Over the past several years, the Maine Department of Health and Human Services (DHHS) and the Department of Education (DOE) have been working together to identify possible improvements to the processes involved with billing for MaineCare reimbursable, medically necessary services provided in a school based setting. The key issue that has been raised by providers during the course of these years is the concern regarding the audit risks involved with billing MaineCare. These concerns have been enhanced by recent State of Maine Program Integrity and federal Office of the Inspector General audits.
In order to better support providers managing their risk and to help review plans for medical necessity, the DHHS has entered into a contract with APS Healthcare to begin conducting prior authorizations for services reimbursed through the MaineCare Benefits Manual, Section 28-Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations and Section 65-Behavioral Health Services, Day Treatment. These prior authorizations will help to assure that services comply with the pre-existing eligibility criteria in those sections, as well as, the definition of medical necessity referenced in the MaineCare Benefits Manual, Chapter 1-General Administrative Policies and Procedures, Section 1.02-4(D).
There will be no new eligibility requirements; APS will only be reviewing requests against criteria that providers are already utilizing. In addition, APS will accept the Individual Education Plan (IEP) for children ages 3-20 or the Individual Family Support Plan (IFSP) for children ages birth-2 as the primary document; as long as all materials identified in rule are included (for example: Section 28.02-Eligibility for Service and 28.05-Member Records, Section 65.04-Eligibility, 65.0613-Children’s Behavioral Health Day Treatment and 65.09-3-Member Records and the audit checklist. APS will be working with providers to assure that all documentation has been completed before approving the service, will which ultimately help providers to be more confident in their future audit risks.
This change in process will be effective as of Dec. 1. You will able receiving a notice from APS in the next few days outlining this process and providing dates when training will be available in your local area. Live web-based training and 1:1 training will be available as well.
Please remember that while APS will be providing prior authorization, providers are still required to comply with the rules and regulations as listed in the MaineCare Benefits Manual. These authorizations will not alleviate any audit risks, but will help to assure that all eligibility requirements (including documentation) are met prior to receiving MaineCare reimbursement for services rendered.
As always, we are committed to supporting you through this change. If you have any questions please do not hesitate to contact 866-521-0027, Option 1, or via email at mainecare-prov@apshealthcare.com or MaineCare Provider Relations at mainecareineducation@maine.gov.