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-46 - Psychiatric Hospital Services
Subsection 144-101-II-46.08 - DEPARTMENTAL UTILIZATION REVIEW
The Department requires utilization review (UR) for services reimbursed under this section. Utilization Review is performed by the Department or its Authorized Agent in coordination with the provider's internal UR process.
Central Enrollment is a process of determining baseline eligibility for behavioral health treatment. DHHS or its Authorized Agent shall facilitate referrals to appropriate service providers, expedite delivery of service to members, and reliably track the service status of members enrolled in the system and gather data that will inform DHHS of resource development needs. This is part of the UR process.
Utilization Review is a formal assessment of the medical necessity, efficiency and appropriateness of services and treatment plans on a prospective, concurrent or retrospective basis. The provider is required to notify the DHHS or its Authorized Agent upon initiation of all services in this Section in order for the Authorized Agent to begin utilization review.
