reglab/statecodes huggingface dataset:
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-13 - TARGETED CASE MANAGEMENT SERVICES › Subsection 144-101-II-13.08 - ACCESS TO RECORDS AND CONFIDENTIALITY

Current through 2024-29, July 17, 2024
A.
Records
Members' records compiled under this policy shall be kept
						current. Records shall be retained for a period of not less than five (5) years
						from the date of service provision. If an audit is initiated within the five
						(5) year retention period, the records must be retained until the audit is
						completed and a cost settlement has been made.
B.
Confidentiality and Disclosure of
					 Confidential Documents
The disclosure of information regarding individuals
						participating in the MaineCare program is strictly limited to purposes directly
						connected with the administration of the MaineCare program. Providers shall
						maintain the confidentiality of information regarding these individuals in
						accordance with 42 CFR §431 et seq. and other applicable sections of state
						and federal law and regulation.
Any release of medical records containing information on
						HIV infection status shall be in compliance with 5 M.R.S.A. §19201 et seq.
						and other applicable sections of state and federal law and regulation.
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-13 - TARGETED CASE MANAGEMENT SERVICES › Subsection 144-101-II-13.09 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
13.09-1
Rates
Reimbursement is specified in Chapter III, Section 13,
						Allowances for Targeted Case Management Services.
Providers of services reimbursed on a quarter hour basis
						under this Section will be reimbursed for any substantive contact at a minimum
						of fifteen (15) minutes. Providers are subject to the rounding requirements in
						Chapter I of the MaineCare Benefits Manual (Provider Participation).
13.09-2
Reimbursement
					 Allowances
In accordance with Chapter I of the MaineCare Benefits
						Manual, it is the responsibility of the provider to seek payment from every
						other source that is available for payment of a rendered service before billing
						MaineCare.
MaineCare will pay the lowest of the following:
A. The fee established by
					 MaineCare;
B. The lowest payment
					 allowed by Medicare; or
C. The
					 provider's usual and customary charge.
Payment will be made under this Section of the MaineCare
						Benefits Manual for case management services provided to an eligible member at
						any given point in time so long as the service provided is not
						duplicative.
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-13 - TARGETED CASE MANAGEMENT SERVICES › Subsection 144-101-II-13.10 - BILLING

Current through 2024-29, July 17, 2024
The documentation must demonstrate that only one staff
						person's time is billed for any specific activity provided to the member.
						Billing must be accomplished in accordance with the Department's "Billing
						Instructions for Targeted Case Management Services" provided by the Office of
						MaineCare Services, Division of Customer Service
(
http://www.maine.gov/dhhs/oms/providerfiles/billing_instructions.html
).
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-14 - Advanced Practice Registered Nursing Services › Subsection 144-101-II-14.01 - DEFINITIONS

Current through 2024-29, July 17, 2024
Advanced Practice Registered Nursing Services
means the practice of a registered professional nurse who, on the basis
						of specialized education and experience, is authorized under the licensing
						rules of the state or province in which services are provided to deliver
						expanded professional health care.
Expanded professional health care
means
						clinical practice in the provision of primary care or other activities such as
						teaching or consultation that have a clinical focus. Advanced Practice
						Registered Nurses (A.P.R.N.s) practicing in Maine must meet guidelines detailed
						in the Department of Professional and Financial Regulations, Maine State Board
						of Nursing, Chapter 8, "Regulations Relating to Advanced Practice Registered
						Nursing".
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-14 - Advanced Practice Registered Nursing Services › Subsection 144-101-II-14.02 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
Individuals must meet the financial eligibility criteria
						as set forth in the
Maine Care Eligibility Manual.Some
members
						may have restrictions on the type and amount of services they are eligible to
						receive.
Providers must verify an individual's MaineCare
						eligibility prior to providing services, asdescribed in Chapter I of the
MaineCare Benefits Manual.
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-14 - Advanced Practice Registered Nursing Services › Subsection 144-101-II-14.03 - DURATION OF CARE

Current through 2024-29, July 17, 2024
Each MaineCare member is eligible for as many covered
						services as are medicallynecessary.The Department of Health and Human Services
						reserves the right to request information to determine medical
						necessity.
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-14 - Advanced Practice Registered Nursing Services › Subsection 144-101-II-14.04 - COVERED SERVICES

Current through 2024-29, July 17, 2024
A covered service is a service for which payment to a
						provider is permitted under this Section of the
MaineCare Benefits
						Manual
(MBM).Covered services are those reasonably necessary medical,
						nursing, and remedial services that:are provided in an appropriate setting;
						reflect coordination and appropriate communication with the prescribing
						licensed physician or dentist where required by the licensing authority; are
						within the scope of practice for the advanced practice registered nurse
						providing the service; and are recognized as standard medical/nursing care
						authorized by the state or province in which services are provided.
Advanced Practice Registered Nurses must also comply with
						all applicable serviceand procedure requirements and guidelines when providing
						services outlined in the
MaineCare Benefits Manual
, Chapter I,
						"General Administrative Policies and Procedures", and Chapter II, Section 90,
						"Physician Services".
A.P.R.N.S with prescriptive and dispensing authority
						(Nurse Practitioners and CertifiedNurse-Midwives) are subject to practice
						within their scope of licensure and approvals by the Maine State Board of
						Nursing, and must additionally follow guidelines as set forth in the
MaineCare Benefits Manual,
Chapter II, Section 80, "Pharmacy
						Services", and Chapter II, Section 90, "Physician Services".
A.P.R.N.S providing psychiatric or psychological services
						as described in the
MaineCare Benefits Manual,
Chapter II,
						Section 90.04, or Chapter II, Section 65, "Mental Health Services", are subject
						to the rules in these sections.
Certified Registered Nurse Anesthetists (CR.N.A.s) are
						subject to service requirements described in Chapter II, Section 90.04,
						"Physician Services", and must use the appropriate modifier to specify the
						provision of anesthesia services as indicated in departmental billing
						instructions.Billing Instructions are available on the department's website
						at:
https://mainecare.maine.gov/Billing%20Instructions/Forms/Publication.aspx
A.P.R.N.S as defined in Section 14.05-1 (Qualified
						Professional Staff), traveling to visit a member to deliver a covered service
						may bill for mileage, one-way, beyond a ten (10)-mile radius of point of origin
						(office or home).MaineCare does not reimburse mileage for trips to the office
						or hospital where the A.P.R.N. and/or the associated or collaborating physician
						or dentist is an active member of the medical staff.
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-14 - Advanced Practice Registered Nursing Services › Subsection 144-101-II-14.05 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
14 05-1
Qualified Professional Staff
A.
Certified Nurse Practitioner (C.N.P.)
means a registered
					 professional nurse who meets all of the requirements of the licensing authority
					 of the state or province where services are provided to practice as a certified
					 nurse practitioner.
B.
Certified Nurse-Midwife (C.N.M.)
means a registered professional
					 nurse who meets all of the requirements of the licensing authority of the state
					 or province where services are provided to practice as a certified
					 nurse-midwife.
C.
Certified
					 Registered Nurse Anesthetist (C.R.N.A.)
means a registered professional
					 nurse who meets all of the requirements of the licensing authority of the state
					 or province where services are provided to practice as a certified registered
					 nurse anesthetist.
D.
Certified Clinical Nurse Specialist (C.N.S.)
means a registered
					 professional nurse who meets all of the requirements of the licensingauthority
					 of the state or province where services are provided to practice as a certified
					 clinical nurse specialist.
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-14 - Advanced Practice Registered Nursing Services › Subsection 144-101-II-14.06 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
For independent practitioners billing for services not
						billed through hospitals, physicians, or dentists, reimbursement for covered
						services shall be the amount listed for services as described inthe Office of
						MaineCare Services' website, for services asdescribed in Chapter II, Section
						90, "Physician Services", as set forth on the Office of MaineCare Services'
						website for Section 90 services, except thatCRNAs shall be reimbursed at 75% of
						the amounts of reimbursement for Section 90.04-1, "Anethesiology Services",
						pursuant to the provisions of Section 90.
In accordance with Chapter I of the
MaineCare
						Benefits Manual,
it is the responsibility of the provider to ascertain
						from each member whether there are any other resources (private or group
						insurance benefits, workers' compensation, etc.) available for payment of the
						rendered services, and to seek payment from such resource prior to billing the
						MaineCare Program.
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-14 - Advanced Practice Registered Nursing Services › Subsection 144-101-II-14.07 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
The Department requires appropriate billing modifiers to
						distinguish A.P.R.N. services when billing for anesthesia services.Certified
						registered nurse anesthetists must refer to the Department's current billing
						instructions regarding modifier usage when billing for anesthesia services
						performed and billed directly by a certified registered nurse
						anesthetist.
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-15 - Chiropractic Services › Subsection 144-101-II-15.01 - PURPOSE

Current through 2024-29, July 17, 2024
The Department's purpose for this rule is to provide
						medically necessary chiropractic services to MaineCare members who are adults
						(age twenty-one (21) and over) with rehabilitation potential, and medically
						necessary chiropractic services to MaineCare members who are under age
						twenty-one (21).
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-15 - Chiropractic Services › Subsection 144-101-II-15.02 - DEFINITIONS

Current through 2024-29, July 17, 2024
15.02-1
Chiropractic Services
are those services provided to a member by a licensed chiropractor.
15.02-2
Chiropractor
is an
					 individual who both is licensed by the state or province in which he/she
					 provides chiropractic services and meets uniform minimum standards promulgated
					 by the Secretary of Health and Human Services under
					 42
					 U.S.C. §
												1395x(r) and
					 42 C.F.R. 440.60.
15.02-3
Rehabilitation Potential
is a documented expectation by the
					 member's primary care provider or prescribing provider (Medical Doctor (MD),
					 Doctor of Osteopathic (DO), Physician Assistant (PA), or Advanced Practice
					 Registered Nurse (APRN)), who is licensed and acting within the scope of his or
					 her license, indicating that the member's condition will improve significantly
					 in a reasonable, predictable period of time as a result of the prescribed
					 treatment plan.
15.02-4
Prior
					 Authorization
is the process of obtaining prior approval from the
					 Department as to the medical necessity and eligibility for certain MaineCare
					 services before they are delivered, as set forth herein and in Chapter I,
					 Section 1 of the
MaineCare Benefits Manual
(MBM
)
.
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-15 - Chiropractic Services › Subsection 144-101-II-15.03 - ELIGIBILITY FOR SERVICES

Current through 2024-29, July 17, 2024
A. Individuals must
					 meet the financial, residency and eligibility criteria as set forth in the
MaineCare Eligibility Manual
in order to be eligible for
					 chiropractic services under this Section. Some members may have restrictions on
					 the type and amount of services they are eligible to receive. It is the
					 responsibility of the primary care provider or prescribing provider (MD,DO, PA,
					 or APRN) who is licensed and acting within the scope of his or her license to
					 verify a member's eligibility for MaineCare, as described in Chapter I, Section
					 I of the "MBM", prior to the provision of chiropractic services.
B. If the Centers for Medicare and Medicaid
					 Services (CMS) approves, covered chiropractic services for members of all ages
					 must be medically necessary for the diagnosis and treatment of a spinal
					 condition, as determined in an initial evaluation by the chiropractor or his or
					 her primary care provider or prescribing provider (MD, DO, PA, or APRN). The
					 Department or its authorized agent has the right to perform eligibility
					 determination and/or utilization review to determine if services provided were
					 medically necessary.
C. A member
					 age twenty-one (21) and over must obtain a referral by his or her primary care
					 provider or prescribing provider (MD, DO, PA, or APRN), who is licensed and
					 acting within the scope of his or her license that documents the member's
					 rehabilitation potential. The provider's documentation of rehabilitation
					 potential must include the reasons used to support this expectation. New
					 rehabilitation potential documentation must be re-authorized per episode of
					 unrelated conditions.
This referral requirement does not apply to members with
						Medicare coverage or other third party health insurance while meeting
						adeductible. This referral requirement will also not apply to members with
						Medicare coverage or other third party health insurance until the coverage for
						chiropractic services by the other payer has been exhausted.
D. If for any reason a course of treatment is
					 discontinued for a period longer than one (1) year, the primary care provider
					 or prescribing provider (MD, DO, PA, APRN) must re-evaluate the member
					 following the guidelines specified in Section
					 15.03.
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-15 - Chiropractic Services › Subsection 144-101-II-15.04 - COVERED SERVICES

Current through 2024-29, July 17, 2024
If CMS approves, the Department shall make payment for
						covered services that are specifically included in the Department's MBM,
						Chapter III, Section
						15, "Allowances for Chiropractic
						Services". Covered services are limited to the following:
A. Evaluation or re-evaluation of spinal
					 conditions to determine the rehabilitative effectiveness of chiropractic
					 manipulation prescribed pursuant to Section
					 15.03(B).
B. Manual or mechanical manipulation of the
					 spine that is medically necessary to treat spinal conditions.
C. X-ray services that are medically
					 necessary for diagnosis and treatment of spinal conditions.
Medical necessity must be supported and documented in
						accordance with criteria defined in Section 15.07-3, "Member Records". The
						Department reserves the right to request additional information to evaluate
						medical necessity.
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-15 - Chiropractic Services › Subsection 144-101-II-15.05 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
If CMS approves, MaineCare reimbursement shall cover only
						x-rays of the spine. X-rays ordered or performed by or for a chiropractor that
						are not of the spine are Non-Covered services. Any service not described and/or
						listed in Chapters II and III, Section
						15, is considered a non-covered
						service.
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-15 - Chiropractic Services › Subsection 144-101-II-15.06 - LIMITATIONS

Current through 2024-29, July 17, 2024
A. Unless otherwise indicated in this
					 Section, reimbursement for chiropractic services for MaineCare members ages
					 twenty-one (21) and over shall be limited to twelve (12) visits per calendar
					 year and based upon medical necessity. For services beyond twelve (12) visits,
					 all eligible MaineCare members twenty-one (21) and over require prior
					 authorization as indicated in Section 15.07-2(B).
B. Reimbursement and limitations on the
					 number of x-rays will be based upon the criteria of medical necessity and
					 documentation as specified in Section
					 15.07, Policies and
					 Procedures.
C. When repeat x-ray
					 examinations of the spine for the same condition are required because of
					 technical or professional error in the original x-rays, such repeat x-rays are
					 not a covered service and are not reimbursable by MaineCare.
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-15 - Chiropractic Services › Subsection 144-101-II-15.07 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
15.07-1
Diagnosis
A. If CMS approves,
					 the chiropractor may use the evaluation and management codes 99201-99215 for
					 the purposes of examining and diagnosing a spinal condition. Treatment of
					 spinal conditions must be billed using the spinal manipulation treatment codes
					 98940-98942 listed in Chapter III of this policy.
B. The Chiropractor's recent examination of
					 the member must include, but is not limited to the examinations listed below:
1. Mensuration;
2. Biomechanical Evaluation;
3. Neurological Evaluation;
4. Kinesiological Evaluation; and
5. Orthopedic Evaluation.
C. For the purposes of this
					 requirement, recent shall mean within thirty (30) days prior to the initiation
					 of treatment.
D. MaineCare members
					 who also qualify for Medicare shall meet the diagnostic requirements of the
					 Medicare program.
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-15 - Chiropractic Services › Subsection 144-101-II-15.08 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
If CMS approves, the payment amount for services rendered
						shall be the lowest of the following:
A. The amount listed in the "Allowances for
					 Chiropractic Services," Chapter III, Section
					 15, MBM; or
B. The lowest amount allowed by the Medicare
					 Part B carrier; or
C. The
					 provider's usual and customary charge; or
D. The amount, if any, by which the MaineCare
					 rate of reimbursement for services billed exceeds the amount of the third-party
					 payment as set in Chapter I of the MBM. MaineCare considers a claim paid in
					 full if the third-party payment amount received exceeds the MaineCare rate of
					 reimbursement.
E. Payment for x-ray
					 services rendered medically necessary for diagnosis and treatment of a spinal
					 condition shall be: the lowest of the amounts set forth in 15.08 (A)-(C); OR,
					 the fee-for-service rate is set at seventy (70%) of the lowest level in the
					 2009 Medicaid fee schedule for Maine area "99" for services under this policy,
					 including adjustments for place of service and modifiers.
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-15 - Chiropractic Services › Subsection 144-101-II-15.09 - COPAYMENT

Current through 2024-29, July 17, 2024
A. A copayment will be charged to each
					 MaineCare member receiving services. The amount of the copayment shall not
					 exceed $2.00 per day for services provided, according to the following
					 schedule: x
MaineCare Payment for
								  Service
MaineCare Payment for
								  Service
$10.00 or less
$ .50
$10.01 - 25.00
$1.00
$25.01 or more
$2.00
B. The member shall be responsible for
					 copayments up to $20.00 per month whether the copayment has been paid or not.
					 After the $20.00 cap has been reached, the member will not be required to make
					 additional copayments and the provider will receive full MaineCare
					 reimbursement for covered services.
C. No provider may deny services to a member
					 for failure to pay a copayment. Providers must rely upon the member's
					 representation that he or she does not have the resources available to pay the
					 copayment. A member's inability to pay a copayment does not, however, relieve
					 him/her of liability for the copayment.
D. Providers are responsible for documenting
					 the amount of copayments charged to each member regardless of whether the
					 member has made payment.
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-15 - Chiropractic Services › Subsection 144-101-II-15.10 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
A. Providers must
					 bill in accordance with the Department's current Billing
					 Instructions.
B. All services
					 provided on the same day shall be submitted on the same claim form for
					 MaineCare reimbursement.
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-15 - Chiropractic Services › Subsection 144-101-II-15.11 - BILLING INSTRUCTIONS (REPEALED)

Current through 2024-29, July 17, 2024
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-17 - Community Support Services › Subsection 144-101-II-17.03 - TIMELINESS AND DURATION OF CARE

Current through 2024-29, July 17, 2024
For Community Integration Services and Assertive
						Community Treatment (ACT) Services, providers must conduct an initial
						face-to-face intake or initial assessment visit within seven (7) calendar days
						of referral, regardless of source of referral. In the event a provider receives
						a referral and does not have capacity to initiate services, the provider must
						offer the option of placing the member on a hold for service. Except as
						expressly provided in Section
						17.04, a member is
						eligible for the covered services specified in Section
						17.04 for as long as
						he or she meets the criteria for eligibility specified in Section
						17.02, subject to
						prior authorization and/or utilization review. Utilization review (Continuing
						stay reviews) consider the member's complete clinical situation and what the
						progress has been throughout treatment, in conjunction with the LOCUS score or
						functional impairment criteria as evidenced by other approved standardized
						assessment tools. An improvement in functioning level or adaptive behaviors
						will not in and of itself necessarily mean ineligibility for services.
Hold for Service
Members have the option to be placed on hold for service
						if the agency, upon receipt of a referral from any source, has determined that
						it does not have the capacity to conduct an intake or initial assessment within
						seven (7) calendar days as required in Sec.
						17.03. To be placed
						on hold for service, providers must offer the member alternatives to being
						placed on hold for service, including but not limited to giving information on
						other service providers within a 25-mile radius servicing the area. This
						information shall be provided in writing. Should members wish to be on hold for
						service with an agency, the provider will document the member choice and the
						offering of alternatives in the member's referral record. At this time, the
						seven (7) calendar day face-to-face requirement will be suspended. Agencies
						must follow up with members no more than thirty (30) calendar days after being
						placed on hold to reevaluate their desire to remain on hold for service, which
						will be documented in the member record. Agencies must continue to follow up
						with members in successive thirty (30) day increments to reevaluate the
						member's desire to remain on hold. When the agency has determined it has the
						capacity to serve the member, it will contact the member immediately and have
						seven (7) calendar days to conduct the intake or initial
						assessment.
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-17 - Community Support Services › Subsection 144-101-II-17.06 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
Services Not MaineCare Reimbursable
. The
						following services are not MaineCare reimbursable under this Section and as
						referenced in Chapter I, Section 1.06-5:
A. Programs, services, or components of
					 services that are primarily opportunities for socialization and activities that
					 are solely recreational in nature (such as picnics, dances, ball games,
					 parties, field trips, religious activities, social clubs, camps, and
					 companionship activities);
B.
					 Programs, services, or components of services the basic nature of which is to
					 maintain or supplement housekeeping, homemaking, or basic services for the
					 convenience of a person receiving covered services (including housekeeping,
					 shopping, childcare, and laundry service).
C. Substance Use Disorder treatment services
					 which do not meet the criteria cited in Subsection 17.02-3(A).
D. Psychotherapy, as defined in Chapter II,
					 Section
					 65, except for Assertive Community
					 Treatment.
E. Costs for paperwork,
					 internal meetings, or appointment reminders associated with the delivery of
					 covered services are built into the rates and are not reimbursable as separate
					 services.
F. Refer to the
MaineCare Benefits Manual
, Chapter I for additional listings
					 of non-covered services.
G.
					 Transportation Services. Costs related to transportation are built into the
					 rates for services provided under this Section. Therefore, separate billings
					 for travel time are not reimbursable.
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-17 - Community Support Services › Subsection 144-101-II-17.07 - PROFESSIONAL AND OTHER QUALIFIED STAFF

Current through 2024-29, July 17, 2024
17.07-1
Mental Health Professionals:
All professional staff must provide
					 services only to the extent permitted by licensure and approval to practice
					 conditions. As used in this Section, "Mental Health Professionals" means the
					 following professionals:
A. A psychiatrist
					 who has current and valid licensure as a physician by the Maine Board of
					 Licensure in Medicine or by the state or province where services are provided,
					 and who:
1. Is certified by the American
					 Board of Psychiatry and Neurology; or
2. Is eligible for examination by that Board
					 as documented by written evidence from that Board; or 3. Has completed three
					 years of post-graduate training in psychiatry approved by the Education Council
					 or the American Medical Association and submits written evidence of the
					 training.
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-17 - Community Support Services › Subsection 144-101-II-17.08 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
17.08-1
Assessments
. The following policies and procedures apply to
					 covered services related to the assessment of a member, as described in Section
					 17.08-1(B):
A. If the member seeking Community
					 Support Services is in a crisis/outreach situation, it may not be necessary or
					 possible for the assessment to cover all of the areas generally covered in an
					 assessment. An exception to the scope of the assessment may be made by a
					 supervisory mental health professional and recorded in the member's record. A
					 complete Community Support Services assessment must be developed as soon as
					 clinically feasible, but no later than thirty (30) days.
B. The clinical components of an assessment
					 will be:
1. Performed by the appropriate
					 mental health professionals acting within the scope of their license;
2. Coordinated by a Community Support
					 Provider.
C. The member
					 or guardian seeking Community Support Services will be an integral part of the
					 assessment and will provide essential information. The member's family or
					 significant other also may be involved, unless such involvement is not feasible
					 or contrary to the wishes of the member or guardian.
D. A Community Support Provider shall develop
					 a comprehensive ISP as defined in 17.04-1(E) within thirty (30) days of
					 application of a member for covered services 17.04-1 (Community Integration),
					 17.04-2 (Community Rehabilitation Services),17.04-3 (Assertive Community
					 Treatment-ACT). For all other Section
					 17 Covered Services, an ISP as
					 specified in
					 17.01-12 must be developed within
					 thirty (30) days of acceptance. These timeframes must be met unless there is
					 documentation in the member's file that supports a clinical reason why the
					 assessment was not done within thirty (30) days. In these cases, the assessment
					 and the ISP or treatment plan must be developed as soon as clinically
					 feasible.
E. Assessments must
					 indicate the member's diagnosis and the name and credentials of the clinician
					 who determined the diagnosis.
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-17 - Community Support Services › Subsection 144-101-II-17.10 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
17.10-1
Rates
. Reimbursement is
					 specified in the
MaineCare Benefits Manual
Chapter III,
					 Section 17.
17.10-2
Services
					 Provided in a Group
. When Community Support Services are provided in a
					 group, one or two Community Support Providers may facilitate the session, as
					 appropriate. However, only one facilitator may bill for the members
					 participating in that group.
17.10-3
Reimbursement
					 Allowances
. In accordance with Chapter I of the
MaineCare
					 Benefits Manual
, it is the responsibility of the provider to seek
					 payment from every other source that is available for payment of a rendered
					 service before billing MaineCare.
MaineCare will pay the lowest of the following:
A. The fee established by
					 MaineCare;
B. The lowest payment
					 allowed by Medicare; or
C. The
					 provider's usual and customary charge.
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-17 - Community Support Services › Subsection 144-101-II-17.11 - CONFIDENTIALITY

Current through 2024-29, July 17, 2024
The disclosure of information regarding persons eligible
						for or receiving covered services under Section
						17 is strictly limited to purposes
						directly connected with the administration of the MaineCare Program. Providers
						must maintain confidentiality of information regarding these persons in
						accordance with applicable sections of state and federal law and
						regulation.
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-17 - Community Support Services › Subsection 144-101-II-17.12 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
Community Support Providers shall bill for services under
						this Section in accordance with the billing requirements of the Department of
						Health and Human Services, including use of the CMS 1500 claim form.
For instructions and to download copies of Form CMS
						1500, please see the OMS "Billing Instructions web page, available at:
https://mainecare.maine.gov/Billing%20Instructions/Forms/Publication.aspx
.
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-18 - RULES GOVERNING IMPLEMENTATION OF THE TRADE ADJUSTMENT ASSISTANCE PROGRAM › Subsection 144-101-II-18.01 - INTRODUCTION

Current through 2024-29, July 17, 2024
This benefit is a Home and Community-Based Waiver for
						Adults with Brain Injury who are 18 or older, meet criteria for care in an
						intermediate care facility or nursing facility and choose to live in the
						community with the support of this waiver. This Home and Community-Based Waiver
						is designed to maximize the opportunity for members to achieve the greatest
						degree of self-sufficiency and independence chosen by the member. Member choice
						in all services and components of services is a primary goal of this waiver.
						Additionally, the principles of conflict-free care coordination, services
						provided in the least restrictive modality and effective use of assistive
						technology for communication, environmental control and safety are inherent to
						this waiver.
This benefit has been designed and will be implemented in
						such a manner so as to ensure that every waiver service setting:
. Is integrated in and supports full access to the
						greater community;
. Is selected by the member from among setting options;
. Ensures members rights of privacy, dignity and respect,
						and freedom from coercion and restraint;
. Optimizes autonomy and independence in making life
						choices; and
. Facilitates choice regarding services and who provides
						them.
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-18 - RULES GOVERNING IMPLEMENTATION OF THE TRADE ADJUSTMENT ASSISTANCE PROGRAM › Subsection 144-101-II-18.05 - COVERED SERVICES

Current through 2024-29, July 17, 2024
18.05-1
Assistive Technology Device and Services
- Assistive Technology Device
					 means an item, piece of equipment, or product system, whether acquired
					 commercially, modified, or customized, that is used to increase, maintain, or
					 improve the functional capabilities of members.
Assistive Technology Service
means a
						service that directly assists a member in the selection, acquisition, or use of
						an Assistive Technology device. Assistive Technology Services include:
A. the evaluation of the Assistive Technology
					 needs of a member, including a functional evaluation of the impact of the
					 provision of appropriate Assistive Technology Devices and appropriate Assistive
					 Technology Services to the member in the customary environment of the
					 member;
B. ) services consisting of
					 purchasing, leasing, or otherwise providing for the acquisition of Assistive
					 Technology Devices for members;
C.
					 services consisting of selecting, designing, fitting, customizing, adapting,
					 applying, maintaining, repairing, or replacing Assistive Technology
					 Devices;
D. coordination and use of
					 necessary therapies, interventions, or services with Assistive Technology
					 Devices, such as therapies, interventions, or services associated with other
					 services in the Care Plan;
E.
					 training or technical assistance for the member, or, where appropriate, the
					 family members, guardians, advocates, or authorized representatives of the
					 member;
F. training or technical
					 assistance for professionals or other individuals who provide services to,
					 employ, or are otherwise substantially involved in the major life functions of
					 members; and
G. transmission of
					 data required for use of the Assistive Technology Device via internet or cable
					 utility.
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-18 - RULES GOVERNING IMPLEMENTATION OF THE TRADE ADJUSTMENT ASSISTANCE PROGRAM › Subsection 144-101-II-18.06 - NONCOVERED SERVICES

Current through 2024-29, July 17, 2024
Services for which reimbursement is not allowed under
						this Section include, but are not limited to, the following:
18.06-1 Services not authorized by the Care
					 Plan.
18.06-2 Services to any
					 member who is hospitalized, a nursing facility resident, or ICF/IID resident.
18.06-3 Any service otherwise
					 reimbursable under the Rehabilitation Act of 1973 or the Individuals with
					 Disabilities Education Act, including but not limited to job development and
					 vocational assessment or evaluations.
18.06-4 Room and board. The term "room" means
					 shelter-type expenses, including all property-related costs, such as rental or
					 purchase of real estate and furnishings, maintenance, utilities, and related
					 administrative services. The term "board" means three meals a day or any other
					 full nutritional regimen.
18.06-5
					 Services provided directly or indirectly by the legal guardian, spouse, or a
					 relative of the member.
18.06-6
					 Work Support when the member is not engaged in employment.
18.06-7 Assistive Technology unless the
					 service has been determined non-reimbursable under Section 60, "Medical
					 Supplies and Durable Equipment", the State Plan and/or other sections of the
					 MaineCare Benefits Manual.
18.06-8
Non-Duplication of Services
Services as defined under this section if the member is
						receiving comparable or duplicative services under this or another section of
						the MaineCare Benefits Manual. A member may not receive services under this
						section, if the member is in a residential treatment facility or if the member
						is receiving services in an institution, including, but not limited to Section
						2, "Adult Family Care Services"; Section 13, "Targeted Case Management
						Services"; Section 45, "Hospital Services"; Section 46, "Psychiatric Hospital
						Services"; Section 50, "ICF/IID Services"; Section 67, "Nursing Facility
						Services" and Section 97, "Private Non-Medical Institution Services". A member
						may not receive services if they are in another Home and Community Based Waiver
						such as Section 19, "Home and Community-Based Benefits for the Elderly and for
						Adults with Disabilities", Section 20, "Home and Community Based Services for
						Adults with Other Related Conditions", Section 21, "Home and Community Benefits
						for Members with Intellectual Disabilities or Autistic Disorder", Section 22,
						"Home and Community Benefits for the Physically Disabled", Section 29, "Support
						Services for Adults with Intellectual Disabilities or Autistic Disorder" and
						Section 32, "Waiver Services for Children with Intellectual Disabilities or
						Pervasive Developmental Disorders".
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-18 - RULES GOVERNING IMPLEMENTATION OF THE TRADE ADJUSTMENT ASSISTANCE PROGRAM › Subsection 144-101-II-18.07 - LIMITS

Current through 2024-29, July 17, 2024
The following service limits apply to each member:
18. 07-1
Assistive Technology
					 Services
- Assistive Technology Services are limited to as described in
					 the covered service 18-05-1. Each system or device will be revised based on
					 medical necessity, efficiency and meets compatibility with safety needs.
18. 07-2
Care Coordination
					 Services
- Care Coordination Services are limited to 400 units for the
					 first year in which the member receives services under this Section and 200
					 units every year after the initial year. The Care Coordination provider may not
					 offer any other services to the member under this Section.
18. 07-3
Career Planning-
The
					 maximum annual allowance is 60 hours to be delivered within a six month period.
					 No two six month periods may be provided concurrently. Career Planning may not
					 be provided at the same time as Home Support, Employment Specialist Services or
					 Work Support.
18. 07-4
Community/Work Reintegration-
A member may have up to 72 units per week
					 of either Community/Work Reintegration, Self Care/Home Management Reintegration
					 or any combination of both. A member may not also access the state plan service
					 in the MaineCare Benefits Manual, Section 102, "Rehabilitative Services".
18.07-5 Home Support Services- are
					 limited as follows:
A. Home Support Services
					 (1/4 hour) Level I-are limited to 64 units per day.
B. Home Support Services (Remote Support)-
					 are limited to 64 units per day.
C. Home Support Services (Increased
					 Neurobehavioral) Level III per diem - Members receiving this service are not
					 authorized to have Self/Home Management Reintegration, Work/Community
					 Reintegration, or Work Ordered Day Club House as separate services.