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-60 - Medical Supplies and Durable Medical Equipment › Subsection 144-101-II-60.07 - PRIOR AUTHORIZATION REQUIREMENTS

Current through 2024-29, July 17, 2024
Some Medical Supplies and DME require PA for MaineCare to
						provide payment. The Department or its authorized entity processes PA requests.
						More information on the PA process is in
MaineCare Benefits
						Manual
, Chapter I, Section
						1. The MaineCare Health
						PAS Online Portal contains a complete list of Medical Supplies and DME that
						require PA and corresponding PA criteria sheets. Providers should research each
						item on the MaineCare website to assure it is covered and check whether it
						requires PA at
https://mainecare.maine.gov/Default.aspx
,
						which includes a link to the PA portal. The Department reserves the right to
						require an evaluation by appropriate clinical professionals of its choice
						before granting PA.
In cases where the member does not meet the PA criteria,
						the provider or member may submit additional supporting evidence, such as
						medical documentation, to demonstrate that the requested service is medically
						necessary.
Providers shall make requests for PA on the Department's
						approved form and get approval prior to the date of service.
Proper documentation includes proof of acquisition cost
						or a price quote from a manufacturer. If a claim is not equal to the exact
						amount of the PA, a subsequent adjustment to the authorization may be made with
						appropriate documentation. Claims should not be submitted until the adjustment
						is made. Alternatively, the Department may choose to issue a letter approving
						the request for PA without assigning an approved amount.
Once documentation of Adjusted Acquisition Cost (AAC) is
						received from the provider, MaineCare staff will assign an allowable amount. A
						completed Medicare Certificate of Medical Necessity (CMN) shall include
						itemized AAC and usual and customary charges for the equipment.
The Department reserves the right to request detailed
						documentation, including material and labor costs and total hours for the
						manufacture or fabrication of orthotic and prosthetic devices. This information
						may be estimated prior to the manufacture or fabrication. However, actual costs
						must be submitted upon completion. Non-compliance may result in denial of
						payment or recoupment of payments.
The Department will not refuse to prior authorize a DME
						item based solely on a diagnosis, type of illness, or condition.
60.07-1
General Categories and
					 Conditions that Require Prior Authorization
In addition to the specific items that require PA, the
						Department also requires PA for the following:
A.
Items with Cost Exceeding
					 $699.00
PA is required for any Medical Supplies and DME that
						costs MaineCare more than $699.00. The item must be prescribed by a Qualified
						Provider and be the most cost-effective item available that meets the medical
						needs of the member.
The cost of an item equals the total cost of all the
						item's constituent pieces. For example, the cost of a wheelchair is the sum of
						the cost of each of its components including, but not limited to, foot plates,
						wheels, wheel rims, armrests, arm troughs, etc. Should the need arise for an
						unanticipated component, that item must have PA, regardless of price.
B.
Rental equipment
Rental equipment requires PA, except in emergency
						situations. Oxygen is considered a rental.
In an emergency, the Department does not require PA to
						rent standard equipment for up to thirty (30) days. The Department will pay the
						rental for this emergency period. In this section, the Department defines
						emergency as a situation where the member would not otherwise be able to return
						home from a hospital, rehabilitation facility, or nursing home, or when a
						prescribing provider determines a member must have the equipment within
						twenty-four (24) hours.
The provider must request PA authorization within thirty
						(30) days of providing the equipment if it is necessary to continue the rental
						beyond thirty (30) days.
The Department will deny reimbursement beyond the thirty
						(30) day emergency period if the provider does not make this request. The
						Department will decide, within thirty (30) days of the date the PA is
						requested, whether to approve, defer, or deny authorization for the rental
						beyond the thirty (30) day emergency period.
C.
Miscellaneous DME
Miscellaneous DME, including those billed under the
						Healthcare Common Procedure Coding System (HCPCS) code E1399 or any other DME
						billed under another code which contains the phrase "miscellaneous,"
						"accessories," "not otherwise specified," or "not otherwise classified" in its
						description when the MaineCare allowed amount exceeds $99.99, requires
						PA.
D.
DME
					 Parts
DME parts for member-owned DME previously supplied and
						covered under MaineCare require PA. For example, a part related to a wheelchair
						that previously required PA would also require PA. DME parts that fall under
						warranty will not be covered.
The Department is not responsible for the cost of parts
						for rented DME.
E.
Repairs to DME
Repairs to member-owned DME with a total cost (parts and
						labor) exceeding sixty percent (60%) of replacement cost require PA, at which
						time the Department will decide if replacement of the DME is
						appropriate.
PA is required for any repair if replacement parts,
						labor, or the combination are over $699.00 to repair medically necessary DME.
						The Department reserves the right to request documentation necessary to
						validate medical necessity before PA is granted.
Reimbursement is not allowed for repair of any DME that
						is still under warranty.
The Department is not responsible for the costs
						associated with repairs to rented DME.
F.
Outright Purchase of Used
					 Equipment
To qualify for PA, information on the Department's
						approved PA form or the appropriate CMN must indicate that the same warranty is
						offered on used equipment as on new equipment. The equipment being
						reconditioned shall not exceed the expense for new equipment.
G.
Other Items Subject to Coverage
					 Limitation
Some items subject to coverage limitations may be covered
						in excess of the limitation under limited circumstances when prior authorized
						by the Department. These items can include power operated vehicles and
						wheelchairs, hospital beds, standard mattresses for hospital beds, prosthetic
						devices to allow functional mobility, nebulizers, respiratory suction pumps,
						and CPAP and Bi-Pap devices and supplies.