10- 144 C.M.R. ch. 272, § V-A

Current through 2024-51, December 18, 2024

Section 144-272-V-A - AUTHORIZATION OF SERVICES AND PROVIDERS

1. Payment for all services must be prior authorized and provided within the State of Maine, with the following exceptions:

) for those children living on the New Hampshire border, out-of state service may be prior authorized if the appropriate out-of-state subspecialty providers are closer to the child's home than comparable services within the State of Maine;

) if after consultation with the appropriate in-state pediatric subspecialist, the C.C.S./C.S.H.N. Program's physician consultant determines that the needed treatment is not available within the state, services may be authorized at an appropriate center outside the state; or

) if the C.C.S./C.S.H.N. Program's physician consultant determines that the previously established patient/provider relationship that has been in place for longer than two (2) years is reasonable to support out-of-state treatment.

2. The C.C.S./C.S.H.N. Program's physician consultant will confirm that the child requires subspecialty interventions; that all services are recommended by the pre-authorized subspecialist and are included in the subspecialty plan of care.

3. All services paid for through Coordinated Care Services for Children with Special Health Needs must be authorized in writing prior to their delivery. It is the provider's obligation and responsibilityto provide written documentation of a child's treatment needs and to verify a child's eligibility for coverage prior to providing service(s). For prior authorization and/or confirmation of eligibility, providers should contact:

Coordinated Care Services for Children with Special Health Needs

Division of Maternal and Child Health

Department of Human Services

State House Station #11

Augusta, Maine 04333-0011

Tel: 207-287-5139

1-800-698-3624

4. All Maine providers of a child's services must:

) meet Maine licensing and certification requirements;

) be certified or be eligible for certification by the appropriate national organization; and

) be enrolled/approved Maine Medicaid providers.

Exception: If the service to be authorized is not a Medicaid covered service, providers do not need to meet Medicaid enrollment requirements.

All out-of-state providers must:

) meet licensure requirements in the state in which services are to be provided;

) be certified or eligible for certification by the appropriate national board;

) be enrolled/approved Maine Medicaid providers.

5. Providers are prior authorized by the C.C.S./C.S.H.N. Program on the basis of the following:

) compliance with State licensing and certification requirements;

) subspecialty certification and pediatric qualifications;

) proximity to the child's area of residence; and

) preference of child and family when there are multiple subspecialty pediatric providers within a community.

6. Primary care physicians may be pre-authorized by the C.C.S./C.S.H.N. Program for that portion of subspecialty treatment that the prior authorized subspecialist delegates to primary care when all of the following conditions are met:

) the original diagnosis has been established or confirmed by the appropriate subspecialist or pediatric specialist;

) the C.C.S./C.S.H.N. Program is in receipt of written documentation and verification that the services are included in the prior authorized subspecialist's plan of care;

) the condition is directly related to or is an exacerbation of the chronic illness; and

) such services are provided under the consultation and direction of the prior authorized subspecialist or pediatric specialist.

7. Children under the age of three with a suspected developmental problem will be referred to a Developmental Evaluation Clinic upon application to the C.C.S./C.S.H.N. Program unless a similar comprehensive evaluation has already taken place.

10- 144 C.M.R. ch. 272, § V-A