Subsection 144-101-II-68.06 - COVERED SERVICES MaineCare will reimburse for covered medically necessary services in all outpatient settings. If CMS approves, covered services requiring a Prior Authorization are limited to one (1) evaluation and one (1) treatment per each condition or per each event unless specified under 68.07. Services must be of such a level, complexity, and sophistication that the judgment, knowledge, and skills of a qualified professional staff is required as defined in 68.09-1.
All services must be in accordance with acceptable standards of medical practice and be a specific and effective treatment for the member's condition. Services related to activities for the general good and welfare of members are not MaineCare covered occupational therapy services.
Pursuant to 42 CFR§440.110, MaineCare occupational therapy services must be prescribed by a physician or other licensed practitioner of the healing arts within the scope of practice under Maine law and must be provided by or under the direction of a qualified professional staff as defined in 68.09-1.
MaineCare reimburses providers for the following occupational therapy services:
68.06-1 Evaluations or re-evaluations: For adults, one evaluation or re-evaluation per member per condition or event is a covered service. For children, additional evaluations or reevaluations are allowed as medically necessary. 68.06-2 Modalities: Modalities are any physical agents applied to produce therapeutic changes to biologic tissues; including but not limited to thermal, acoustic, light, mechanical, or electric energy. Except when performing supervised modalities, the therapist is required to have direct (one-on-one) continuous patient contact.68.06-3 Therapeutic Procedures: Therapeutic procedures effect change through the application of clinical skills and/or services that attempt to improve function.68.06-4 Tests and measurements: The therapist is required to have direct (one-on-one) continuous patient contact in performing testing and measurement.68.06-5 Splinting: Providers may bill for splinting supplies necessary for the provision of occupational therapy services. Covered supplies under this Section must be billed and reimbursed at the lesser of acquisition cost or the maximum allowed cost set by the Department. The acquisition cost must be documented by an invoice in the member's file. Please visit http://www.maine.gov/dhhs/audit/rate-setting/documents/S68OccupationalTherapyServices.pdf to access maximum allowed cost. C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-68, subsec. 144-101-II-68.06