utilization review.
The only exception to this policy is when a member is admitted prior to utilization review for an acute condition that requires medically necessary treatment that is only available in a hospital and it is medically necessary for the treatment to be delivered prior to the time it feasible for the case to be reviewed. Services rendered prior to the review are not reimbursable unless the utilization review is conducted within one (1) business day of the admission. (For example, if a member is admitted on a Friday at 6:00 P.M., is first reviewed on Monday at 11:00 A.M. and denied at that time: three (3) days are reimbursable.) The member or responsible party must be notified in writing if these criteria will not be met and all or part of the admission will not be a MaineCare covered service; and must sign an acknowledgement of financial responsibility for this non-covered service.
MaineCare will not reimburse for any days awaiting placement or NF level services providing swing beds that have not been approved by the Department or its Authorized Agent.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-45, subsec. 144-101-II-45.06