Prior authorization (PA) is required for certain
services. The PA requirement is spelled out in each section of other Chapters
of this Manual whenever it applies to a covered service. In addition,
management of high cost member services and/or supplies may require PA by the
Department or its Authorized Entity.
1.14-1
In-State Services
A. The dated and signed request for PA must
be made by the member's provider in writing and sent to the MaineCare Prior
Authorization Unit, or as appropriate, to the Department's Authorized Entity or
any other office as required by the Department and provided in other sections
of this Manual.
For PA, contact information and where to send completed
PA forms, visit the MaineCare Services website at:
https://mainecare.maine.gov.
A request for prior authorization must be signed by the
provider and must include:
1. Member's
name and MaineCare identification number;
2. Diagnosis for which the request is being
made;
3. The procedure(s) requested
and its/their corresponding code(s);
4 Date(s) of the scheduled procedure, if
known;
5. The billing provider ID
number of the physician and/or physicians practice or other authorized provider
that will render the requested service(s), if known;
6. All clinical records to support the
requested service (describing diagnostic studies and treatment completed to
date along with results, and clinical records upon which the request has been
made); and
7. Additional
information as determined by the Department or its Authorized Entity.
B. PA may be effective for up to
twelve (12) months as determined by medical criteria and documentation of
ongoing necessity. In some cases, for covered health care expenditures that
require PA, financial eligibility for medical services may be determined
retroactively. MaineCare will provide reimbursement for these services if it
can be shown that all Departmental requirements were met at the time the
services were performed.
C. For
enrolled MaineCare members, the provider must verify the need for PA with the
Department and subsequently, ensure that authorization has been obtained when
applicable. This must be done priorto provision of services, except in cases of
medical emergency, or as described in Section 1.14-2(B).
D. Notwithstanding any other provision
herein, MaineCare Services or its Authorized Entity shall act on requests for
PA with reasonable promptness and shall adjust the time periods specified
herein as circumstances require. In circumstances that do not require an
immediate decision, MaineCare Services or its Authorized Entity will make a
decision to authorize or deny the request for PA within thirty (30) days of the
receipt of the completed request, or thirty (30) days after the date the
application is determined to be complete following a decision in an
administrative hearing as provided herein, or services will be considered
authorized. MaineCare Services will notify the provider and member of the
decision.
E. The thirty (30) day
provision regarding the treatment of complete requests shall not apply in the
case of an emergency. In the case of an emergency, the PA decision will be made
expeditiously to address the emergency, including notifying the provider of an
incomplete request.
F. Providers
that submit an incomplete request for authorization of services will be
notified within thirty (30) days of receipt of the incomplete request.
MaineCare Services or its Authorized Entity will defer the request until the
specific additional information necessary to complete the request is received.
Such notice shall be sent to the provider and member, within thirty (30) days
of receipt of the incomplete request and shall clearly identify the following:
1. The information necessary to complete the
request;
2. Specific citation of
the regulations requiring the information; and
3. The name and telephone number of the
person in MaineCare Services or its Authorized Entity, who should be contacted
should the provider and/or member have questions regarding the
deferral.
G. The
member's provider shall make a reasonable effort to submit to MaineCare or its
Authorized Entity the information requested within thirty (30) days from the
date that notice is received that it is incomplete, failing which the
application may be considered abandoned and may be denied for that reason.
Any notice that an application is incomplete, sent out
by MaineCare or its Authorized Entity, more than thirty (30) days from the date
the original application was filed with MaineCare, shall be considered an
adverse action by MaineCare. Such notice shall be accompanied with a statement
advising the applicant of an opportunity for an administrative hearing to
challenge the determination that the application is incomplete.
In the case of a notice of incompleteness given more than
sixty (60) days from the date the original application was filed, the statement
shall advise the applicant of an opportunity for an administrative hearing to
determine not only whether the application is complete, but, in the event that
it is deemed so, whether MaineCare Services should be ordered to take final
action on the application within ten (10) days. Any such order by the
administrative hearing officer shall provide that the request shall be
considered authorized if a decision is not made within such ten (10) day
period.
H. Once approval
has been given, if the provider originally requesting PA is unable or unwilling
to provide the service requested within a reasonable time, the member may
choose another provider. The second provider is responsible for notifying
MaineCare Services of his/her intention to provide the service subject to the
initial approval. MaineCare Services, upon request, will assist the member in
attempting to locate a provider when the member is unable to do so.
I. If the request for prior authorization is
denied, MaineCare or its Authorized Entity will clearly explain the denial
reasons in the denial notice. This explanation shall include any facts,
circumstances, calculations, and other data that were used as a basis for
making the denial and shall specify any additional information that could be
supplied, by the provider or member, to permit the request to be approved. This
explanation shall be set forth clearly and conspicuously and shall be phrased,
to the extent possible, in simple terms easily understandable by a
layperson.
J. MaineCare will not
deny a request for services without examining the nature of the request to
determine whether any portion of the services requested or reasonable
alternative services thereto might be covered by MaineCare. A notice of denial
shall be given when the services requested are denied in whole or in part.
If a portion of the request is covered under MaineCare
and a portion is not, MaineCare or its Authorized Entity shall give notice of a
denial of only those services not covered and shall give approval of those
services that are covered.
K. MaineCare Services or its Authorized
Entity shall promptly refer requests for PA for mental health services not
covered (or for the portion of services not covered for partially denied
services) by MaineCare to DHHS, Adult Mental Health Services or Children's
Behavioral Health Services.
Such referrals will be made within three (3) business
days of the determination that mental health services requested are not covered
by MaineCare and shall be made to the appropriate regional office of DHHS by
telephone or electronic mail or other method to ensure that the referral is
received as soon as practicable. Any denial of requested services, in whole or
in part, shall be accompanied by a statement advising the applicant of a right
to an administrative hearing. If an applicant chooses to request a hearing, the
request shall be made no later than thirty (30) days from the date of receipt
of the notice and, if requested, MaineCare Services or its Authorized Entity,
shall forward the request to the DHHS Division of Administrative Hearings (DAH)
within twenty-four (24) regular business hours (that is, by the next day if not
a holiday or weekend) and a hearing shall be held within seven (7) working days
thereafter. (See Sections
1.23 &
1.24).
L. When a participating provider
furnishes a service or equipment and has either failed to request PA or has
been notified that PA has been refused, that provider is liable for the costs
of those services and that provider may not bill either the Department or the
member for such care or services, except in the following situation: Prior to
the provision of the services the member shall acknowledge in writing that he
or she is aware that PA has not been granted and, therefore, MaineCare will not
pay for the services and that he or she accepts financial liability to pay for
the services.
In addition, if and when a member chooses not to utilize
the PA process, the service is considered non-covered by MaineCare if the
member acknowledged in writing that he or she understood that he or she would
assume financial responsibility for the service.
1.14-2
Out-Of-State Services
Unless otherwise allowed in Chapter II of this Manual,
medical care that is covered under MaineCare that is only available outside the
State of Maine requires prior authorization. MaineCare will not guarantee
payment for services received out-of-state unless PA has been granted pursuant
to the procedure outlined in Section 1.14-2(A).
The provider is responsible for verifying the need for PA
and subsequently, that authorization has been obtained from the Department or
its Authorized Entity when applicable. This needs to be done priorto provision
of services, except in cases of medical emergency, or as described in Section
1.14-2(B).
PA for services will be granted to out-of-state providers
for covered services described in this Manual, only when a member's continuity
of care must be preserved for medical reasons and only after it is determined
that the needs of the member cannot be met in the State of Maine.
Notwithstanding any other provision herein, MaineCare
Services or its Authorized
Entity shall act on applications for PA for out-of-state
services with reasonable promptness and shall adjust the time periods specified
herein as circumstances require.
If the request for PA is denied, MaineCare or its
Authorized Entity will clearly explain the reasons for denial in the denial
notice. This explanation shall include any facts, circumstances, calculations,
and other data that were used as a basis for making the denial and shall
specify any additional information that could be supplied, by the provider or
member, to permit the request to be approved. This explanation shall be set
forth clearly and conspicuously and shall be phrased, to the extent possible,
in simple terms easily understandable by a layperson.
A. Procedure and Requirements for
Out-Of-State Services
The procedure to request prior authorization is as
follows:
1. Each member must be
currently under the care of a licensed professional providing physician
services, or a recognized primary care provider acting within the scope of
his/her license, and practicing in the State of Maine, or within fifteen (15)
miles of the Maine/New Hampshire border.
2. The request for PA must be made by the
Maine physician for services provided out-of-state. Criteria for PA of
out-of-state services shall be as set forth in this Chapter and in the specific
section of this Manual covering those services. PA contact information and
prior authorization forms can be found at
http://www.maine.gov/dhhs/oms/provider_index.html.3. The request must be made at
least thirty (30) calendar days prior to the date medical care/services are to
be provided in another state. The only exception would be for medical or
behavioral health emergency cases.
In cases involving such an emergency, the PA decision
will be made as soon as necessary to relieve the emergency. Emergency cases
will be given special consideration and should be so identified by the
physician or provider requesting approval.
Telephone requests, which must be followed by written
materials, will be accepted only in emergency situations. Faxed requests are
allowed.
4. The provider's
request for PA must include:
a. Member's
name;
b. Member's MaineCare
identification number;
c. Diagnosis
(describe diagnostic studies and treatment completed to date along with
results, and clinical records upon which the request for out-of-state referral
has been made). Send clinical records to support diagnosis and
referral;
d. Names of physicians
and/or facilities that the member has previously been referred in Maine for
diagnosis and/or treatment. Include second opinion documentation;
e. Physicians consulted by attending
physician relative to availability of diagnosis and/or recommended treatment in
Maine. Send second opinion documentation supporting out-of-state
referral;
f. Recommended treatment
or further diagnostic work;
g.
Reasons why medical care cannot be provided in Maine or the next closest
location outside the State;
h.
Names of physicians and facility outside of Maine to provide services and date
of appointment(s) if known, and i. Additional information if specified in
applicable Chapters of this Manual.
5. If additional information is needed or it
appears that the service may be available within the State, the Department or
its Authorized Entity reserves the right to require that the patient seek
consultation and/or treatment from providers of the service within the
State.
6. The reviewing Department
or its Authorized Entity will notify the provider and member of approval or
disapproval. If approved, a letter will be sent to the member and the
out-of-state provider(s) authorizing medical care. The out-of-state provider
must enroll as a MaineCare provider for the State of Maine and must accept
MaineCare reimbursement as payment in full for the covered services authorized.
The Department reserves the right to set rates for services. If disapproved, an
explanation will be given, and notice of the member's right to request an
administrative hearing will be given.
7. The procedures for granting, denying and
processing requests for in state services, as set forth in Section 1.14-1,
shall apply to requests for out-of-state services.
8. Once approval has been given, if the
provider originally requesting prior authorization is unable or unwilling to
provide the service requested within a reasonable time, the member may choose
another provider. The second provider is responsible for notifying the
applicable Department of his or her intention to provide the service subject to
the initial approval and conditions set forth above. The applicable Department,
upon request, will assist the member in attempting to locate a provider when he
or she is unable to do so.
9. The
attending physician in the State of Maine is expected to perform follow up for
medical procedures provided out-of-state, unless medical necessity requires
return to the out-of-state provider. Therefore, it is expected that the
referring physician will receive medical reports of services provided by the
out-of-state provider and follow the above procedures for any required
out-of-state follow up.
B.
Exceptions
MaineCare will evaluate claims for MaineCare services
rendered to eligible members out-of-state without prior authorization only
under the following circumstances.
1.
Emergency medical services rendered to members who are temporarily absent from
the State, and for which they cannot reasonably be expected to return to Maine
or because the member's health would be endangered if required to travel back
to the State of Maine. Out of state emergency medical services will be reviewed
for medical appropriateness. Providers must notify the Department, or its
Authorized Entity, within one (1) business day of an emergency admission for a
MaineCare member. For inpatient emergency services, the provider must seek and
receive approval for an appropriate length of stay, determined by the
Department or its Authorized Entity, based on the evidence of medical necessity
provided in the member's medical documentation. In order to be reimbursed by
MaineCare for emergency inpatient services, the provider must submit an
authorization number on the claim form submitted to the Department. In cases
where the provider is unable to confirm proof of MaineCare coverage (e.g.
member is unconscious, or the member does not have MaineCare card readily
available), the provider may exceed the one-day requirement by providing a
sufficient explanation of the case.
2. MaineCare covered services rendered to
eligible members who intend to remain out-of-state. The Office of for Family
Independence will determine when MaineCare coverage will terminate.
3. MaineCare covered services rendered to
eligible members by qualified providers within fifteen (15) miles of the
Maine/New Hampshire border.
4.
MaineCare covered services rendered to persons prior to their date of
application, when eligibility is determined retroactively to cover the time
period in which the services were provided.
5. MaineCare covered services received by
qualified Medicare beneficiaries out-of-state when the providers have accepted
Medicare assignment and only the deductible and coinsurance are to be
billed.
6. MaineCare covered
services provided through out-of-state, culturally appropriate, alcohol
treatment and substance abuse services, that are fully reimbursed (100%) by
Indian Health Service funds, and provided by enrolled MaineCare providers.
These services are subject to post payment review by the Division of Program
Integrity.
C. Specific
Requirements for Behavioral Health Emergencies and Mental Health Services for
Children
Requests involving behavioral health emergencies are in
a unique group that does not require PA.
1. The definition of a behavioral health
emergency is as follows:
The member displays significant, prolonged, escalation
of volatile or suicidal behaviors to the point that the parent, guardian, or
service provider is unable to reasonably assure the safety of the member and/or
others. There must be clinical documentation of professional inability to
secure safety, as well as inability to obtain the necessary behavioral health
emergency services in the State of Maine.
1.14-3
Early and Periodic
Screening, Diagnosis and Treatment Services
MaineCare Services shall take reasonable and necessary
steps to ensure that all requests for PA of services for MaineCare members
under age twenty-one (21) are not denied without first taking reasonable steps
to determine if the services can under the MBM, Section 94, Early and Periodic
Screening, Diagnosis and Treatment Services. Reasonable steps may include, but
are not limited to, contacting the provider to inform the provider of the EPSDT
for these treatment services. Such services include those medically necessary
treatment/diagnostic services and other measures provided to correct or
ameliorate conditions discovered during a screening performed under the EPSDT
benefit and are described in a member's comprehensive plan of care.
These MaineCare covered services are furnished in
accordance with the Omnibus Budget Reconciliation Act (OBRA) of
1989 and are covered under federal regulations.
1.14-4
Medical Necessity
Some services under this section require prior
authorization by the Department or its Authorized Entity. Prior authorization
contact information and prior authorization forms can be found at:
http://www.maine.gov/dhhs/oms/provider_index.html.
The Department may use evidence-based criteria and/or may use criteria based on
national standards for evaluating what is considered medically
necessary.
