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-101 - Medical Imaging Services › Subsection 144-101-II-101.05 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
When repeat x-ray examinations of the same body part 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 the MaineCare Program if performed twice by the same
						provider.
101.05-1 Mammography
					 Performed in Non-Compliance with the MQSA
Mammograms are not covered services when provided in:
(1) a mammography facility which does
					 not possess a Certificate issued by an accrediting body or is out of compliance
					 with State of Maine Radiation Regulations;
(2) a mammography facility with a Certificate
					 that has expired; or
(3) a
					 mammography facility whose Certificate has been revoked or denied. Mammography
					 facilities may not charge a member for a service denied by the MaineCare
					 Program due to the mammography facility's non-compliance with the Mammography
					 Quality Standards Act (MQSA), Public Law - 102-539.
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-101 - Medical Imaging Services › Subsection 144-101-II-101.06 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
101.06-1 Medical
					 Imaging Services
The professional, administrative and technical
						components of a medical imaging procedure are covered when medically necessary
						and provided by, or provided under the supervision of a physician practicing
						within the scope of his or her profession as defined by state or provincial
						law. All imaging procedures must be performed with appropriately licensed
						equipment operated by appropriately licensed or certified staff. It is the
						responsibility of the imaging provider to assure compliance with all current
						federal, state or provincial guidelines and regulations, maintain appropriate
						records and provide documentation upon request.
Additionally, any mammography services (including but
						not limited to, breast cancer screening or diagnosis through mammography) must
						be provided in accordance with the MQSA, Public Law 102-539 and any applicable
						regulations of the FDA. A mammography facility must possess a current
						certificate issued by an accredited body and maintain compliance with State of
						Maine radiation regulations or those of the province in which services are
						provided. It is the responsibility of the mammography facility to provide the
						MaineCare Program with current, as well as any updated Certificate(s).
						Certificate renewals must be provided to MaineCare before expiration of the
						previous certificate.
The professional component includes the following
						services:
1. determining the
					 presenting problems, by interviewing the member, obtaining member history and
					 making appropriate physical examination to decide upon the method of performing
					 the medical imaging procedure; and
a.
					 performing the procedure, including instructing technologists or other
					 assistants; and/or
b. performing
					 diagnostic, therapeutic, or screening procedures personally; and
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-101 - Medical Imaging Services › Subsection 144-101-II-101.07 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
101.07-1 The amount of payment for services
					 rendered shall be the lowest of the following:
A. Upon implementation of MIHMS, the fee for
					 service rate is set at seventy percent (70%) of the lowest level in the 2009
					 Medicare fee schedule for Maine area "99" for all services under this policy
					 including adjustments for place of service and modifiers; or
B. the lowest amount allowed by the Medicare
					 Part B carrier; 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-101 - Medical Imaging Services › Subsection 144-101-II-101.08 - COPAYMENT

Current through 2024-29, July 17, 2024
101.08-1 Copayment Amount
A. A copayment will be charged to each
					 MaineCare member receiving services. The amount of the copayment shall not
					 exceed $1.00 per day for services provided, according to the following
					 schedule:
MaineCare Payment For
								  Services
Member Copayment
$10.00 or less
$ .50
$10.01 or more
$1.00
B. The member shall be responsible for
					 copayments up to $10.00 per month whether the copayment has been paid or not.
					 After the $10.00 cap has been reached, the member shall not be required to make
					 additional copayments and the provider shall 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 a copayment.
D. Providers are responsible for documenting
					 the amount of copayments charged to each member (regardless of whether the
					 member has made payment) and shall disclose that amount to other providers, as
					 necessary, to confirm previous copayments.
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-101 - Medical Imaging Services › Subsection 144-101-II-101.09 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
A. Billing must be
					 accomplished in accordance with the Department's current billing instructions
					 and Chapter III, Section 90 of the MBM, "Physician Services."
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-102 - Rehabilitative Services › Subsection 144-101-II-102.01 - PURPOSE

Current through 2024-29, July 17, 2024
The purpose of this rule is to cover rehabilitative
						services for eligible members who have sustained a brain injury. This section
						does not include coverage for services for people with brain injuries that are
						congenital or induced by birth. Rehabilitative services are specialized,
						interdisciplinary, coordinated, and outcomes focused. The services are designed
						to address the unique medical, physical, cognitive, psychosocial, and
						behavioral needs of members with acquired brain injuries. Limitations apply;
						services are appropriate if there is the potential for rehabilitation and the
						expectation of functionally significant improvements in the member's status, or
						in certain cases where services are necessary because their withdrawal would
						result in the member's measurable decline in functional status.
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-102 - Rehabilitative Services › Subsection 144-101-II-102.04 - DURATION OF CARE

Current through 2024-29, July 17, 2024
MaineCare will only cover medically necessary services
						for eligible members. Covered services are subject to utilization review (UR),
						as well as the limits in Section 102.06. Rehabilitative services are covered
						for an approved period for each eligible MaineCare member. Beginning and end
						dates of the member's approved service period correspond to beginning and end
						dates for MaineCare reimbursement. MaineCare coverage will end on the period
						end date unless the Department or its Authorized Agent has authorized a new
						period. 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-102 - Rehabilitative Services › Subsection 144-101-II-102.06 - LIMITATIONS

Current through 2024-29, July 17, 2024
A. Exclusive of Clinical Assessment and
					 Reassessment, Services are limited to a combination of no more than eighteen
					 (18) hours (72 units) per week. MaineCare will only cover one service at a time
					 for each eligible member under this Section.
B. A member may not receive coverage for
					 services under this Section if he or she is involved in acute hospital
					 rehabilitation services.
C A
					 member may not receive coverage for services under this Section if he or she is
					 receiving intensive rehabilitative NF services, as defined in Section
					 102.02-8.
D. Services must not
					 duplicate services delivered under any other Section of the MBM, including but
					 not limited to: Section 97, Private Non-Medical Institution Services; Section
					 12, Consumer Directed Attendant Services; Section 22, Home and Community-Based
					 Waiver Services for the Physically Disabled; Section 19, Home & Community
					 Benefits for the Elderly and for Adults with Disabilities; Section 96, Private
					 Duty Nursing & Personal Care Services; Section 68, Occupational Therapy
					 Services; Section 85, Physical Therapy Services; Section 109, Speech and
					 Hearing Services; Section 111,
Substance Abuse Treatment Services; Section 17,
						Community Support Services; Section 24, Day Habilitation Services for Persons
						with Mental Retardation; Section 26, Day Health Services; and Section 65,
						Behavioral Health Services.
E. MaineCare will only reimburse for initial
					 clinical Assessment services (described in Sections 102.05-1 and 102.08-7(A)(1)
					 up to eight (8) hours (32 units) of service, per member, per occurrence of
					 acquired brain injury. MaineCare will reimburse Clinical Reassessment for up to
					 eight (8) hours (32 units) per year.
F. MaineCare will reimburse for a covered
					 service provided in an individual or a group session. A "group" must not exceed
					 four (4) members per each licensed or certified clinician or other qualified
					 staff person. When group services are provided, a brief notation must be made
					 for each member in his or her medical record.
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-102 - Rehabilitative Services › Subsection 144-101-II-102.07 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
Refer to Chapter I, General Administrative Policies and
						Procedures for rules governing non-covered services. Services that are
						primarily vocational, custodial, academic, socialization, or recreational are
						not covered.
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-102 - Rehabilitative Services › Subsection 144-101-II-102.09 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
The amount of payment for services will be the lowest of
						the following:
A. the appropriate
					 amount listed in the Chapter III, Section 102, "Allowances for Rehabilitative
					 Services;"; or
B. the amount
					 allowed by the Medicare carrier.
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-102 - Rehabilitative Services › Subsection 144-101-II-102.10 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
Providers must bill on the CMS 1500 using the procedure
						codes in Chapter III and in accordance with the Department's billing
						instructions for Rehabilitative Services.
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-103 - Rural Health Clinic Services › Subsection 144-101-II-103.01 - DEFINITIONS

Current through 2024-29, July 17, 2024
103.01-1
Covered Services
are
					 those services described in 103.04 for which payment can be made under Title
					 XIX and Title XXI by the Department of Health and Human Services.
103.01-2
A Homebound Member
is
					 an individual who is permanently or temporarily confined to his or her place of
					 residence because of a medical or health condition. The individual may be
					 considered homebound if he or she leaves the place of residence infrequently.
					 For this purpose, "place of residence" does not include a hospital or long term
					 care facility.
103.01-3
Plan
					 of Treatment
is a written plan of medical services for part-time or
					 intermittent visiting nurse care that is established and reviewed at least
					 every sixty (60) days by a supervising physician of the clinic. When delegated
					 by the supervising physician, and when in compliance with all other State
					 licensure requirements it may also be established by a physician assistant,
					 nurse practitioner, nurse midwife, or clinical nurse specialist and reviewed
					 and approved at least every sixty (60) days by a supervising physician of the
					 clinic.
103.01-4
Primary
					 Health Care
refers to preventative, diagnostic and therapeutic services
					 furnished by the clinic's professional staff and, where appropriate, the
					 supplies commonly used to support those services, basic laboratory services
					 essential for diagnosis and treatment, and emergency medical care for the
					 treatment of life-threatening injuries and acute illness.
103.01-5
Rural Health Clinic
means a Primary Health Care clinic that is both certified as a Rural Health
					 Clinic by Medicare and enrolled as a MaineCare provider. A clinic may be either
					 a provider based clinic or an independent clinic.
A. A provider-based clinic exists when:
1. the clinic is an integral part of an
					 existing hospital, skilled nursing facility, or home health agency
					 participating in Medicare; and
2.
					 the clinic is operated with other departments of the provider under common
					 licensure, governance, and professional supervision.
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-103 - Rural Health Clinic Services › Subsection 144-101-II-103.02 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
Individuals must meet the financial eligibility criteria
						as set forth in the
MaineCare Eligibility Manual
. Some members
						may have restrictions on the type and amount of services they are eligible to
						receive.
It is the responsibility of the provider to verify a
						member's eligibility for MaineCare prior to providing services as described in
						Chapter I.
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-103 - Rural Health Clinic Services › Subsection 144-101-II-103.03 - DURATION OF CARE

Current through 2024-29, July 17, 2024
Each Title XIX and Title XXI member may receive as many
						Covered Services as are medically necessary. 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-103 - Rural Health Clinic Services › Subsection 144-101-II-103.04 - COVERED SERVICES

Current through 2024-29, July 17, 2024
Covered Services include core services, and other
						ambulatory services.
103.04-1 Core
					 Services are billable at the PPS rate. Core Services include:
A. services provided by physicians, physician
					 assistants, advanced practice registered nurses, clinical psychologists,
					 licensed clinical social workers, and licensed clinical professional
					 counselors;
B. services and
					 supplies furnished as incident to services of conditionally, temporarily, fully
					 licensed, otherwise legally recognized or approved practitioners who are
					 designated in Section 103.06-1 of this Manual; and
C. basic laboratory services essential for
					 the immediate diagnosis and treatment of illness or injury, including, but not
					 limited to:
1. chemical examination of urine
					 by stick or tablet method or both (including urine ketones);
2. hemoglobin test or hematocrit;
3. blood sugar test;
4. examination of stool specimens for occult
					 blood;
5. pregnancy tests;
					 and
6. primary culturing for
					 transmittal to a certified laboratory.
Note: To qualify for reimbursement, laboratory services
						must be in compliance with the rules implementing the
Clinical
						Laboratory Improvement Amendments of 1988
(CLIA "88") and any related
						amendments.
D.
					 emergency medical care treating life-threatening injuries and acute illnesses,
					 including drugs and biologicals such as:
1.
					 analgesics
2. local
					 anesthetics
3. antibiotics
4. anticonvulsants
5. antidotes and emetics
6. serums and toxoids
E. visiting nurse services (as described in
					 103.04-4).
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-103 - Rural Health Clinic Services › Subsection 144-101-II-103.05 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
All services must be provided geographically in the
						federally defined service area, and/or be otherwise provided in conformance
						with federal requirements. See Chapter I of the
MaineCare Benefits
						Manual
for other details on non-covered services.
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-103 - Rural Health Clinic Services › Subsection 144-101-II-103.06 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
103.06-1
Professional Staff
In order for a clinic to receive reimbursement, its
						professional staff must be conditionally, temporarily or fully licensed, or
						otherwise recognized or approved to practice, in the state where services are
						provided as documented by written evidence from the appropriate governing body,
						including: physicians, podiatrists, physician assistants, advanced practice
						registered nurse practitioners, nurse-midwives, clinical nurse specialists,
						clinical psychologists, clinical social workers, clinical professional
						counselors, registered nurses, licensed practical nurses, respiratory
						therapists, dentists and dental hygienists. MaineCare will also reimburse for
						advanced practice or registered nurses who hold a current, unencumbered compact
						license from another compact state that they claim as their legal residence.
						Qualifications of any other staff must be provided and billed in accordance
						with all other applicable sections of the
MaineCare Benefits
						Manual
.
103.06-2
Supervision By a Physician
The responsible supervising physician, or other suitably
						licensed practitioner, to the extent required by applicable state laws or
						regulations, whose presence at the clinic is not required at all times,
						must:
1. always be available through
					 telecommunication for consultation, assistance or referral;
2. supervise the services of the clinic's
					 medical staff providing services under the responsible physician supervisory
					 agreement;
3. supervise nurses and
					 other auxiliary medical staff providing services or supplies; and
4. review, approve, cosign and date the
					 medical records of members seen by the clinic's medical staff practicing under
					 the physician's supervision.
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-103 - Rural Health Clinic Services › Subsection 144-101-II-103.08 - COPAYMENT

Current through 2024-29, July 17, 2024
Providers will charge a copayment to each MaineCare
						member receiving services, unless exempt per the provisions of Chapter I of the
MaineCare Benefits Manual
. Effective August 1, 2014, no
						copayment shall be charged for tobacco cessation treatment services. The amount
						of the copayment shall not exceed $3.00 per day for services provided,
						according to the following schedule:
MaineCare Payment for Service
Member Copayment
$10.00 or less
$ .50
$10.01 - 25.00
$1.00
$25.01 - 50.00
$2.00
$50.01 or more
$3.00
The member shall be responsible for copayments up to
						$30.00 per month whether the copayment has been made or not. After the $30.00
						cap has been reached, the member shall not be required to make additional
						copayments and the provider shall receive full MaineCare reimbursement for
						Covered Services. Providers are subject to the Department's copayment
						requirements. Refer to Chapter I, "General Administrative Policies and
						Procedures", for rules governing copayment requirements, exemptions and dispute
						resolution.
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-103 - Rural Health Clinic Services › Subsection 144-101-II-103.09 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
In accordance with Chapter I, Section 1, 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, worker's compensation, etc.) that are
						available to pay for the rendered service, and to seek payment from such
						resources prior to billing MaineCare.
If a member has third party coverage other than
						MaineCare, and if that third party carrier requires a co-pay but makes no
						fee-for-service payment in order to cover Rural Health Clinic Services,
						MaineCare reimbursement will be limited to the amount of the co-pay
						alone.
Providers billing for RHC services must bill using
						standard CPT and HCPC procedure codes as detailed in Chapter III, Section
						103, Table 1. For Core Services,
						as described under Covered Services-Section
						103.04, providers
						must bill the code T1015 and include the appropriate revenue codes. When
						billing, providers must use a UB 04 claim form. Effective October 1, 2010, in
						addition to billing the code T1015 for Core and Ambulatory Services, providers
						must also report all services provided including all procedures with the
						standard CPT and HCPCS codes on the UB 04 claims form for reporting
						purposes.
RHCs have the option of obtaining a separate MaineCare
						provider billing number for the limited purpose of fee-for-service billing and
						reimbursement for such services as X-ray, EKG, inpatient hospital visits and
						other Medicare defined non-RHC Services that are billable under Medicare
						PartB.
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-107 - Psychiatric Residential Treatment Facility Services › Subsection 144-101-II-107.01 - LEGAL AUTHORITY

Current through 2024-29, July 17, 2024
The following federal statutory and regulatory
						authorities govern these services:
Section 1905(a)(16) and (h) of the Social Security
						Act
42 CFR §
												441.150 through §
											441.184
42 CFR §
												483.350 through §
											483.376
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-107 - Psychiatric Residential Treatment Facility Services › Subsection 144-101-II-107.02 - DEFINITIONS

Current through 2024-29, July 17, 2024
107.02-01
Abuse or Neglect
is a
					 threat to a child's health or welfare as defined in
					 22 M.R.S.
					 §4002(1); or Abuse,
					 Neglect, or Exploitation of an adult means those terms as defined in
					 22 M.R.S.
					 §3472.
107.02-02
Caregiver
is an
					 individual who is responsible for the custodial care, and protective oversight
					 and supervision of a youth. Caregivers may include but are not limited to a
					 member's parents, babysitter, immediate or extended family, other natural
					 supports fulfilling this role, or professional staff providing protective
					 oversight and supervision in a variety of settings.
107.02-03
Child and Adolescent Needs
					 & Strengths (CANS)
assessment is a multipurpose tool that assesses
					 the needs and strengths of children and adolescents with mental illness,
					 developmental disabilities/intellectual disabilities, and autism spectrum
					 disorders. The CANS may be used to support decision making (including level of
					 care and service planning), to facilitate quality improvement initiatives, and
					 to allow for the monitoring of outcomes of services.
107.02-04
Clinical Staff
means
					 licensed staff, to include the following:
1.
					 Physicians, including psychiatrists
2. Psychiatric Mental Health Nurse
					 Practitioners
3. Registered Nurses
					 (RNs)
4. Licensed Clinical Social
					 Workers (LCSWs)
5. Licensed
					 Clinical Professional Counselors (LCPCs)
6. Licensed Marriage and Family Therapists
					 (LMFTs), and 7. Licensed Psychologists
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-107 - Psychiatric Residential Treatment Facility Services › Subsection 144-101-II-107.03 - INTRODUCTION

Current through 2024-29, July 17, 2024
This rule describes the standards for the provision of
						Psychiatric Residential Treatment Facility (PRTF) services. PRTFs are jointly
						federally and state regulated, and providers must follow all federal and state
						requirements to provide this service. This includes standards for staffing of
						PRTFs, as described in this policy.
The purpose of a PRTF is to provide comprehensive mental
						health treatment and/or substance abuse treatment to children and adolescents
						who, due to mental illness, substance abuse, or severe emotional disturbance,
						meet level of care requirements for a PRTF.
For members who have co-occurring intellectual or
						developmental disability, all applicable state and federal laws, including
						Title 34-B of the Maine Revised Statutes must be followed.
In order for a member to qualify for PRTF services, all
						other community based resources must have been determined to be inadequate to
						meet the member's needs. PRTF services are designed to be short term and
						intensive in nature, with the goal of successfully transitioning the member
						back to his or her community. The PRTF is expected to actively engage the
						member's natural supports to offer culturally competent, medically appropriate
						treatment designed to meet the individual needs of the
						member.
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-107 - Psychiatric Residential Treatment Facility Services › Subsection 144-101-II-107.04 - MEMBER ELIGIBILITY

Current through 2024-29, July 17, 2024
107.04-01
General Eligibility
To access PRTF services, members must meet all the
						following criteria:
A. Be under the
					 age of 21.
B. Meets Clinical
					 Certification of Need (CCON) requirements, as set forth in 107.04-02.
C. The parent or legal guardian, when
					 applicable has approved of this level of service; and
D. The member meets all other MaineCare
					 eligibility requirements.
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-107 - Psychiatric Residential Treatment Facility Services › Subsection 144-101-II-107.05 - COVERED SERVICES

Current through 2024-29, July 17, 2024
107.05-01
Active Treatment:
PRTFs must provide active psychiatric treatment,
					 including all the following:
A. Assessment
					 and evaluation, including review of CCON team documents, to be completed in
					 accordance with Section 107.07-07.A.;
B. Medical supervision seven days per week
					 and 24 hours per day;
C. Intensive
					 psychiatric monitoring and intervention, to include medication management and
					 medication administration:
1. Medication
					 Management sessions must occur at least once per week;
D. Behavioral and/or rehabilitative
					 therapies, the specific modality to be described in the member's Treatment
					 Plan. Therapy must include at a minimum, the following:
1. Individual Therapy, at least two (2) hours
					 weekly;
2. Group Therapy, at least
					 one (1) hour daily; and
3. Family
					 Therapy, at least two (2) hours weekly;
E. Comprehensive and individualized discharge
					 planning, to be commenced upon admission to the PRTF and meeting the
					 requirements described in Sections 107.05-04 and 107.07-07 below;
F. Crisis planning and
					 intervention;
G. Development of a
					 Positive Behavioral Support Plan (PBSP) as described in 107.07-08.B;
H. Case management;
I. All transportation services;
J. Personal care, activities of daily living
					 services, and instrumental activities of daily living services, and;
K. Room and board.
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-107 - Psychiatric Residential Treatment Facility Services › Subsection 144-101-II-107.06 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
Include services described in the
MaineCare
						Benefits Manual
, Chapter I, "General Administrative Policies and
						Procedures."
Duplicative services are non-covered services. A listing
						of duplicative and allowable concurrent services are described in detail in
						Appendix E.
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-107 - Psychiatric Residential Treatment Facility Services › Subsection 144-101-II-107.07 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
107.07-01
Licensing, Certification, and Accreditation
A. All PRTFs must maintain current CMS
					 certification and state licensure as administered by the Department of Health
					 and Human Services.
B. All PRTFs
					 must maintain current accreditation by one of the following entities:
1. The Joint Commission on Accreditation of
					 Healthcare Organizations, or
2. The
					 Commission on Accreditation of Rehabilitation Facilities, or
3. The Council on
					 Accreditation
C. All
					 accreditation reports, with findings & remediation, must be submitted to
					 the Maine Center for Disease Control and Prevention (CDC).
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-107 - Psychiatric Residential Treatment Facility Services › Subsection 144-101-II-107.08 - MEDICATION PRO RE NATA (PRN)

Current through 2024-29, July 17, 2024
A. PRN medication
					 orders are written on an "as needed" basis for the treatment of a member's
					 medical or psychiatric condition;
B. PRN medication orders can only be issued
					 if developed as part of the member's Treatment Plan;
C. PRN medication orders must be signed and
					 dated by authorized licensed practitioners and must include detailed
					 behavior-specific written instructions, including symptoms that might require
					 use of such medication, exact dosage, exact time frames between dosages, and
					 the maximum dosage to be given in a 24-hour period;
D. The PRTF may only administer a PRN
					 medication order for antipsychotic-type psychotropic medication when the PRTF
					 also has an order prescribing routine scheduled and administered doses of the
					 antipsychotic-type psychotropic medication for the member;
E. PRN medication orders shall not be used as
					 a form of restraint and shall not be written in anticipation of an emergency
					 safety situation. PRN medication cannot be given in response to a member's
					 aggressive behavior, in order to restrict a member's movement or given to
					 prevent the resident from acting out violently;
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-107 - Psychiatric Residential Treatment Facility Services › Subsection 144-101-II-107.09 - REQUIREMENTS FOR USE OF RESTRAINT AND SECLUSION

Current through 2024-29, July 17, 2024
107.09-01
General Requirements
Restraint and Seclusion may be utilized by the provider
						and must be done in adherence with 42 C.F.R. part 483 Subpart G, the Maine
						Rights of Recipients of Mental Health Services, and the Rights of Recipients of
						Mental Health Services who are Children in Need of Treatment. Restraints or
						Seclusion. When there are conflicting provisions in these sources, the
						provision that provides the member the most protection applies. Restraint and
						seclusion may only be employed under the following circumstances:
A. When the intervention is absolutely
					 necessary to protect the member from causing serious physical harm to self or
					 others. Restraint or seclusion must not be utilized solely to address the
					 comfort, convenience, or anxiety of staff, or as a form of coercion,
					 discipline, or retaliation;
B. The
					 intervention is the least restrictive emergency safety intervention necessary
					 to resolve the emergency safety situation after other methods have been proven
					 ineffective or inappropriate;
C.
					 The restraint or seclusion is performed only by staff with specific training in
					 these interventions. These interventions are applied in a manner that is safe,
					 proportionate, and appropriate to the severity of behavior, and the member's
					 chronological and developmental age, size, gender, physical conditions,
					 psychiatric conditions, medical conditions, and personal history. The restraint
					 or seclusion must not result in harm or injury to the member and must be used
					 only:
1. To ensure the safety of the member
					 or others during an emergency safety situation; and
2. Until the emergency situation has ceased
					 and the member's safety and the safety of others can be ensured, even if the
					 restraint or seclusion order has not expired; and
D. Restraint (including physical and
					 mechanical restraints) and seclusion must not be used simultaneously;
					 and
E. Locked seclusion is
					 prohibited. The member may not be confined alone to any area with the door
					 locked, barred, or held shut by staff.
F. For minor members, the Treatment Planning
					 Team must decide and document in the Treatment Plan whether to allow restraints
					 to be employed on a particular member in the event of an emergency safety
					 situation and where the requirements of this section are met
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-107 - Psychiatric Residential Treatment Facility Services › Subsection 144-101-II-107.10 - WAIVERS

Current through 2024-29, July 17, 2024
107.10-01
Waiver Criteria.
In
					 certain circumstances, DHHS may authorize waivers of Specific PRTF
					 Requirements. All waiver requests must be submitted to the Office of Child and
					 Family Services, and approvals must be obtained in writing prior to initiating
					 any waiver request. Federally mandated requirements are not waivable under any
					 circumstance. Any approved waiver request must be clearly documented in the
					 member's record.
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-107 - Psychiatric Residential Treatment Facility Services › Subsection 144-101-II-107.11 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
107.11-01
Principles of Reimbursement.
The PRTF Principles of Reimbursement are specified in the
MaineCare Benefits Manual
, Chapter III, Section 107.
For each MaineCare provider enrolled as a participating
						Psychiatric Residential Treatment Facility, the Department will determine a
						prospective per diem rate for routine and fixed costs, as determined under
						Chapter III, Section 107, Principles of Reimbursement for Psychiatric
						Residential Treatment Facilities. Medical, clinical, and direct care services
						are reimbursed per diem as described in Chapter III, Section 107, Principles of
						Reimbursement for Psychiatric Residential Treatment Facilities Providers are
						required to obtain separate MaineCare provider number(s) for each PRTF. Upon
						completion of the provider's fiscal year, the providers shall submit to the
						Department, a cost report for each PRTF that has been assigned a provider
						number(s) in accordance with Chapter III of the Principles of
						Reimbursement.
A. In accordance with
					 Chapter I of the
MaineCare Benefits Manual
, it is the
					 responsibility of the provider to seek from any other sources payment for the
					 rendered service prior to billing the MaineCare Program.
B. Psychiatric Residential Treatment
					 Facilities may not accept or receive payment for covered services in addition
					 to the MaineCare 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-107 - Psychiatric Residential Treatment Facility Services › Subsection 144-101-II-107.12 - BILLING INFORMATION

Current through 2024-29, July 17, 2024
Providers must bill in accordance with the Department's
						billing Instructions for the UB-04 Claim Form. Billing instructions are
						available at: http://www.maine.gov/bms/provider.htm.
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-107 - Psychiatric Residential Treatment Facility Services › Appendix 144-101-II-107-B - CANS Domains

Current through 2024-29, July 17, 2024
1. Child Behavioral / Emotional Needs:
Two or more ratings of '3' or;
Three or more ratings of at least a '2' on the following:
Psychosis / Thought Disturbances Depression Anxiety
						Impulse/Hyperactivity
Oppositional Behavior Conduct Anger Control Substance
						Use
2. Child Risk Factors:
Two or more ratings of '3' or;
Three or more ratings of at least a '2' on any of the
						following:
Self-Injurious Behavior
Suicide Risk Reckless Behavior (other Self Harm)
Danger to Others Sexual Aggression Runaway Delinquent
						Behavior
Fire Setting Intentional misbehavior Bullying
						Others
3. Caregiver Needs:
Two or more ratings of '3' or;
Three or more ratings of '2' on any of the following:
Supervision Involvement with Care Knowledge of Child's
						Needs Organizational Skills Social Resources Residential Stability Physical
						Mental Health Substance Abuse Developmental Family Stress
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-107 - Psychiatric Residential Treatment Facility Services › Appendix 144-101-II-107-C - Staffing Requirements

Current through 2024-29, July 17, 2024
Required Minimum Staffing Requirement The PRTF must
						employ staffing to adequately meet the needs of the program, and must minimally
						meet the following staffing requirements:
Medical Director - on site: 1 Full Time Equivalent (FTE)
Facility Administrator - on site: 1 FTE Clinical
						Coordinator - on site: 1 FTE Clinician - on site: 1 FTE per 5 members Nurse -
						on site: 1 FTE per 10 members awake, 1 FTE per 20 members asleep Nurse Support
						- on site: 1 FTE per 20 members awake Direct Care - on site: 1 FTE per 2
						members awake, 1 FTE per 4 members asleep
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-109 - Speech and Hearing Services › Subsection 144-101-II-109.01 - PURPOSE

Current through 2024-29, July 17, 2024
The purpose of this rule is to provide medically
						necessary speech-language pathology and audiology services to MaineCare members
						who are adults (age twenty-one (21) and over) with rehabilitation potential or
						to those who have demonstrated medical necessity for speech therapy to avoid a
						significant deterioration in ability to communicate orally/visually, safely
						swallow or masticate that would result in an extended length in stay or
						placement in an institutional or hospital setting, and medically necessary
						speech-language pathology and audiology services to MaineCare members who are
						under age twenty-one (21).