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-65 - Behavioral Health Service › Subsection 144-101-II-65.07 - LIMITATIONS

Current through 2024-29, July 17, 2024
65.07-1
Services in Individualized
					 Treatment Plan (ITP)
Only services included in the ITP will be reimbursed.
						Reimbursement will be allowed for covered services prior to the approval of the
						initial ITP, when the provider obtains subsequent approval of those services
						within thirty (30) days of the date the member begins treatment.
65.07-2
Prior Authorization
					 and Utilization Review
Some services in this section require Prior
						Authorization, including Crisis Residential, Children's Assertive Community
						Treatment, Children's Home and Community Based Treatment and Collateral
						Contacts for Children's Home and Community Based Treatment. Prior Authorization
						may not be required for members with a diagnosed Opioid Use Disorder seeking
						Intensive Outpatient Therapy Services. Prior Authorization criteria can be
						found at: https://mainecare.maine.gov/ProviderHomePage.aspx After submitting a
						Prior Authorization request the provider will receive Prior Authorization with
						a description of the type, duration and costs of the services
						authorized.
The provider is responsible for providing services in
						accordance with the Prior Authorization letter. The Prior Authorization number
						is required on the CMS 1500 claim form. All extensions of services beyond the
						original authorization must be Prior Authorized by this same procedure.
All other services in this section require notification
						of initiation of services for Utilization Review purposes.
65.07-3
Crisis Resolution
A treatment episode includes face-to-face visits and
						related follow up phone calls, as clinically indicated, up to (60) days after
						the first face to face visit. DHHS Office of Child and Family Services (OCFS)
						or Office of Behavioral Health (OBH) Medical Director or Designee may approve
						additional time, if medically necessary and clinical documentation supports the
						need for the service. Crisis resolution services will cover the time necessary
						to accomplish appropriate crisis intervention, collateral contact,
						stabilization and follow-up. When increased staffing is necessary to ensure
						that a member receives necessary services while the safety of that member is
						maintained, MaineCare reimbursement for these services will be made to more
						than one (1) Clinician and/or other qualified staff at a time. Providers must
						maintain documentation of the necessity of this treatment.
More than one agency may be reimbursed for crisis
						contacts and respective face-to-face follow-up contacts for children and adult
						crisis resolution services only when the two agencies have a formal agreement
						or sub-contract stipulating one (1) or more agencies deliver phone services and
						the other agency (or agencies) provide follow-up, and face-to-face
						services.
65.07-4
Crisis Residential
Prior Authorization for up to seven (7) consecutive days,
						beginning with the date of admission must be obtained for all medically
						necessary Crisis Residential Services. Providers may not provide Crisis
						Residential Services for longer than the seven (7) day period, unless DHHS or
						an Authorized Entity has Prior Authorized an extension of the seven (7) day
						period of service and the extension is medically necessary.
65.07-5
Outpatient Services
65.07-5.A.
Comprehensive
					 Assessment
Comprehensive Assessments are limited two (2) hours or
						eight (8) units annually and to only those needed to determine appropriate
						treatment, such as whether or not to treat, how to treat and when to stop
						treating. Reimbursement for a Comprehensive Assessments does not include
						psychological testing. Reimbursement for Comprehensive Assessments shall not
						exceed two (2) hours or eight (8) units annually, except when a member requires
						a change in the level of care or a new provider, an additional one (1) hour or
						four (4) units will be authorized for the provider of the new service to do an
						addendum to the original Comprehensive Assessment.
Additional Comprehensive Assessments of two (2) hours or
						eight (8) units may be authorized during the same year if a copy of the
						existing annual assessment cannot be obtained after reasonable efforts or if
						the member chooses not to authorize access to the existing assessment.
65.07-5.B.
Individual
					 Outpatient Therapy
For members, individual and Family mental health or
						co-occurring individual outpatient is limited to two (2) hours per week except
						when a member requires services for an emergency or crisis situation or when a
						service is medically necessary to prevent hospitalization. For members,
						individual and Family outpatient for those needing interpreter services will be
						limited to three (3) hours per week. For members, substance use individual and
						family outpatient is limited to three (3) hours per week.
MaineCare reimbursement for individual outpatient will be
						made to only one (1) provider at any given time unless temporary coverage is
						provided in the absence of the usual provider. A member may receive mental
						health individual outpatient and substance use individual outpatient
						concurrently from two (2) separate providers in accordance with the individual
						service limits. If a member is receiving integrated Co-occurring Services with
						one (1) provider for a mental health and a substance use diagnosed condition;
						the member may not also receive separate mental health or substance use
						individual outpatient therapy services under Section
						65 Behavioral Health
						Services.
65.07-5.C.
Group Outpatient Therapy
1.
					 Members receiving group outpatient therapy must be eight (8) years of age or
					 older, unless members less than eight (8) years of age receive Family therapy
					 or receive outpatient therapy in a group to specifically address a severe
					 childhood trauma that may include, but is not limited to, a serious threat to
					 one's life or physical integrity, a serious threat or harm to a Parent, or
					 sudden destruction of one's home or community.
2. Reimbursement for group outpatient therapy
					 is limited to ninety (90) minutes per week except for:
a. Members in an inpatient psychiatric
					 facility for whom services shall be provided in accordance with the plan of
					 care; or
b. Members who are in
					 group outpatient therapy that is designated for the purpose of trauma
					 treatment; or
c. Members who are
					 sex offenders or victims of sexual abuse, and are in group outpatient therapy
					 designated for treatment of sex offenders or victims of sexual abuse;
					 or
d. Members aged twenty (20)
					 years or less, whose ITP documents the need for weekly outpatient therapy in
					 excess of ninety (90) minutes per week.
e. Members who receive Dialectical Behavior
					 Therapy (DBT) meet for two (2) to two and a half (2 1/2) hours per week for up
					 to one (1) year but may meet more frequently for a shorter duration than one
					 (1) year.
f. Members who receive
					 Differential Substance Abuse Treatment (DSAT) meet for two (2) three (3) hour
					 groups per week for up to eight (8) weeks during the intensive phase of this
					 Evidence Based Practice. The DSAT maintenance phase follows the intensive DSAT
					 treatment and members attend one (1) two (2) hour group per week for up to
					 twenty-three (23) weeks.
3. Group outpatient therapy for mental
					 health, substance use, and Co-occurring Services requires a minimum of three
					 (3) members and is limited to no more than ten (10) members in a group when one
					 (1) Clinician is conducting the group. No more than two (2) members of the same
					 Family shall receive services in the same group, unless it is a Family
					 outpatient therapy group. When group outpatient therapy is provided to a group
					 of more than four (4) members, it can be provided by up to two (2) therapists
					 at one time. If more than ten (10) members attend, two (2) Clinicians must
					 conduct the group. Reimbursement for group outpatient therapy is allowed if
					 more than three (3) members are scheduled for the session but only three (3) or
					 fewer members attend due to unavoidable circumstances.
4. Both Clinicians may not bill for providing
					 the same services to the same members at the same time. When group outpatient
					 therapy is provided by both professionals at the same time, they can bill as
					 follows:
a. One provider seeks reimbursement
					 for the provision of services to the total number of members in the group;
					 or
b. Each therapist bills for
					 services provided to a portion of the total number of members in the group.
					 Each co-therapist may bill only for the portion of members for which the other
					 co-therapist has not billed. The total amount submitted by both therapists for
					 MaineCare reimbursement must not exceed the total number of members in the
					 group. For example, if there are eight (8) members in group outpatient therapy,
					 each provider may bill the group rate for the session, accounting for four (4)
					 members each.
The provider billing for the member is responsible for
						maintaining all clinical records relating to that member.