Intensive Outpatient Program (IOP) Clinical Eligibility Review and Billing Criteria for Section 45 and 46 Hospitals Update

Beginning September 1, 2026, IOP services delivered by hospitals enrolled under MaineCare Benefits Manual (MBM) Chapter II, Sections 45 and 46 will require clinical eligibility review and billing criteria in alignment with Medicare’s IOP services billing requirements.  

Effective for dates of service on, or after, September 1, 2026, hospitals delivering IOP services must: 

  1. Submit a clinical review request to Acentra Health before delivering services to determine a MaineCare member’s IOP service eligibility. Members determined to meet clinical eligibility criteria as defined in MBM, Chapter II, Section 65 will receive a Case ID number to authorize billing for the delivery of IOP services by Section 45 and 46 providers. 

  2. With clinical review approval, deliver IOP services in accordance with their hospital licensure and the requirements of MBM, Chapter II, Section 65.05-4.  

  3. Submit claims using the corresponding CPT/HCPCS codes or revenue codes for actual services delivered including modifier(s) as applicable. Condition Code 92 (CC 92) is required in Form Locator fields 18-24. 

  4. Retain the clinical review Case ID number in the member’s medical record. Because IOP services without a clinical review Case ID are not eligible for reimbursement, providers must maintain clinical review approval records for Program Integrity purposes. 

  5. Deliver services in accordance with Division of Licensing and Certification (DLC) requirements.   

Please note: This notice supersedes previous MaineCare Section 45 and 46 IOP billing instructions including, but not limited to, the June 14, 2023 and August 18, 2023 messages.  

Medicare’s claims criteria are outlined in the Centers for Medicare & Medicaid Services (CMS) publication, including MLN 13496 – Billing Requirements for Intensive Outpatient Program Services with New Condition Code 92.

For questions regarding hospital licensure requirements for the delivery of IOP services, please reach out to Anna Blackwell, Associate Director of DLC: Medical Facilities Unit.  

For questions regarding IOP service and eligibility standards set forth in Section 65, or the billing requirements for providers enrolled under Sections 45 and 46, please contact Provider Relations Specialist Tiffany Norton.