85.07-1
All
ages
1. MaineCare will not reimburse
for more than two (2) hours of physical therapy services per day.
2. Supervised modalities (those without
direct one-to-one continuous contact) that are provided on the same day as
modalities requiring constant attendance or on the same day as any other
therapeutic procedure are not billable. Billing for supervised modalities as
stand-alone treatment is limited to one (1) unit per modality per
day.
85.07-2
Children (under twenty-one (< 21))
All services must be medically necessary.
85.07-3
Adults (age
twenty-one (21) and over)
If CMS approves, Prior Authorization is required for all
services.
The Department or its Authorized Agent processes the
Prior Authorization requests. Prior Authorization is approved upon medical
necessity, as determined by the clinical judgment of the Department's medical
staff. Prior Authorization forms can be found at:
https://mainecare.maine.gov/ProviderHomePage.aspx. More information on the
Prior Authorization process is in MaineCare Benefits Manual, Chapter I. Prior
Authorizations will be issued in accordance with the following limits:
1. Services for adults who meet the specific
eligibility requirements in Section 85.04 must be initiated within sixty (60)
days from the date of physician or PCP referral.
2. Within the scope of 85.04(1)-(3), services
are limited to two (2) visits per condition or event.
3. Services for maintenance care are limited
to two (2) visits per year to design a plan of care, to train the member or
caretaker of the member to implement the plan, or to reassess the plan of care.
This limitation does not apply to maintenance care for members who would
experience deterioration in function as described in 85.04(6).
4. Services for adults with rehabilitation
potential must be medically necessary as certified by a physician or PCP. The
physician's documentation of rehabilitation potential must include the reasons
used to support the physician's expectation. Such treatment is limited to no
more than six (6) visits per condition by qualified staff.
5. Services that are medically necessary will
be covered for terminally ill members.
6. Services for sensory integration are
limited to a maximum of two (2) visits per year.
7. Members receiving physical therapy in
conjunction with a pain management care plan may not receive more than five (5)
treatment visits and one (1) evaluation within twelve months (12), and
reimbursement for such visits is conditional on Prior Authorization based on a
demonstration that the service is medically necessary. The Prior Authorization
criteria include:
A. The member has long-term
chronic pain that has lasted, or is expected to last, more than sixty (60) days
and impacts or is expected to impact a member's level of function for more than
sixty (60) days; and
B. The member
requires physical therapy services for the treatment of long-term chronic pain
to end or avoid the use of narcotics.
