90.05 RESTRICTED SERVICES (cont.) 90.05-3 Services Covered When Rehabilitation Potential Is Documented Some MaineCare services that are not routinely performed by a physician nevertheless require documentation by a physician of medical necessity or rehabilitation potential. services include, but are not limited to, chiropractic services, home health services, physical therapy, occupation therapy, or speech therapy services. For services requiring documentation of rehabilitation potential, providers should include diagnosis or complaint, how member was assessed, (e.g. by phone, exam, therapist evaluation) why rehabilitation potential is expected, (e.g. acute condition, acute exacerbation of chronic condition, past response to therapy, etc.) and indicators of measurable functional improvement. Other providers may, if requested by the physician, use an evaluation to assist the physician in determining the member’s rehabilitation potential. In the case of a service requiring recent surgery to obtain prior authorization, such as in the case of chiropractic services, surgery must have been performed within the previous sixty (60) days (to the PA request). 90.06 SERVICES FOR MEMBERS IN DIFFERENT SETTINGS 90.06-1 Nursing Facilities and Other Group Care A. Nursing Facility Admissions The admission of a member to a nursing facility the MaineCare program requires prior approval from the Department of Health and Human Services. Approval for admission is given only when a member meets the medical eligibility requirements for nursing facility services, as set forth in Chapter II, Section 67 of the and when adequate alternate MaineCare Benefits Manual, arrangements cannot be made for home or community based care. NF applicants must receive a medical eligibility assessment with the Department's approved assessment instrument (see Section 67). B. On-Going Nursing Facility Care When the physician continues to serve as the attending physician to members after they enter a nursing facility, or accepts as new patients members who are receiving care in a nursing facility, he or she is expected to provide, at a minimum, those physician services that are required, by Federal regulations and by the State of Maine Regulations Covering the Licensing and Functioning of to be provided in licensed MaineCare approved facilities. Nursing Facilities,
90.05 RESTRICTED SERVICES (cont.) 90.05-3 Services Covered When Rehabilitation Potential Is Documented Some MaineCare services that are not routinely performed by a physician nevertheless require documentation by a physician of medical necessity or rehabilitation potential. services include, but are not limited to, chiropractic services, home health services, physical therapy, occupation therapy, or speech therapy services. For services requiring documentation of rehabilitation potential, providers should include diagnosis or complaint, how member was assessed, (e.g. by phone, exam, therapist evaluation) why rehabilitation potential is expected, (e.g. acute condition, acute exacerbation of chronic condition, past response to therapy, etc.) and indicators of measurable functional improvement. Other providers may, if requested by the physician, use an evaluation to assist the physician in determining the member’s rehabilitation potential. In the case of a service requiring recent surgery to obtain prior authorization, such as in the case of chiropractic services, surgery must have been performed within the previous sixty (60) days (to the PA request). 90.06 SERVICES FOR MEMBERS IN DIFFERENT SETTINGS 90.06-1 Nursing Facilities and Other Group Care A. Nursing Facility Admissions The admission of a member to a nursing facility the MaineCare program requires prior approval from the Department of Health and Human Services. Approval for admission is given only when a member meets the medical eligibility requirements for nursing facility services, as set forth in Chapter II, Section 67 of the MaineCare Benefits Manual, and when adequate alternate arrangements cannot be made for home or community based care. NF applicants must receive a medical eligibility assessment with the Department's approved assessment instrument (see Section 67). B. On-Going Nursing Facility Care When the physician continues to serve as the attending physician to members after they enter a nursing facility, or accepts as new patients members who are receiving care in a nursing facility, he or she is expected to provide, at a minimum, those physician services that are required, by Federal regulations and by the State of Maine Regulations Covering the Licensing and Functioning of Nursing Facilities, to be provided in licensed MaineCare approved facilities.
c2s090.docx