Changes to MaineCare Benefits Manual, Section 68-Occupational Therapy and Section 85-Physical Therapy, Effective 1/1/14, CR 33179

January 16, 2014

MaineCare Services’ Policies/Rules has been updated to include the recently adopted Section 68 and Section 85 policies, and can be found at: http://www.maine.gov/dhhs/oms/rules/index.shtml

MaineCare has updated policy to reflect the following changes to both Sections 68 and 85:

1) Added new definitions and updated existing definitions;

2) Added new covered services and clarified covered services and their limits;

3) Limited supplies to splinting only;

4) Added a link to the Department’s Rate Setting website; and,

5) Added a Prior Authorization (PA) requirement for services provided to adult members, age 21 and older. Please note:

i) The PA requirement applies to Physical and Occupational Therapy services when they are provided in the following settings:

(a) Section 67: Outpatient Physical and Occupational Therapy Services provided in a Nursing Facility in accordance with Section 67.05-13(D) of the MaineCare Benefits Manual

(b) Section 31: Ambulatory Services provided in a Federally Qualified Health Center in accordance with Section 31.04-2(A) of the MaineCare Benefits Manual

(c) Section 103: Ambulatory Services provided in a Rural Health Clinic in accordance with Section 103.04 of the MaineCare Benefits Manual

(d) Section 9: Indian Health Services in accordance with Section 09.04(C) of the MaineCare Benefits Manual

(e) Section 90: Physical Therapists or Occupational Therapists in a physician or hospital based physician group must bill in accordance with Sections 90.04-28 and 90.04-29 of the MaineCare Benefits Manual

(f) Section 45: Outpatient Physical and Occupational Therapy Services provided in a Hospital in accordance with Section 45.05-10 of the MaineCare Benefits Manual

ii) Services may be provided beyond the limits listed in rule if medically necessary and approved through PA by the Department’s medical staff.

iii) PA forms are now available in the Authorizations and Referrals folder of the Provider Forms page of the Health PAS Online Portal.

The provider administering the service is responsible for requesting the PA. You must first request a PA for an evaluation and will receive a PA number if approved. At the time of evaluation, the identified modality/treatment may be provided if medically necessary. You must then use the Update Form, including the PA number issued, to request approval of additional services.

Please contact your Provider Relations Specialist with questions.