C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-90, subsec. 144-101-II-90.06
The admission of a member to an NF under the MaineCare program requires prior approval from the Department of Health and Human Services.
Approval for admission is given only when a member meets the medical eligibility requirements for NF services, as set forth in Chapter II, Section 67, Nursing Facility Services, of the MBM, and when adequate alternate arrangements cannot be made for home or community based care. NF applicants must receive a medical eligibility assessment with the Department's approved assessment instrument (see Section 67) .
When the physician continues to serve as the attending physician to members after they enter an NF, or accepts as new patients members who are receiving care in an NF, he or she is expected to provide, at a minimum, those physician services that are required, by federal regulations and by the State of Maine Regulations Covering the Licensing and Functioning of Nursing Facilities, to be provided in licensed MaineCare approved facilities.
All services provided to members in group care facilities by the physician or rendering provider are to be documented by the provider in the member's chart maintained in the facility. All orders to be carried out by facility staff are to be signed by the physician or rendering provider. A rubber stamp of the signature is not considered adequate.
Professional services in a group care facility are only covered when ordered by the attending physician or the rendering provider working under his/her supervision.
No charges may be made for services provided to members in a group care facility by a physician or rendering provider in a physician's practice who derives a direct or indirect profit from ownership of the facility, except for emergency services provided for acute illness.
A physician or rendering provider may refer members for essential services such as laboratory tests, x-ray examination, etc., that are provided by a hospital on an outpatient basis.
Emergency services are those services provided to persons requiring immediate care in the emergency room of the hospital, necessitated by unforeseen conditions such as injury, accident or sudden illness.
Charges may be made by a physician who personally attends a member in the emergency room providing he or she is not salaried by the hospital or whose salary is or associated with a group of physicians with a financial contract to provide emergency room care.
A provider may admit a member for essential inpatient hospital services in connection with covered treatment of an illness or injury. The facility's patient care coordinator monitors the medical need for hospital admission and the length of the hospitalization. There are limitations on the length of stay according to the specific needs of the individual member for hospital care. The Department will only make payment for days certified by the patient care coordinator. MaineCare will deny payment of additional provider services provided during the non-certified hospitalization.
Exception: The Department will reimburse for provider services rendered from date of admission to the first review date even if the patient care coordinator denies the admission.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-90, subsec. 144-101-II-90.06