Code of Maine Rules
10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL
Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL)
Chapter II - Specific Policies By Service
Section 144-101-II-13 - TARGETED CASE MANAGEMENT SERVICES
Subsection 144-101-II-13.06 - LIMITATIONS

1. New members to this service must choose only one approved Comprehensive Targeted Case Management provider.

2. Documentation of the member's choice of comprehensive case management services must be retained in the member's record and will serve as an enrollment, dis-enrollment, or reenrollment of the member with the provider.

3. MaineCare Services will reimburse only for Targeted Case Management Services provided by the approved provider chosen by the member new to the service and only for one Comprehensive Targeted Case Manager.

4. A member may choose a new Comprehensive Targeted Case Management provider at any time.

5. In specific circumstances and through prior authorization, members may be eligible to receive a 30 (thirty) day transition period in which two (2) comprehensive case managers may provide services concurrently. This applies only when members are transitioning from one eligibility category to another (e.g. child to adult).

A. Section 13 (TCM) services provided to children with behavioral health needs, chronic health conditions, and/or developmental disabilities require prior authorization.

B. The providers of Targeted Case Management are required to submit a Prior Authorization request to the Department or its Authorized Agent. The provider and recipient will receive prior authorization with a description of the type, duration and costs of the services authorized. The provider is responsible for providing services in accordance with the prior authorization letter. The prior authorization number is required on the CMS 1500 claim form. All extensions or amendment of services beyond the original authorization must be prior authorized by this same procedure.

C. DHHS or its Authorized Agent reserves the right to approve continuation of any covered services as described in this Section, applying the standards established by this Section for eligibility and for continuation of services. All case management services may require utilization review.