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 VI
Section 144-101-VI-01 - Primary Care Case Management (replaced by Section 03 on June 21, 2022)
Subsection 144-101-VI-01.04 - MANAGED SERVICES
Current through 2024-38, September 18, 2024
Managed services are the services defined in the categories listed below, and are described in Chapter II of this Manual. Any future policy revisions to the service categories described in this Section will automatically be included as part of Section 1.04 unless specifically exempted by rule. These services are payable by MaineCare only when provided by the member's PCP or his or her designee, or by other MaineCare providers with a referral by the member's PCP or his or her designee. Reimbursement for the provision of managed services is made in accordance with the policies set forth in Chapters I, II, and III, of this Manual. Unless otherwise exempt, MaineCare members enrolled in Primary Care Case Management are subject to co-payments for all MaineCare services that require co-payments.
Certain services that fall within the service categories described in Section 1.04, may be accessed directly by members and do not require a referral by the member's PCP. Please see Section 1.05 for a description of these services.
All claims for managed services must have the PCP's referral number in the appropriate block on the claim form regardless of whether the services were delivered by the member's PCP or his or her designee, or another provider to whom an authorized referral was made.
The following services, described in Chapters II or V of the MaineCare Benefits Manual, are managed:
1.04-1 Ambulatory Surgical Center Services, Section 4.
1.04-2 Advanced Practice Registered Nursing Services, Section 14, with the exception of those services which do not require referral by the PCP, as described in Section 1.05-1 and those services provided by an Advanced Practice Registered Nurse serving as the member's PCP.
1.04-3 Chiropractic Services, Section 15.
1.04-4 Clinic Services: Section 3, Ambulatory Care Clinics (with the exception of school-based health centers); Section 31, Federally Qualified Health Centers; and Section 103, Rural Health Clinics.
1.04-5 Prevention, Health Promotion and Optional Treatment Services, Section 94.
1.04-6 Hearing Aids and Services, Section 35.
1.04-7 Home Health Services, Section 40.
1.04-8 Hospital Services, Section 45, with the exception of those services that do not require referral by the PCP, as described in Section 1.05.
1.04-9 Medical Supplies and Durable Medical Equipment, Section 60.
1.04-10 Occupational Therapy Services, Section 68.
1.04-11 Vision Services, Sections 75 and 90. Members may, however, self-refer for routine annual eye examinations. See Section 1.05-1.
1.04-12 Physical Therapy Services, Section 85.
1.04-13 Physician Services, Section 90.
1.04-14 Podiatric Services, Section 95.
1.04-15 Speech and Hearing Services, Section 109.
