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-55 - Laboratory Services › Subsection 144-101-II-55.04 - COVERED SERVICES

Current through 2024-29, July 17, 2024
55.04-1
General Provisions
A covered service is a service for which payment can be
						made by the Department.
Laboratory Services which are medically necessary for
						diagnosis and control of a medical condition, are covered services. These
						services must be ordered by a physician or other licensed practitioner of the
						healing arts authorized to order lab services within the scope of his or her
						license and be consistent with good medical practice.
55.04.2
Bundling or Grouping of
					 Laboratory Tests
Panels are tests that are frequently done as a group
						(profile) on automated equipment. If a group of tests overlaps two or more
						panels, the panel that incorporates the greater number of tests to fulfill the
						code definition is reimbursable. The remaining tests are individually
						reimbursable. Additionally, the provider shall not "unbundle" and bill
						separately for tests included as part of a group (profile or panel) that pay at
						a lower rate. Use the Physicians' Current Procedural Terminology (CPT) Manual
						Codes for the proper Automated, Multichannel Tests, and for the proper Organ or
						Disease Oriented Panels.
As noted in Section 55.07(B) Medicaid will pay no more
						than the lowest amount payable by Medicare. Therefore, in those cases where the
						Medicaid allowance for a procedure exceeds the Medicare allowance, the program
						will pay the lowest Medicare-allowed rate.
55.04-3
Drug Testing
A. decision making for all drug testing
					 including urine drug screening and confirmation testing must be supported by
					 documentation in the medical record maintained by the individual's physician or
					 other licensed practitioner as provided by Section 55.04-1.
B. Frequency and choice of assay used should
					 be based on medical necessity and a complete clinical assessment of the
					 individual member's risk potential for abuse and diversion.
C. The Department will not make separate
					 payment for the testing of adulterants or specimen validity. There are a number
					 of multi-panel, CLIA waived urine drug test kits available which test for pH,
					 specific gravity, and oxidants to determine if the specimen has been
					 adulterated.
D. Confirmation
					 testing is covered only to:
1. Confirm an
					 unexpected result; or
2. Identify
					 specific drugs or metabolites that cannot be detected on a urine drug screen.
Confirmation tests should be based on the member's
						presentation and history and only include what is needed for safe patient
						management. The definitive test(s) must be supported by documentation that
						specifies the rationale for each definitive test ordered. Drug confirmation
						testing must be performed by a second method. A presumptive test cannot be
						performed to confirm a presumptive test. Confirmation testing must be requested
						in writing by the ordering provider.
E. Urine drug testing is limited to three (3)
					 specimens per rolling month. Additional test(s) may be requested with a Prior
					 Authorization, to be issued in six (6) month authorizations. Individuals
					 meeting the following criteria are exempt from this limitation, and are not
					 required to seek Prior Authorization for testing beyond three (3) specimens per
					 month:
1. Pregnant members;
2. Members involved with an active Office for
					 Child and Family Services (OCFS) case;
3. Members in Intensive Outpatient Treatment
					 (IOP);
4. Members being established
					 in Medication-Assisted Treatment (MAT) up to six months (including methadone,
					 sub oxone, and other MAT treatments);
5. Members receiving services in an Emergency
					 Department; and
6. Members in
					 Residential Treatment for substance abuse (Chapter 97 Appendix B
					 facilities)
F. Substance
					 abuse treatment is to be measured by random testing rather than scheduled
					 testing.
G. Routine urine drug
					 screening is a presumptive procedure that should focus on detecting the
					 specific drug(s) of concern based on the member's medical history and/or the
					 prevalence of drugs, geographically.
H. Standing orders written to the laboratory
					 for presumptive testing must be signed and dated by the ordering provider no
					 more than six (6) months prior to the date of specimen collection. Standing
					 orders must contain the frequency of laboratory testing and be documented in
					 the member's record. Standing orders for confirmation and/or quantitative
					 testing are prohibited.
I.
The following are not medically necessary:
1. Tests performed by an in-house laboratory
					 and independent laboratory for the same test on the same date of
					 service.
2. Testing for residential
					 monitoring.
3. Specimen validity
					 testing.
4. Urine drug testing
					 ordered by third parties, such as schools, employers, or requested by a
					 provider for the sole purpose of meeting the requirements of a third party.