Subsection 144-101-II-94.05 - Treatment Services94.05-1Providers Providers of treatment services must:
A. be appropriately credentialed or licensed individuals or entities and be working within the scope of their licensure. For example: All durable medical equipment (DME) must be supplied through a DME provider,B. sign a MaineCare Provider/Supplier Agreement,C. comply with Chapter I, Administrative Policies and Procedures, of the MaineCare Benefits Manual, andD. comply with all MaineCare policies found in those sections of the MaineCare Benefits Manual applicable to the service provided, including but not limited to provider qualification requirements.94.05-2Covered Services Treatment services covered under the EPSDT Program consist of all medically necessary services listed in §1905(a) of the Social Security Act ( 42 U.S.C. §1396(a) and (r) ) that are needed to correct or ameliorate defects and physical or mental conditions detected through the EPSDT screening process. The program covers only those treatment services that are not specifically included under any other MaineCare regulation, because:
A. They are of a type not described in any other regulation.B. The frequency exceeds that covered by the regulation.C. The duration exceeds that covered by the regulation. To receive payment for services under the EPSDT program, the member or provider must:
A. obtain prior authorization;B. demonstrate that the service is medically necessary, as the term is defined in Chapter I, §1.02 (D) of the MaineCare Benefits Manual; andC. show that the service is not covered by another MaineCare regulation. Treatment Services must:
A. be documented scientifically with valid clinical evidence of effectiveness. (The Department may request additional information to support the assertion that there is scientifically valid evidence of the efficacy of the proposed treatment or service. The Department will request this information if it determines that the service requested is outside the scope of standard medical practice.);B. not be considered investigational or experimental;C. be the most cost effective service that would provide the member with the same medically necessary outcome and intended purpose;D. be prior authorized by the Authorization Unit of MaineCare Services. Requests for prior authorization of Durable Medical Equipment will be reviewed by an authorized agent of the Department.E. be medically necessary as defined in Chapter I, Section 1.02 (D);F. not be custodial, academic, educational, vocational, recreational or social in nature as described in Chapter I, Section 1.02 (D), General Administrative Policies and Procedures, of this Manual;G. not be respite care, which is defined as services given to individuals unable to care for themselves that are provided on a short-term basis because of the absence or need for relief of those persons normally providing the care.94.05-3Prior AuthorizationA.Written Requests The MaineCare provider who is prescribing the treatment service must request and receive prior authorization from the Authorization Unit of MaineCare Services or the Departments' Authorized Agent before the service is referred and/or provided.
To obtain prior authorization, the prescribing provider must complete the appropriate prior authorization request form available from the MaineCare Authorization Unit or on the Department's website at: http://www.maine.gov/dhhs/oms/providerfiles/pa_inst_sheets_forms.html.
To obtain prior authorization for durable medical equipment (DME), the request must be submitted on the MA-56R form. Any request for DME that is denied under Chapter II, Section 60, Medical Supplies and Durable Medical Equipment will be considered and reviewed under EPSDT criteria.
In addition, the MaineCare Authorization Unit may request the following additional information:
1. A plan of care that: a. describes the problem(s) or conditions(s) the plan addresses;b. identifies the service(s) needed to address the problem(s) or condition(s) and why they will meet the medical needs;c. describes the frequency, duration, and goal of each needed service;d. identifies the provider(s) who will provide each needed service; ande. includes the prescribing provider's signature. The prescribing provider must review and revise the plan at least annually. If a change in the child's health status requires a plan modification, the prescribing provider must revise and sign the plan within one week of the health status change.
2. Documentation of medical necessity of the services identified in the plan of care that, at a minimum, includes: a. Supporting medical records;b. What other service(s)/equipment has been tried, if any, and why it was unsuccessful;c. Explains clearly why the services are of a type, frequency or duration not otherwise covered by MaineCare regulations;d. Clearly addresses why services covered elsewhere in the MaineCare Benefits Manual are inappropriate or insufficient to meet the member's needs;e. Any supporting medical literature which demonstrates that the proposed service/equipment will be effective in addressing the member's need. The MaineCare Authorization Unit will notify providers of its decision regarding the request for prior authorization in accordance with Chapter I, Administrative Policies and Procedures, of the MaineCare Benefits Manual.
B.Emergency Requests In an emergency where the member's condition does not allow time for the prescribing provider to submit a written request, he/she may phone or fax the MaineCare Authorization Unit requesting prior authorization of the service.
In an emergency where the prescribing provider is unable to contact the MaineCare Authorization Unit (e.g. evenings, weekends, holidays, mandatory shut-down days) and has documented the reasons why contact could not be made, MaineCare after receipt and review of such stated documentation may at the discretion of the Department authorize services retroactively to the start of the medical emergency. The prescribing provider must contact the MaineCare Authorization Unit the next business day. In these cases, the prescribing provider must submit all necessary written documentation within seven (7) business days of the phone or fax contact.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-94, subsec. 144-101-II-94.05