A Provider's Guide to MaineCare Prior Authorization –

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					                                                                   Department of Health and Human Services
                                                                                          MaineCare Services
                                                                                    Prior Authorization Unit
                                                                                     # 11 State House Station
                                                                                 Augusta, Maine 04333-0011
                                                                          Tel: (207) 287-2033; 1-866-796-2463
                                                                                           Fax: (207) 287-7643
                                                                                         TTY: 1-800-423-4331


                   A Provider’s Guide to MaineCare Prior Authorization –
              Medical Services, Durable Medical Equipment and Medical Supplies
Introduction:

The purpose of this manual is to give information and guidance on accessing medical services that
require prior authorization.

The DHHS MaineCare structure:
The Department of Health and Human Services
Office of MaineCare Services
Division of Health Care Management
Prior Authorization Unit [PA Unit]

Prior Authorization is the process where an assigned MaineCare employee formally reviews a
certain medical service[s] to be administered to a specific MaineCare member by a specific
provider.

(1) Specific delivery timeframes, units and dollar amounts are part of a prior authorization.
(2) Prior authorization means that the medical service in question must be requested by the
provider and approved by the Department before it is administered/delivered to the member.
(3) It is the provider’s responsibility to know what services need PA and to request them before
delivery.
(4) A request for prior authorization that has been reviewed and approved is issued a nine (9) digit
prior authorization number.
(5) The prior authorization number must be put on the provider’s claim form, in the designated
box, in order to receive payment.
(6) Each prior authorization number is unique and specific to the member and provider service
authorization. The prior authorization number is non-transferable.
Please allow up to 30 calendar days from the date the request is received in the Prior
Authorization Unit to review the request and make a decision.

The PA Unit only processes requests for the medical services listed below.
For any other services you will need to contact the appropriate state agency.

                    Service                                 MaineCare Benefits Manual
Administration of MaineCare benefits              Chapter I oversees all decisions
Durable Medical Equipment and Medical             Chapter II, Section 60
Supplies [DME]
DME General Information                                                                     Revised: 12/29/2008
                                        Caring..Responsive..Well-Managed..We are DHHS.
Instate services, such as surgical and medical        Chapter I, Section 1.14
procedures. The Prior Authorization Unit does         Chapter II, Section 90, Physician Services
not process requests for therapies, social workers
in private practice, Private Duty Nursing,
medications, immunizations, Child Health
services, Social Services, children’s mental health
services, Breast & Cervical Health services,
nursing home classifications. We do not process
billing problems [call the Provider Relations Unit
at 1-800-321-5557, Option 8 or 207-624-7539,
Option 8.]
Out of state services, such as surgical and medical   Chapter I, Section 1.14
procedures, hospitalizations, treatment centers,      Chapter II, Section 90, Physician Services
transplants. All out-of state services and out-of-
state providers need prior authorization, including
DME providers.
Dental Services                                       Chapter II, Section 25
Optional Treatment Services for members under         Chapter I, Section 1.14
age 21                                                Chapter II, Section 94

Transportation [to medical appointments]              Chapter II, Section 113

Vision Services                                       Chapter II, Section 75

Hearing Aids                                          Chapter II, Section 35
The Medical Eye Care Benefit                          10-144 Chapter 107

    Office of MaineCare Services provides on-line information:
    MaineCare web addresses:
    Office of MaineCare Services [formerly     www.maine.gov/bms
    Bureau of Medical Services]                There is a lot of information available here for
                                               provider convenience. Please browse.
    MaineCare Benefits Manual [policy]:        http://www.maine.gov/sos/cec/rules/10/ch101.htm
                                               or, open www.maine.gov/bms, click on ‘Manuals
                                               and Publication’
    PA Request form, ‘MA56’:                   Open www.maine.gov/bms, click on ‘Provider’, then
                                               ‘PA forms’, then ‘DME Equip[MA56]’
    Procedure code look-up:                    Open www.maine.gov/bms, click on ‘Provider’, then
    You can check to see if a code needs       ‘codes’, then ‘Procedure look-up’. Once you locate
    PA at this site. All out-of state services the code you want, click on the code number to
    and all out-of-state providers need prior open the detail screen for that code.
    authorization for every service.
    To check the status of a request:          Open www.maine.gov/bms, click on ‘Provider’, then
                                               ‘PA Portal.’ This will tell you if we got the request
                                               and the decision, if made, plus the PA number, PA
                                               units and approved amounts.
    Billing instructions:                         Open www.maine.gov/bms, click on ‘Provider’, then
                                                  ‘Billing Instructions’. Billing issues should be
                                                  discussed with your Provider Relations
                                                  representative, call 1-800-321-5557, press option 8,
                                                  instate callers, or 207-287-3094.



                            To check a member’s MaineCare eligibility - call the
                                Automated Voice Response System [AVR] at
                                            1-800-452-4694.



   All out-of state services and all out-of-state providers need prior authorization for any
   service.



How to contact the PA Unit and where to send a request for prior authorization:

Office of MaineCare Services
Division of Health Care Management
Prior Authorization Unit                                   PA Unit telephone: 207-287-2033
State House Station #11                                                   or 1-866-796-2463
Augusta, ME 04333-0011                                     PA Unit fax:        207-287-7643


               Please either fax or mail your request, do not do both.


How to request Prior Authorization of MaineCare Services:

1. Getting started: the person must be MaineCare eligible [enrolled in MaineCare]:
Check for MaineCare financial eligibility. Eligibility status can be verified by calling MaineCare’s automated
Voice Response at 800-321-5557, press option 2 or 1-800-452-4694.

Remember: Coverage of a service depends upon the member being eligible on the day of service.
Reimbursement cannot be given if eligibility has ceased or never existed.

Financial eligibility is determined by the Office of Integrated Access and Support [OIAS, formerly known as
Bureau of Family Independence, BFI].
OIAS has offices in the Regional DHHS buildings throughout the state.

*Some members have restrictions to their services. For details see Chapter I, Section 1.04.
Exception:
Chapter I, Section 1.04-1, A; 1.05
Retroactive eligibility: there are circumstances where financial eligibility is granted retroactively [by
OIAS], and so the PA Unit can approve services retroactively if all criteria were met on the date[s] of
service and the request was submitted timely.

2. The provider must be enrolled with MaineCare:
Chapter I, Section 1.03; and Chapter II section 60.07-1, F
MaineCare cannot approve services to a non-enrolled provider.
To enroll with MaineCare contact the Provider Enrollment Unit and request enrollment instructions.
Telephone 207-287-4082 or [instate only] 1-800-321-5557, press option 6
Enrollment information can be seen at our web site: www.maine.gov/dhhs/bms

3A. If you are a physician/PCP seeking medical equipment that your practice will not be supplying, either
give the member/parent/caregiver a prescription for the equipment and/or instruct them to take it to a
MaineCare participating DME dealer, or make a referral to a dealer. The dealer will then send in the forms and
information we need to review the request.
In addition we will also need supporting clinical documentation via a letter of medical necessity from you that
details the member’s clinical condition, and explains the medical necessity for the equipment. That
documentation can be given to the DME dealer to include with the request they send us, or faxed to the PA Unit
at 207-287-7643.

3B. If you are a physician/PCP seeking medical equipment or supplies to be supplied by your practice,
send the request form (MA-56), include documentation of medical necessity, plus either your manufacturer’s
invoice showing your adjusted acquisition cost, or if the item is custom made, include your usual and customary
fee.

4. The request must be received at the PA Unit BEFORE services are delivered.
MaineCare does not approve retroactive coverage unless OIAS grants the member retroactive enrollment.
The provider is responsible for [1] obtaining needed prior authorizations [Chapter I, section 1.03-3, Z; 1.14-1,
B; and [2] doing that on time. 1.03-3, Z
Provider who is providing the service is responsible, per Provider Agreement, not the member or the
physician/PCP.

5. Check for third party coverage:
[Chapter I, Section 1.07]
Medicare: 1.07-5
MaineCare is always the payer of last resort. [Chapter I, section1.07-3, B]

A. If the member has Medicare B and lives in a Nursing Facility, Medicare will not cover Durable Medical
Equipment.
Send a request for prior authorization before services are delivered.

B. If the member has Medicare B and lives in at home, Medicare will pay on items they cover and MaineCare
pays the co-pay.
Send a request for prior authorization before services are delivered. The provider should apply to MaineCare at
the same time as Medicare or any third party payers.

C. If the member has third party insurance or other types of coverage, apply to them.
If the member has coverage such as Worker’s Comp or Veterans Affairs (VA), investigate further for 3rd party’s
responsibility. Include this information with your request.
Send a request for prior authorization before services are delivered.

6. Is the item covered by MaineCare or does it need a PA?

Check the procedure code on-line at our web site: http://www.maine.gov/bms/providerfiles/codes.htm
Check policy for coverage: http://www.maine.gov/sos/cec/rules/10/ch101.htm
Call MaineCare 1-800-796-2463 or 207-287-2033

For provider convenience, the need for Prior Authorization [PA] of a piece of durable medical equipment can be
viewed at our website: http://www.maine.gov/dhhs/bms/providerfiles/codes.htm by entering the appropriate
procedure code. Hopefully, this website will decrease the provider’s time spent and expense of doing
unnecessary requests for PA. Please call if you have any questions.

7. Check the member’s age: If member is under age 21, consider under Optional Treatment Services. See
Covered Services, in Chapter I, 1.06-1 and Chapter II, appropriate service section.

     If the member is under 21 years old, and item/service requested is not covered anywhere in the
     MaineCare Manual, or the child needs more services than normally allowed, consider submitting the
     request under Chapter II, Section 94-5, Prevention, Heath Promotion and Optional Treatment
     Services, [also known as EPSDT-Optional Services].
     Request must include the physician justification form and supporting clinical documentation.


Note: MaineCare currently uses Z codes [called local codes] at present for Optional Treatment coverage. This
will change to HCPC codes in the near future.

8. Does the member live in Nursing Facility [NF] or ICF-MR?
Some services, particularly DME, are expected to be provided by the Nursing Facility or ICR-MR as part of
their regular rate of reimbursement. Check the list in Chapter II, section 60.04-4. Example: Portable oxygen is
not covered for members living in a nursing facility, it is the NF’s financial responsibility.

9. Did you know that a provider can check a PA Request status on-line?
Check it out: http://www.maine.gov/dhhs/bms/providerfiles/pa_portal.htm. The provider must use the member’s
MaineCare ID number as well as the correct provider number. Information is available for past 30 days.

10. What does the Department consider a letter of medical necessity? It is a medical document written and
signed by the physician/PCP [not an office staff person]. It gives a clear clinical picture of the member’s
condition leading to the requested service, and justifies the medical necessity of the requested service. It must
be written on the physician/PCP’s official letterhead. A prescription with a diagnosis is not adequate, it does not
supply the clinical detail that MaineCare requires.

11. What is a Deferral? It is a MaineCare decision to delay a final decision for up to 30 days in order to
obtain missing information that is needed to make a determination on a request for service. If the PA Unit does
not receive the requested information by the assigned deadline, then the request is denied, it is considered
abandoned. [Chapter I, Section 1.14-1, F
The required information can be sent after the deadline [within reason] and the request will be reviewed again.
Note: It is the provider’s [DME Dealer] responsibility to obtain all required information, not the member.
12. Where does it say in policy that MaineCare can defer a request?
Chapter I, Section 1.14-1, E and Chapter II, section 60.07-5

13. FYI: A Primary Care Case Management Referral Form is not sufficient documentation for requesting
PA, the two are not interchangeable.

14. Where does it say in policy that MaineCare needs documented medical necessity by the
physician/PCP?
Chap I, Section 1.14 and Chapter II, section 60.07-5

15. Where does it say in policy that MaineCare needs the manufacturer’s invoice for DME?
Chapter II, Section 60.07-5

16. Where does it say in policy that MaineCare can ask for additional information?
Chapter I, Section 1.06-1; Chapter II, section 60.03, 60.07-5

17. What happens once the request is received in the PA Unit?

A request is day-of- receipt date stamped, scanned into our archive file and data entered into our data base.
The paper copy is then placed in our central file and processed as quickly as possible, in chronological order of
receipt, by a member of our review team.
Providers can check the status of a request via the on-line portal, see address.
Once a decision is made, a decision letter is mailed to the member and one to the provider.

18. Request will be deferred (need additional information) when:
      There is insufficient documentation of the required clinical criteria from the ordering physician/PCP
        and medical necessity cannot be established by the Department.
      DME requests: No invoice or request form submitted.

19. Request will be denied when:
     Member does not meet policy criteria.
     Requesting provider has not submitted required information.

20. Do you need a PA error corrected?
Send an explanation of the problem. An easy and accurate method is to copy the PA letter and write your
comments and correction request on it. Send it to the attention of the person who signed the PA letter.

Reminders:
Per Chapter I, Section 1.05 and 1.06-4, MaineCare members cannot be charged for covered services during any
period of eligibility unless a member has knowingly misrepresented her/himself as a MaineCare member or
applicant.

MaineCare policy can be downloaded at our website: http://www.maine.gov/bms/


           When sending a request please either fax or mail. Don’t do both.

                           Puzzled? Perplexed? A little confused?
                          CALL US: (207) 287-2033 or 1-866-796-2463

				
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