Code of Maine Rules › 14 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 193 - OFFICE OF ADULT MENTAL HEALTH › Chapter 40 - REVIEW OF REQUESTS FOR SPECIALIZED OUT-OF-STATE MENTAL HEALTH TREATMENT FOR ADULTS › Section 193-40-3 - Procedures

Current through 2024-29, July 17, 2024
1. Notwithstanding any other provisions
				herein, DMHMRSAS shall act on applications for prior authorization for
				specialized out-of-state services with reasonable promptness and shall adjust
				the time periods specified herein as circumstances require in order to do so.
				In cases of an emergency, the prior authorization process will be completed as
				expeditiously under the circumstances as necessary to alleviate the
				emergency.
2. All requests for
				Departmental funding for specialized out-of-state mental health treatment shall
				be directed to the appropriate Regional Mental Health Team Leader. All requests
				for funding in excess of $5000 must be accompanied by the completed application
				form and substantiating documentation to demonstrate eligibility as described
				in Section 2, above. The Team Leader, who will function as coordinator for
				processing the request, will review the request for completeness and will
				notify the party making the request, within three (3) working days of receipt,
				that it is complete or that specific information is missing. For purposes of
				the foregoing, an application transferred from the Department of Human Services
				(DHS) shall be deemed received three (3) working days after the referral is
				sent by DHS to DMHMRSAS. Such transfer shall be accompanied with a notice of
				the transfer to the applicant and the provider, such notice being sent by DHS
				in the form of a denial letter, together with the name and telephone number of
				the contact person at DMHMRSAS (the Team Leader) who will be responsible for
				processing the application. For purposes of this Protocol and any application
				form implementing it, an application shall be deemed complete if the attending
				physician addresses each of the criteria with an opinion accompanied by a
				reasonable amount of supporting information.
3. The applicant shall make a reasonable
				effort to submit to DMHMRSAS the information requested within thirty (30)
				calendar days from the date that notice is received that the application is
				incomplete, failing which the application may be considered abandoned. Any
				notice that an application is incomplete sent out by DMHMRSAS more than thirty
				(30) calendar days from the date the original application was filed or deemed
				filed with DMHMRSAS shall be considered an adverse action by DMHMRSAS and shall
				be accompanied with a statement advising the applicant of an opportunity for a
				fair hearing to challenge the determination that the application is incomplete.
				In the case of a notice of incompleteness given more than sixty (60) calendar
				days from the date the original application was filed or deemed filed, the
				statement shall advise the applicant of an opportunity for a fair hearing to
				determine not only whether the application is complete, but, in the event it is
				deemed so, whether DMHMRSAS should be ordered to take final action on the
				application within ten (10 ) calendar days. Any such order by the fair hearing
				officer shall provide that the request shall be considered authorized if a
				decision is not made within such ten (10) day period. Any denial of requested
				services, in whole or in part, shall be accompanied by a statement advising the
				applicant of a right to a fair hearing. If an applicant chooses to request a
				hearing, the request shall be made no later than thirty (30) calendar days from
				the date of receipt of the notice and DMHMRSAS shall forward such requests to
				the Maine Department of Labor Division of Administrative Hearings (or its
				successor) within 24 regular business hours (that is, by the next working day)
				and a hearing shall be held within 7 working days thereafter.
4. When the Team Leader determines that the
				request is complete, the Team Leader will convene a team which shall include at
				minimum the regional Medical Director and the Regional Director to review the
				documentation and make a recommendation about the appropriateness of the
				request for funding. This recommendation will be completed within two weeks of
				the notification to the party making the request that the application is
				complete.
5. Once the request has
				been approved on the regional level, the Team Leader shall forward a written
				recommendation to the Associate Commissioner for Operations (or designee) with
				completed application form and supporting documentation for
				consideration.
6. The Associate
				Commissioner (or designee) shall make a final determination within two weeks of
				receipt of the regional recommendation. The determination shall include
				specific length of stay and terms for concurrent review of treatment
				progress.
7. Requests for approval
				of funding for specialized out-of-state treatment shall be finally acted upon
				within four (4) calendar weeks of the date the application is complete or
				determined as a result of a fair hearing to be complete. Applications still
				pending after this four (4) calendar week period shall be deemed
				approved.