Program Integrity - Member Reviews

Program Integrity is responsible for reviewing the health care services provided to MaineCare members to ensure that their utilization is appropriate and the services meet current standards of care. This is accomplished through analysis of health care trends and reviewing individual health care service usage along with clinical justification from the health care providers.  A registered nurse reviews utilization patterns and the accompanying clinical records.  The nurse may refer aberrations of health usage to the Member Review Team. This Team consists of a physician, pharmacist, and a registered nurse. This Team can recommend certain restrictions on health care services for individuals whose health care utilization is determined to be improper and/or detrimental to their health.  A restriction generally limits the member to specific health care providers, i.e. physician, pharmacy, or hospital.  Some restrictions are designed to specifically address drug diversion or dependence and may include restricting a member to a single prescriber.  See Chapter IV of the MaineCare Benefits Manual.