C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-90, subsec. 144-101-II-90.05
Some services and procedures require prior authorization for MaineCare to provide payment. MaineCare lists provider procedures, the amount paid for the service, and whether the procedure requires prior authorization on the MaineCare Services website. When new procedure codes are added to MaineCare reimbursement, MaineCare may require prior authorization. Only some of the categories of procedures requiring prior authorization are detailed in this section; providers are responsible for checking each procedure code on the OMS website to determine whether it is covered and whether it requires prior authorization. Providers can find procedures requiring PA and PA requirements at: https://mainecare.maine.gov. In cases where the criteria are not met, the provider or member may submit additional supporting evidence such as medical documentation, to demonstrate that the requested service is medically necessary.
All services, including but not limited to diagnosis, evaluation or treatment to be provided outside the State of Maine require prior authorization. (See MBM, Chapter I, Section 1.14 for policies and procedures regarding out-of-state services). Use of out-of-state diagnostic services, excluding lab or radiology tests by enrolled MaineCare providers, requires prior authorization. MaineCare providers referring out-of-state services are responsible for assuring that services are referred to a MaineCare provider. Providers cannot bill the member unless the member was advised at the provider's office prior to provision of the service that the service may not be covered by MaineCare and that the member may be responsible for the services. Prior notification must be documented in the member's record.
MaineCare covers medically necessary vagus nerve stimulation for treatment of partial onset seizures for adults and children over twelve (12) years of age when clinically appropriate medications are refractory.
Orthognathic surgery requires prior authorization, and is not covered for cosmetic purposes. Orthognathic surgery is only covered for medically necessary indications such as:
Documentation must include, but is not limited to, study models with appropriate bite registration, intra-oral and extra-oral photographs, and cephalometric x-ray.
Gender dysphoria related surgery requires prior authorization and will be reimbursed by MaineCare, based on the following standards:
For members under the age of twenty-one (21), the following additional criteria must be met:
Reimbursement will be made to the physician, hospital or other health care provider for services related to gastric bypass, gastroplasty surgery or adjustable gastric banding only when prior approval has been granted by the Department . The request for prior authorization must be submitted by the surgeon who will be performing the surgery.
For Members age twenty-one (21) years and younger, the surgery must also be recommended by all of the following, with documentation submitted with the prior approval request:
MaineCare covers the services described below when performed in accordance with the following criteria:
In compliance with PL 103-112, the Health and Human Services Appropriations bill, reimbursement for abortion services will be made only if necessary to save the life of the pregnant person or if the pregnancy is the result of an act of rape or incest.
Medication abortions shall be performed in compliance with applicable FDA law and guidelines. All other abortion services are covered only when performed in a licensed general hospital or outpatient setting, and when the following conditions are met:
Effective September 19, 2019, Health care professional is defined as a physician or physician assistant licensed under Title 32, ch. 36 or 48 or a person licensed under Title 32, ch. 31 to practice as an advanced practice registered nurse.
A sample letter of certification is shown below:
I, _______________ (Name of health care professional), certify that on the basis of my professional judgment, an abortion is necessary for _______________(name of member) of _______________________ (member's address) for the following reason(s): (Check all that apply)
() in order to save the member's life.
() the pregnancy is the result of an act of rape.
() the pregnancy is the result of an act of incest.
Present justification as to the necessity of an abortion performed in order to save the life of the member. (Attach supporting information, as necessary.)
_______________________________ _________
(Signature of Health Care Professional) (Date)
The health care professional's certification must be submitted to the Department. The member's medical record is not required for submission, however, it must be available for review by the Department, upon request.
In compliance with federal requirements, the Department will reimburse for the procedure if the treating health care professional certifies that in his or her professional opinion, the member was unable for physical or psychological reasons to comply with established reporting requirements, if any, in cases of rape or incest.
Although no payment can be made until the provider submits all required documentation to the Department, the provider should provide necessary medical services immediately as needed.
MaineCare will reimburse for sterilization procedures and hysterectomies only when all of the conditions spelled out below are met in order to comply with 42 C.F.R. 441.250 through 441.259 of the Code of Federal Regulations.
Reimbursement for sterilization procedures will be made only if they are performed in accordance with the following criteria:
A member may consent to be sterilized at the time of a premature delivery if at least seventy-two hours (72) has passed since the member gave informed consent for the sterilization and the informed consent was obtained at least thirty (30) days before the expected delivery date.
Sterilization Consent Form
A properly completed consent form must be attached to the billing invoices. If it is necessary to send the consent form in separately, please send it to:
MaineCare Services
Claims Unit
11 State House Station
Augusta, Maine 04333- 0011
Additional copies of the consent form are available upon request from the unit named at the above address.
Two approved pamphlets containing required information on sterilization are available. They are entitled "Information for Women" and "Information for Men." Copies may be obtained from the Family Planning Association of Maine, 43 Gabriel Drive, Augusta, Maine 04330 or The National Clearinghouse for Family Planning Information, PO 2225, Rockville, Maryland 20852.
In accordance with Federal regulations ( 42 C.F.R. 441.255 and 441.256 ) payment for a hysterectomy and related services may be made from MaineCare funds only when specific criteria are met.
The "Hysterectomy Information Form" (BMS-045), which meets federal requirements, is available to meet this informed consent requirement. Documentation submitted in lieu of the above informed consent form, which contains all required information as shown on the BMS-045 is acceptable.
One (1) copy of the informed consent form is to be given to the member, one (1) copy is to be retained by the physician or hospital, and one (1) copy is to be forwarded to MaineCare with the usual billing invoice.
The only exceptions to the above requirements are:
If it is necessary to submit the hysterectomy Informed Consent form separately please send it to:
MaineCare Services Claims Unit 11 State House Station Augusta, Maine 04333-0011 Additional copies of the "Hysterectomy Information Form" (BMS-045) are available upon request from the unit named at the above address.
Circumcision for cosmetic or routine purposes is not covered.
These criteria apply to all members: Documentation must outline conservative therapies tried for at least ninety (90) days, and the failure of these measures.
Therapies to be tried include, when appropriate, behavioral and topical therapies. If no conservative therapy is medically appropriate, none is required.
The record must clearly document the medical condition for which the circumcision was performed and, when appropriate, conservative therapies tried and failed as outlined above. If the record is inadequate to document that the circumcision was not performed for cosmetic, routine, or ritual purposes, the procedure may be determined to not be medically necessary and per Chapter I of the MBM, payments may be recouped.
All cochlear implants must meet the following criteria:
MaineCare covers cochlear implants for prelinguistically and postlinguistically deafened children over the age of one (1). For children ages twelve (12) months through twenty-three (23) months providers must demonstrate bilateral profound sensorineural hearing loss and lack of progress in the development of auditory skills with hearing aid(s) or other amplification.
For children ages twenty-four (24) months to seventeen (17) years, providers must demonstrate bilateral severe-to-profound hearing loss and lack of progress in the development of auditory skills with hearing aid(s) or other amplification.
MaineCare covers cochlear implants for prelinguistically, perilinguistically, and postlinguistically deafened adults. Providers must demonstrate little or no benefit from hearing aids, defined as speech recognition scores of less than fifty percent (50%) on sentence level testing in the ear to be implanted and less than sixty percent (60%) in the non-implanted ear or in the binaural condition.
MaineCare does not cover medical or surgical procedures performed solely for cosmetic purposes. Examples of potentially cosmetic procedures include, but are not limited to abrasion of skin or lesion, chemical peel or salabrasion, and cervicoplasty. Some procedures that are potentially cosmetic procedures are covered when done to correct deformities resulting from cancer, disease, trauma, or birth defects. All procedures that may be performed for cosmetic reasons require documentation of medical indication in the medical record for utilization review purposes.
Hyperbaric oxygen (HBO) therapy is a modality in which the entire body is exposed to oxygen under increased atmospheric pressure.
The use of HBO therapy for diabetic wounds is covered as adjunctive therapy only after there are no measurable signs of healing for at least thirty (30)-days of treatment with standard wound therapy and must be used in addition to standard wound care.
Standard wound care in members with diabetic wounds includes: assessment of a member's vascular status and correction of any vascular problems in the affected limb if possible, optimization of nutritional status, optimization of glucose control, debridement by any means to remove devitalized tissue, maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings, appropriate off-loading, and necessary treatment to resolve any infection that might be present. Failure to respond to standard wound care occurs when there are no measurable signs of healing for at least thirty (30) consecutive days. Wounds must be evaluated at least every thirty (30) days during administration of HBO therapy. Continued treatment with HBO therapy is not covered if measurable signs of healing have not been demonstrated within any thirty (30)-day period of treatment.
Infertility services, including evaluation and treatment, are not covered by MaineCare. Treatments and procedures that are usually performed for the sole purpose of evaluation or treatment of infertility require utilization review to document medical necessity of the procedure for reasons other than the treatment of infertility.
Penile implants, including insertion, repair, or replacement will only be covered after surgery for cancer, trauma, or birth defect where pharmacologic treatments have failed or as prescribed as medically necessary under the Transgender Services or Gender Dysphoria Related Surgery provisions.
MaineCare does not cover these surgeries for cosmetic purposes. Medical necessity must be documented to show that symptomatic, ongoing, or recurrent breathing obstructions or infections are present despite at least a sixty (60) day trial of conservative treatment.
MaineCare will only cover skin tag removal when there is significant, ongoing, or recurrent irritation or discomfort that is documented in the medical record.
Some MaineCare services that are not routinely performed by a physician nevertheless require documentation by a physician of medical necessity or rehabilitation potential. These services include, but are not limited to, chiropractic services, home health services, physical therapy, occupation therapy, or speech therapy services.
For services requiring documentation of rehabilitation potential, providers should include diagnosis or complaint, how member was assessed, (e.g., by phone, exam, therapist evaluation) why rehabilitation potential is expected, (e.g., acute condition, acute exacerbation of chronic condition, past response to therapy, etc.) and indicators of measurable functional improvement. Other providers may, if requested by the physician, use an evaluation to assist the physician in determining the member's rehabilitation potential. In the case of a service requiring recent surgery to obtain prior authorization, such as in the case of chiropractic services, surgery must have been performed within the previous sixty (60) days (to the PA request).
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-90, subsec. 144-101-II-90.05