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-28 - Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations › Subsection 144-101-II-28.01 - DEFINITIONS

Current through 2024-29, July 17, 2024
28.01-1
Authorized Agent
shall
					 mean the organization authorized by the Department to perform specified
					 functions pursuant to a signed contract or other approved signed
					 agreement.
28.01-2
Central
					 Enrollment
is a process of determining eligibility for treatment
					 services. The goals of central enrollment are to determine a member's
					 eligibility for treatment; facilitate referrals to appropriate service
					 providers; expedite delivery of service to members in need of treatment;
					 reliably track the service status of members enrolled in the system; and gather
					 data that will inform DHHS of resource development needs.
28.01-3
Child
is a person
					 between the ages of birth through twenty (20) years of age. Children aged
					 eighteen (18) through twenty (20) years of age may choose to receive children's
					 or adult services, whichever best meets their individual needs.
28.01-4
Comprehensive Assessment
is used to identify strengths and needs of the member and family and develop an
					 Individual Treatment Plan. The comprehensive assessment process determines the
					 intensity and frequency of medically necessary services and includes
					 utilization of instruments as may be approved or required by DHHS.
28.01-5
Crisis Plan/Safety Plan
is a plan that must address the safety of the member and others surrounding a
					 member experiencing a crisis.
28.01-6
Discharge plan
is a plan
					 incorporated in the Individualized Treatment Plan that describes the member's
					 planned exit from treatment. The plan must identify discharge criteria,
					 documentation of any after care or support services recommended at the time of
					 discharge, and must be minimally reviewed by the treatment team every ninety
					 (90) days.
28.01-7
Family
means the primary caregiver(s) in a member's daily life, and
					 may include a biological or adoptive parent, foster parent, legal guardian or
					 designee, sibling, stepparent, stepbrother or stepsister, brother-in-law,
					 sister-in-law, grandparent, spouse of grandparent of grandchild, a person who
					 provides kinship care, or any person sharing a common residence as part of a
					 single family unit.
28.01-8
Family Participation
may include being a member of the treatment
					 team, participation in the assessment process, and helping to develop the
					 Individual Treatment Plan (ITP). Family participation may also mean
					 participating in treatment, modeling, and reinforcing skills learned in the
					 course of treatment.
28.01-9
Individual Treatment Plan (ITP)
is the plan of care developed by
					 the treatment team and includes the member, if appropriate, the parent or
					 guardian, the provider and natural supports, and is based on a comprehensive
					 assessment and a diagnostic evaluation of the member. The Individual Treatment
					 Plan shall include a Crisis/Safety Plan and a Discharge Plan, along with other
					 elements of the plan of care. The Individual Treatment Plan describes the
					 medically necessary treatment the member will receive.
28.01-10
Natural Supports
include the relatives, friends, neighbors, and community resources that a
					 family goes to for support. They may participate in the treatment team, but are
					 not MaineCare reimbursable.
28.01-11
Parent or Guardian
may be the biological, adoptive, or legal
					 guardian. They must be a participant in the treatment team, but are not
					 MaineCare reimbursable. They must sign the ITP.
28.01-12
Prior Authorization
is
					 the process of obtaining approval prior to the start of the service. All
					 services in this Section require prior authorization, except that for the time
					 period 7/1/2010 through 10/31/2010, prior authorization is not required. The
					 provider will receive a prior authorization letter containing an authorization
					 number and a description of the type, duration and costs of the services
					 authorized. The provider shall retain this letter in the case record for audit
					 purposes. 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.
28.01-13
School
is a program
					 that has been approved by the Department of Education, as either a Special
					 Purpose Private School or a Regular Education Public School Program under
					 05-071 C.M.R. ch. 101 § XII and
					 20-A MRSA
					 §7204(4),
					 7252-A
					 and
					 7253,
					 and 05-071 C.M.R. ch.101, §
											12, or a program operated by the
					 Child Development Services System
					 20-A MRSA
					 §7001(1-A).
28.01-14
Specialized Services
are medically necessary treatment services that utilize the process of
					 systematically applying interventions based upon empirically derived principles
					 of behavior to improve socially significant behaviors to a measurable degree,
					 and to demonstrate that interventions employed are responsible for improvements
					 in behavior. Assessment includes systematic information gathering regarding
					 factors that influence occurrence of a behavior including interview, direct
					 observation and experimental analysis.
28.01-15
Treatment Team
is the
					 group of people responsible for developing and reviewing a member's ITP. The
					 team may include the member, to the extent possible, and must include the
					 parent/guardian and provider. The member's family, case manager, any other
					 professionals, and those who provide natural supports may also be
					 included.
28.01-16
Utilization Review
is a formal assessment by the Department of the
					 medical necessity, efficacy and appropriateness of services and treatment plans
					 minimally on an annual basis.