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 VI › Section 144-101-VI-01 - Primary Care Case Management (replaced by Section 03 on June 21, 2022) › Subsection 144-101-VI-01.04 - MANAGED SERVICES

Current through 2024-29, July 17, 2024
Managed services are the services defined in the
						categories listed below, and are described in Chapter II of this Manual. Any
						future policy revisions to the service categories described in this Section
						will automatically be included as part of Section 1.04 unless specifically
						exempted by rule. These services are payable by MaineCare only when provided by
						the member's PCP or his or her designee, or by other MaineCare providers with a
						referral by the member's PCP or his or her designee. Reimbursement for the
						provision of managed services is made in accordance with the policies set forth
						in Chapters I, II, and III, of this Manual. Unless otherwise exempt, MaineCare
						members enrolled in Primary Care Case Management are subject to co-payments for
						all MaineCare services that require co-payments.
Certain services that fall within the service categories
						described in Section 1.04, may be accessed directly by members and do not
						require a referral by the member's PCP. Please see Section 1.05 for a
						description of these services.
All claims for managed services must have the PCP's
						referral number in the appropriate block on the claim form regardless of
						whether the services were delivered by the member's PCP or his or her designee,
						or another provider to whom an authorized referral was made.
The following services, described in Chapters II or V of
						the MaineCare Benefits Manual, are managed:
1.04-1
Ambulatory Surgical Center
					 Services
, Section 4.
1.04-2
Advanced Practice Registered Nursing Services
, Section 14, with
					 the exception of those services which do not require referral by the PCP, as
					 described in Section 1.05-1 and those services provided by an Advanced Practice
					 Registered Nurse serving as the member's PCP.
1.04-3
Chiropractic Services
,
					 Section 15.
1.04-4
Clinic
					 Services
: Section 3, Ambulatory Care Clinics (with the exception of
					 school-based health centers); Section 31, Federally Qualified Health Centers;
					 and Section 103, Rural Health Clinics.
1.04-5
Prevention, Health Promotion and
					 Optional Treatment Services
, Section 94.
1.04-6
Hearing Aids and
					 Services
, Section 35.
1.04-7
Home Health Services
,
					 Section 40.
1.04-8
Hospital
					 Services
, Section 45, with the exception of those services that do not
					 require referral by the PCP, as described in Section 1.05.
1.04-9
Medical Supplies and Durable
					 Medical Equipment
, Section 60.
1.04-10
Occupational Therapy
					 Services
, Section 68.
1.04-11
Vision Services
,
					 Sections 75 and 90. Members may, however, self-refer for routine annual eye
					 examinations. See Section 1.05-1.
1.04-12
Physical Therapy
					 Services
, Section 85.
1.04-13
Physician Services
,
					 Section 90.
1.04-14
Podiatric Services
, Section 95.
1.04-15
Speech and Hearing
					 Services
, Section 109.