C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-65, subsec. 144-101-II-65.07
Only services included in the ITP will be reimbursed. Reimbursement will be allowed for covered services prior to the approval of the initial ITP, when the provider obtains subsequent approval of those services within thirty (30) days of the date the member begins treatment.
Some services in this section require Prior Authorization, including Crisis Residential, Children's Assertive Community Treatment, Children's Home and Community Based Treatment and Collateral Contacts for Children's Home and Community Based Treatment. Prior Authorization may not be required for members with a diagnosed Opioid Use Disorder seeking Intensive Outpatient Therapy Services. Prior Authorization criteria can be found at: https://mainecare.maine.gov/ProviderHomePage.aspx After submitting a Prior Authorization request the provider will receive Prior Authorization with a description of the type, duration and costs of the services authorized.
The provider is responsible for providing services in accordance with the Prior Authorization letter. The Prior Authorization number is required on the CMS 1500 claim form. All extensions of services beyond the original authorization must be Prior Authorized by this same procedure.
All other services in this section require notification of initiation of services for Utilization Review purposes.
A treatment episode includes face-to-face visits and related follow up phone calls, as clinically indicated, up to (60) days after the first face to face visit. DHHS Office of Child and Family Services (OCFS) or Office of Behavioral Health (OBH) Medical Director or Designee may approve additional time, if medically necessary and clinical documentation supports the need for the service. Crisis resolution services will cover the time necessary to accomplish appropriate crisis intervention, collateral contact, stabilization and follow-up. When increased staffing is necessary to ensure that a member receives necessary services while the safety of that member is maintained, MaineCare reimbursement for these services will be made to more than one (1) Clinician and/or other qualified staff at a time. Providers must maintain documentation of the necessity of this treatment.
More than one agency may be reimbursed for crisis contacts and respective face-to-face follow-up contacts for children and adult crisis resolution services only when the two agencies have a formal agreement or sub-contract stipulating one (1) or more agencies deliver phone services and the other agency (or agencies) provide follow-up, and face-to-face services.
Prior Authorization for up to seven (7) consecutive days, beginning with the date of admission must be obtained for all medically necessary Crisis Residential Services. Providers may not provide Crisis Residential Services for longer than the seven (7) day period, unless DHHS or an Authorized Entity has Prior Authorized an extension of the seven (7) day period of service and the extension is medically necessary.
Comprehensive Assessments are limited two (2) hours or eight (8) units annually and to only those needed to determine appropriate treatment, such as whether or not to treat, how to treat and when to stop treating. Reimbursement for a Comprehensive Assessments does not include psychological testing. Reimbursement for Comprehensive Assessments shall not exceed two (2) hours or eight (8) units annually, except when a member requires a change in the level of care or a new provider, an additional one (1) hour or four (4) units will be authorized for the provider of the new service to do an addendum to the original Comprehensive Assessment.
Additional Comprehensive Assessments of two (2) hours or eight (8) units may be authorized during the same year if a copy of the existing annual assessment cannot be obtained after reasonable efforts or if the member chooses not to authorize access to the existing assessment.
For members, individual and Family mental health or co-occurring individual outpatient is limited to two (2) hours per week except when a member requires services for an emergency or crisis situation or when a service is medically necessary to prevent hospitalization. For members, individual and Family outpatient for those needing interpreter services will be limited to three (3) hours per week. For members, substance use individual and family outpatient is limited to three (3) hours per week.
MaineCare reimbursement for individual outpatient will be made to only one (1) provider at any given time unless temporary coverage is provided in the absence of the usual provider. A member may receive mental health individual outpatient and substance use individual outpatient concurrently from two (2) separate providers in accordance with the individual service limits. If a member is receiving integrated Co-occurring Services with one (1) provider for a mental health and a substance use diagnosed condition; the member may not also receive separate mental health or substance use individual outpatient therapy services under Section 65 Behavioral Health Services.
The provider billing for the member is responsible for maintaining all clinical records relating to that member.
Intensive Outpatient Program Services must be delivered for a minimum of three (3) hours per day, three (3) days a week. A provider may not be reimbursed for delivering more than one (1) outpatient service to a member at the same time. An outpatient service is Outpatient Services as described in (65.05-3), Intensive Outpatient Program Services (IOP) as described in (65.05-5), or Opioid Treatment Program Services with Methadone as described in (65.05-11).
IOP group services require a minimum of three (3) members. If more than ten (10) members attend, two (2) qualified staff must conduct the group. Reimbursement for IOP group services is allowed if more than three (3) members are scheduled for the group but only three (3) or fewer members attend due to unavoidable circumstances.
Members may receive additional outpatient services as medically necessary when the treating condition(s) is distinct from the condition(s) addressed by the IOP.
Medication management limits for reimbursement are as follows:
All subsequent sessions for medication management and evaluation are limited to thirty (30) minutes. Any additional time beyond the thirty (30) minutes is considered outpatient counseling and is only reimbursable if it is a covered outpatient service, as defined in this Section. Providers must have documentation in their records to support those billings. Providers may bill for only one encounter with a member per day.
Psychological testing includes the administration of the test, the interpretation of the test, and the preparation of test reports. Psychometric testing does not include preliminary diagnostic interviews or subsequent consultation visits. Reimbursement for psychological testing will be limited to testing administered at such intervals indicated by the testing instrument and as clinically indicated.
Psychological testing is limited to no more than four (4) hours for each test except for the tests listed below. Providers must maintain documentation that clearly supports the hours billed for administration and associated paperwork.
Each Halstead-Reitan Battery or any other comparable neuropsychological battery is limited to no more than seven (7) hours (including testing and assessment). This is to be used only when there is a question of a neuropsychological and cognitive deficit.
Testing for intellectual level is limited to no more than two (2) hours for each test. Each self-administered test is limited to thirty (30) minutes. Only the testing for the eligible member is reimbursable. This includes self- administered tests completed for the benefit of the member as indicated by the testing instrument. The following tests are considered self-administered, and include but are not limited to:
Adaptive assessments are limited to no more than two (2) hours per assessment. One assessment is allowable per member per calendar year. Providers must maintain documentation that clearly supports the hours billed for administration and associated paperwork.
Reimbursement for Multisystemic Therapy and Functional Family Therapy will be based on a weekly case rate. In order to be eligible for the weekly case rate, providers must meet a minimum contact standard. Minimum contacts for each of the services are as follows:
Multisystemic Therapy (MST):
Providers must meet a monthly average minimum of two (2) contacts per week, met by a combination of one (1) face-to-face or interactive telehealth MST therapist (master's or bachelor-level). Contacts may include individual therapy session for identified Child, Family therapy session, or clinically necessary team or stakeholder meetings.
Multisystemic Therapy for Problem Sexualized Behaviors (MST-PSB):
Providers must meet a monthly average a minimum of three (3) face-to-face or telehealth contacts per week with an MST therapist (master's or bachelor-level) per month. Contacts may include individual therapy session(s) for the identified Child, Family therapy session(s), or clinically necessary team or stakeholder meetings.
Functional Family Therapy (FFT):
Providers must meet a minimum of one (1) face-to-face or telehealth clinical intervention per week with an FFT therapist (master's or bachelor's degree-level) in which the treatment goals are addressed. Contacts may include Family therapy session, individual therapy session for Child and/or team meetings where client and/or Parent are present.
For the purposes of collateral contacts for Children's Home and Community Based Treatment, MaineCare reimburses only up to forty (40) units or ten (10) hours of billable face-to-face collateral contacts per member per year of service.
Reimbursement for MST, MST-PSB, and FFT services will be based on a weekly case rate. Costs for collateral contacts are incorporated into this rate of reimbursement and are not separately billable.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-65, subsec. 144-101-II-65.07