Subsection 144-101-II-68.07 - LIMITED SERVICES68.07-1All ages:1. MaineCare will not reimburse for more than two (2) hours of occupational therapy services per day.2. Supervised modalities (those without direct one-to-one continuous contact) that are provided on the same day as modalities requiring constant attendance or on the same day as any other therapeutic procedure are not billable. Billing for supervised modalities as stand-alone treatment is limited to one (1) unit per modality per day.68.07-2 Children (under twenty-one (<21)):All services must be medically necessary.
68.07-3Adults (age twenty-one (21) and over): If CMS approves, Prior Authorization is required for all services.
The Department or its Authorized Agent processes the Prior Authorization requests. Prior Authorization is approved upon medical necessity, as determined by the clinical judgment of the Department's medical staff. Prior Authorization forms can be found at: https://mainecare.maine.gov/ProviderHomePage.aspx. More information on the Prior Authorization process is in MaineCare Benefits Manual, Chapter I. Prior Authorizations will be issued in accordance with the following limits:
1. Services for adults who meet the specific eligibility requirements in 68.04 must be initiated within sixty (60) days from the date of physician or PCP referral..2. Within the scope of 68.04(1)-(3) services are limited to two (2) visits per condition or event.3. Services for maintenance care are limited to two (2) visits per year to design a plan of care, to train the member or caretaker of the member to implement the plan, or to reassess the plan of care. This limitation does not apply to maintenance care for members who would otherwise experience deterioration in function as described in Section 68.04(6).4. Services for adults with rehabilitation potential must be medically necessary as certified by a physician or PCP. The physician's documentation of rehabilitation potential must include the reasons used to support the physician's expectation. Such treatment is limited to no more than six (6) visits per condition by qualified staff.5. Services that are medically necessary will be covered for terminally ill members.6. Services for sensory integration are limited to a maximum of two (2) visits per year.7. Members receiving occupational therapy in conjunction with a pain management care plan may not receive more than five (5) treatment visits and one (1) evaluation within twelve months (12), and reimbursement for such visits is conditional on Prior Authorization based on a demonstration that the service is medically necessary. The Prior Authorization criteria include:A. The member has long-term chronic pain that has lasted, or is expected to last, more than sixty (60) days and impacts or is expected to impact a member's level of function for more than sixty (60) days; andB. The member requires occupational therapy services for the treatment of long-term chronic pain to end or avoid the use of narcotics. C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-68, subsec. 144-101-II-68.07