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-25 - Dental Services and Reimbursement Methodology
Subsection 144-101-II-25.05 - POLICIES AND PROCEDURES

25.05-1 Prior Authorization

Providers shall use the appropriate PA criteria sheet on the Department's HealthPAS Portal when requesting PA. If a covered service does not have a unique criteria sheet with specific criteria, providers shall use the Supplemental Dental Services PA Form and include a narrative of medical necessity, appropriate radiographs, and any other documentation that demonstrates medical necessity. The Department may use PA criteria that are industry recognized criteria from a national company under contract. In cases where criteria are not met, providers may submit additional supporting evidence such as medical documentation to demonstrate that the requested service is medically necessary. Providers may submit a PA to exceed the limit for a covered service, and the Department will approve the PA if it determines exceeding the limit is medically necessary. The Department may request additional documentation before approving a PA if the documentation provided is insufficient.

25.05-2 Provider Requirements

Providers of covered services described in Section 25.03 shall be appropriately licensed by the Board, abide by the Board's rules, and meet requirements and only deliver services in accordance with their scope of practice as defined in 32 M.R.S. Chapter 143.

Covered services rendered by Dental Residents and Dental Externs shall be reimbursed to entities enrolled as MaineCare providers employing or sponsoring Dental Residents and Dental Externs.

25.05-3 Timeframe Limits for Covered Services

"Year," in the context of covered service limits, means "calendar year" when the limit is defined on a "per year" basis. For covered service limits that are defined on a multi-year basis, each "year" means a rolling 365-day period or the 365 days following the date of the delivery of the first covered service subject to the limit. For example, a "two per three years" limit means a member cannot receive more than two of the specified services in any given 1,095-day period.