Subsection 144-101-II-68.04 - Specific Eligibility for CareServices for members of all ages must be medically necessary. The Department or its authorized agent has the right to perform eligibility determination and/or utilization review to determine if services provided are medically necessary.
Adult members (age twenty-one (21) and over) in an outpatient setting must have rehabilitation potential documented by a physician or primary care provider (PCP). Adult members are specifically eligible only for:
1. Treatment following an acute hospital stay for a condition affecting range of motion, muscle strength and physical functional abilities. If CMS approves, the treatment must start within six months of the hospital discharge and be specific to the diagnosed condition; 2. Treatment after a surgical procedure performed for the purpose of improving physical function. If CMS approves, the treatment must start within six months of discharge and be specific to the diagnosed condition; 3. Treatment for which a physician or PCP has documented that the patient has, at some time during the preceding thirty (30) days, required extensive assistance in the performance of one or more of the following activities of daily living: eating, toileting, locomotion, transfer or bed mobility;4. Medically necessary treatment for other conditions including maintenance, subject to the limitations in Section 68.07; 5. Maintenance care to prevent deterioration in function that would result in an extended length of stay or placement in an institutional or hospital setting, as documented by physician or PCP;6. If CMS approves, rehabilitative services ordered by a physician or other licensed practitioner of the healing arts for the maximum reduction of physical disability and restoration of a member to his/her best possible functional level;7. If CMS approves, medically necessary treatment when diagnosed with a terminal illness; or8. Treatment used for pain management in conjunction with a prescribed pain management care plan subject to section 68.07. C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-68, subsec. 144-101-II-68.04