Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 272 - COORDINATED CARE SERVICES FOR CHILDREN WITH SPECIAL HEALTH NEEDS › Chapter V - C.C.S./C.S.H.N. PROGRAM POLICIES › Section 144-272-V-A - AUTHORIZATION OF SERVICES AND PROVIDERS

Current through 2024-29, July 17, 2024
1. Payment for
				  all services must be prior authorized and provided within the State of Maine,
				  with the following exceptions:
) for those children living on the New Hampshire border,
					 out-of state service may be prior authorized if the appropriate out-of-state
					 subspecialty providers are closer to the child's home than comparable services
					 within the State of Maine;
) if after consultation with the appropriate in-state
					 pediatric subspecialist, the C.C.S./C.S.H.N. Program's physician consultant
					 determines that the needed treatment is not available within the state,
					 services may be authorized at an appropriate center outside the state;
					 or
) if the C.C.S./C.S.H.N. Program's physician consultant
					 determines that the previously established patient/provider relationship that
					 has been in place for longer than two (2) years is reasonable to support
					 out-of-state treatment.
2.
				  The C.C.S./C.S.H.N. Program's physician consultant will confirm that the child
				  requires subspecialty interventions; that all services are recommended by the
				  pre-authorized subspecialist and are included in the subspecialty plan of
				  care.
3. All services paid for
				  through Coordinated Care Services for Children with Special Health Needs must
				  be authorized in writing prior to their delivery. It is the provider's
				  obligation and responsibilityto provide written documentation of a child's
				  treatment needs and to verify a child's eligibility for coverage prior to
				  providing service(s). For prior authorization and/or confirmation of
				  eligibility, providers should contact:
Coordinated Care Services for Children with Special
					 Health Needs
Division of Maternal and Child Health
Department of Human Services
State House Station #11
Augusta, Maine 04333-0011
Tel: 207-287-5139
1-800-698-3624
4. All Maine providers of a child's services
				  must:
) meet Maine licensing and certification
					 requirements;
) be certified or be eligible for certification by the
					 appropriate national organization; and
) be enrolled/approved Maine Medicaid providers.
Exception: If the service to be authorized is not a
					 Medicaid covered service, providers do not need to meet Medicaid enrollment
					 requirements.
All out-of-state providers must:
) meet licensure requirements in the state in which
					 services are to be provided;
) be certified or eligible for certification by the
					 appropriate national board;
) be enrolled/approved Maine Medicaid providers.
5. Providers are prior authorized
				  by the C.C.S./C.S.H.N. Program on the basis of the following:
) compliance with State licensing and certification
					 requirements;
) subspecialty certification and pediatric
					 qualifications;
) proximity to the child's area of residence; and
) preference of child and family when there are multiple
					 subspecialty pediatric providers within a community.
6. Primary care physicians may be
				  pre-authorized by the C.C.S./C.S.H.N. Program for that portion of subspecialty
				  treatment that the prior authorized subspecialist delegates to primary care
				  when all of the following conditions are met:
) the original diagnosis has been established or confirmed
					 by the appropriate subspecialist or pediatric specialist;
) the C.C.S./C.S.H.N. Program is in receipt of written
					 documentation and verification that the services are included in the prior
					 authorized subspecialist's plan of care;
) the condition is directly related to or is an
					 exacerbation of the chronic illness; and
) such services are provided under the consultation and
					 direction of the prior authorized subspecialist or pediatric specialist.
7. Children under the age of three
				  with a suspected developmental problem will be referred to a Developmental
				  Evaluation Clinic upon application to the C.C.S./C.S.H.N. Program unless a
				  similar comprehensive evaluation has already taken place.