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-7 - FREE-STANDING DIALYSIS SERVICES
Subsection 144-101-II-7.07 - POLICIES AND PROCEDURES

Universal Citation: 10 ME Code Rules § 144-101-II-7.07

Current through 2024-38, September 18, 2024

7.07-1 Provider Eligibility

A free-standing dialysis center must be a MaineCare provider on the date of service in order to be eligible for reimbursement.

In-State Providers: To be eligible for participation as a MaineCare provider, a free-standing dialysis center must be:

1. located and doing business in the State of Maine (out-of-state providers within fifteen (15) miles of the Maine/New Hampshire border and within five (5) miles of the Maine/Canada border are treated the same as Maine providers in all aspects of policy requirements, including enrollment, rates of reimbursement, and payment methodologies);

2. certified by Medicare and providing services to the standards of a Medicare provider as provided in 42 CFR Part 494;

3. licensed as an out-of-hospital dialysis unit by the Maine Center for Disease Control and Prevention;

4. in compliance with all applicable federal, state and local laws and regulations and;

5. enrolled separately for facilities with multiple sites with the same owner/director.

7.07-2 Medicare Eligibility

Dialysis providers must assist MaineCare members in applying for and pursuing final Medicare eligibility determinations. If the Social Security Administration determines that an individual is not eligible for Medicare, documentation must be attached to the next MaineCare dialysis claim form.

7.07-3 Member Records

Providers must maintain written member records for all services, in chronological order. All member records must contain the following general categories of information:

A. Member's name, address, birth date and MaineCare number

B. The members file must include documentation supporting the following:

1 timely assessment and reassessment (at least annually or more frequently as indicated) of the needs of the patient by the dialysis facility's interdisciplinary team. The interdisciplinary team should consist of, at a minimum, the patient or patient's designee, a registered nurse, a physician treating the patient for ESRD, a social worker and a dietician. The assessments must be completed within the later of 30 calendar days or 13 outpatient hemodialysis sessions after the member's first dialysis treatment;

2. whether the patient is treated with a reprocessed hemodialyzer;

3. establishment of a personalized plan of care and treatment and expectations for care based on current clinical standards;

4. the care and services provided;

5. the patient was fully informed of the results of the assessment regarding their suitability for transplantation and home dialysis;

6. Signed consent forms, referral information and authentification of diagnosis;

7. Member's medical, nursing and social history;

8. Reports of physician examinations;

9. Diagnostic and therapeutic orders;

10. Observations and progress notes;

11. Reports of treatments and clinical findings;

12. Reports of laboratory and other diagnostic tests and procedures;

13. Discharge summary including final diagnosis and prognosis;

14. Full account of any unusual condition or unexpected event.

7.07-4 Quality Assurance

The Department will conduct periodic review of cases to assure quality and appropriateness of care in accordance with the quality assurance (QA) protocols established by the Department consistent with federal Quality Assurance and Process Improvement (QAPI) requirements found at 42 CFR § 494.110.

Reviews will be in writing, signed and dated by the reviewers, and included in the clinical record.

The Department permits QA documentation to be kept in a separate and distinct file parallel to the clinical record.

7.07-5 Program Integrity (PI)

All providers are subject to the Department's Program Integrity activities. Refer to the MaineCare Benefits Manual, Chapter I, General Administrative Policies and Procedures for rules governing these functions.

Disclaimer: These regulations may not be the most recent version. Maine may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.

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