Utilization Review is required for PT, OT and Speech Therapy Services

July 24, 2012

Utilization Review (UR) is required for Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy services for adults age 21 years and over. UR is not required for those who are dually eligible for MaineCare and Medicare, or those receiving services under the HIV waiver program. These therapy services must have Prior Authorization (PA) following the first assessment visit.

All cases should be submitted to OMS/PA within 1 business day of being opened. The plan of care/treatment plan along with any documentation supporting the medical necessity and rehabilitation potential of the member should be faxed to (207) 626-2984.

New cases and recertification cases will be reviewed by OMS/PA clinical staff. Services will be approved, denied, or deferred for additional supporting documentation and written notification will be faxed back to the provider. MaineCare Members will also receive written notice of the service coverage decisions.

If you have questions about the review process, call the Help Desk at 1-866-796-2463, and asking for the MaineCare PA Unit.

Providers will be advised if MaineCare PA Unit determines medical necessity criteria has not been met, based on submitted information. Providers can then take appropriate action.

If a provider disagrees with a decision concerning medical necessity, frequency or duration of services, they may contact MaineCare PA Unit to request a reconsideration of the decision. Additional information in support of the request may be submitted at this time. If the provider remains dissatisfied with the final decision issued by the MaineCare PA Unit, the provider may appeal the decision to MaineCare Services. The appeal procedure for providers is described in Chapter 1, Section 1.21 of the MaineCare Benefits Manual. MaineCare members also have appeal rights and will receive a separate notice in cases where requested services are denied or curtailed.

Please be advised that the MaineCare PA determination concerning medical necessity will be used to authorize services for coverage. If a provider submits a claim for services that have not been prior authorized, the claim will not be paid. If a provider submits a claim for a greater number of units than what were prior authorized, the claim is subject to review and possible recoupment by Program Integrity. PA requirements are described in the MaineCare Benefits Manual, Chapter II, Section 68 (OT), Section 85 (Physical Therapy), Section 109 Speech and Hearing Services.

NOTE: If you did not get a Prior Authorization (PA) for a service and you provided the service to the MaineCare member, you will not be reimbursed for the service and you are not permitted to bill the member for the service.