C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-90, subsec. 144-101-II-90.08

Current through 2024-51, December 18, 2024

Subsection 144-101-II-90.08 - POLICIES AND PROCEDURES

The following policies and procedures supplement the general information within this section:

90.08-1Medical Record Requirements

Each provider shall maintain financial and professional records of sufficient quality to fully and accurately document the nature, scope, and details of the health care provided. Providers shall provide copies of financial and professional records to the Department in the form and manner requested without charge to the Department or the member. Chapter I details the five (5) year requirement for maintaining records.

A. Physicians must maintain one office medical record for each member even in group practices, partnerships, and other shared practices. Providers must document specific services rendered in chronological order. Chapter I provides additional requirements for record-keeping. The medical records corresponding to office, home, nursing facility, hospital, outpatient and emergency room services billed to the Department must include but shall not be limited to:

1. Date of each service ordered and provided;

2.

2. Member's name, name of responsible person (if different from the member, e.g., parent or guardian), date of birth, and MaineCare ID number;

3. Name and title of provider performing the service if it is other than the billing physician;

4. Medical history/ including member's health condition;

5. Pertinent findings on examination;

6. Medications administered or prescribed, when applicable;

7. Description of treatment, when applicable;

8. Recommendations for additional treatments or consultations;

9. Medical goals;

10. Supplies dispensed or prescribed (if any);

11. Tests and results; and

12. Dated provider signature.

B.Record Requirements for Psychotherapy Services

In addition to the above medical record requirements, when psychotherapy services are provided, a personalized plan of care must be developed and incorporated into the member's medical record, along with written progress notes. MaineCare requires that medical records and other pertinent information will be transferred, upon request, to other physicians or clinicians with member's consent.

The plan of care shall include, but is not limited to:

1. Member's presenting problem and diagnosis;

2. Long and short range goals;

3. A description of the service(s) needed by the member to address the goal(s);

4. An estimate of the frequency and duration of the needed service(s) and support(s);

5. The identification of providers of the needed service(s) and support(s);

6. Plans for coordination of services with other health care providers, as appropriate; and

7. A discharge plan.

The provider must document each service provided, showing the date of service; the type of service performed; its relationship to the plan of care; the length of time of the service; and the signature of the individual performing the service.

Providers must write progress notes regularly that state the progress the member has made toward the long and short-term goals.

90.08-2Evaluation and Management (E/M) Services

Providers should utilize the most recent edition of the Current Procedural Terminology (CPT), published by the American Medical Association, for definitions of levels and components of Evaluation and Management (E/M) Services.

Medical examinations, evaluations, treatment, and other services are defined by the component and level of service provided. The various components and levels require differing degrees of skill, knowledge, time, effort, and responsibility. The components and levels of service and the member status apply to evaluation and management services provided in the provider's office, the hospital, the member's home, and long-term care facilities. Providers must use appropriate CPT codes to indicate appropriate levels and components of service. Providers must document levels and components of service in the medical record.

90.08-3Disclosure Requirements

Upon request, the provider must furnish to the Department, without additional charge, the medical records, or copies thereof, corresponding to and substantiating services billed by that provider.

90.08-4Supplementation

A.Covered Services. The provider shall accept as payment in full the amounts established by the Department for covered services.

Therefore, the provider shall not charge a member an amount in addition to the payment received, or to be received, from MaineCare for a covered service. This is a violation of federal and state laws.

In addition, providers may not bill members or other providers for documentation fees or to complete paperwork required for referrals for prior authorization, to document rehabilitation potential, to certify medical necessity of a MaineCare covered service, or to provide other written information required for services covered by MaineCare. Providers must provide copies of such documentation at no charge to members and to relevant providers upon the member's request and upon completion of appropriate consents for release of information.

B.Non-covered Services. The member may be charged for a non-covered service. However, prior to provision of a non-covered service, the provider must clearly explain to the member that he or she will be financially liable for payment for such service. Providers shall document in the member's record that notification of financial liability for non-covered services has been made.

Providers may not bill MaineCare or the member for missed appointments.

Please refer to MBM, Chapter I, for policies and procedures applicable to all non-covered and non-reimbursable services. Providers must apply for prior authorization and receive a denial stating that the procedure is non-covered prior to initiating member consent for liability of non-covered services.

The member may voluntarily choose to pay for non-covered services and may be charged for those services, as long as he or she clearly understands prior to provision that he or she will be financially liable for such service. Providers must document the member's informed consent for provision of these non-covered services.

90.08-5Procedure to Request Prior Authorization (PA)

All PA requests should include pertinent information concerning the nature, extent, need, and charge for the procedure or service. For more information regarding PA forms and contact information, please visit: https://mainecare.maine.gov/

Note: Refer to MBM, Chapter I, for policies and procedures regarding prior authorization for out-of-state services.

90.08-6Program Integrity (PI)

All MaineCare services are subject to Program Integrity procedures as described in the MBM, Chapter I.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-90, subsec. 144-101-II-90.08