C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-60, subsec. 144-101-II-60.07
Some Medical Supplies and DME require PA for MaineCare to provide payment. The Department or its authorized entity processes PA requests. More information on the PA process is in MaineCare Benefits Manual, Chapter I, Section 1. The MaineCare Health PAS Online Portal contains a complete list of Medical Supplies and DME that require PA and corresponding PA criteria sheets. Providers should research each item on the MaineCare website to assure it is covered and check whether it requires PA at https://mainecare.maine.gov/Default.aspx, which includes a link to the PA portal. The Department reserves the right to require an evaluation by appropriate clinical professionals of its choice before granting PA.
In cases where the member does not meet the PA criteria, the provider or member may submit additional supporting evidence, such as medical documentation, to demonstrate that the requested service is medically necessary.
Providers shall make requests for PA on the Department's approved form and get approval prior to the date of service.
Proper documentation includes proof of acquisition cost or a price quote from a manufacturer. If a claim is not equal to the exact amount of the PA, a subsequent adjustment to the authorization may be made with appropriate documentation. Claims should not be submitted until the adjustment is made. Alternatively, the Department may choose to issue a letter approving the request for PA without assigning an approved amount.
Once documentation of Adjusted Acquisition Cost (AAC) is received from the provider, MaineCare staff will assign an allowable amount. A completed Medicare Certificate of Medical Necessity (CMN) shall include itemized AAC and usual and customary charges for the equipment.
The Department reserves the right to request detailed documentation, including material and labor costs and total hours for the manufacture or fabrication of orthotic and prosthetic devices. This information may be estimated prior to the manufacture or fabrication. However, actual costs must be submitted upon completion. Non-compliance may result in denial of payment or recoupment of payments.
The Department will not refuse to prior authorize a DME item based solely on a diagnosis, type of illness, or condition.
In addition to the specific items that require PA, the Department also requires PA for the following:
PA is required for any Medical Supplies and DME that costs MaineCare more than $699.00. The item must be prescribed by a Qualified Provider and be the most cost-effective item available that meets the medical needs of the member.
The cost of an item equals the total cost of all the item's constituent pieces. For example, the cost of a wheelchair is the sum of the cost of each of its components including, but not limited to, foot plates, wheels, wheel rims, armrests, arm troughs, etc. Should the need arise for an unanticipated component, that item must have PA, regardless of price.
Rental equipment requires PA, except in emergency situations. Oxygen is considered a rental.
In an emergency, the Department does not require PA to rent standard equipment for up to thirty (30) days. The Department will pay the rental for this emergency period. In this section, the Department defines emergency as a situation where the member would not otherwise be able to return home from a hospital, rehabilitation facility, or nursing home, or when a prescribing provider determines a member must have the equipment within twenty-four (24) hours.
The provider must request PA authorization within thirty (30) days of providing the equipment if it is necessary to continue the rental beyond thirty (30) days.
The Department will deny reimbursement beyond the thirty (30) day emergency period if the provider does not make this request. The Department will decide, within thirty (30) days of the date the PA is requested, whether to approve, defer, or deny authorization for the rental beyond the thirty (30) day emergency period.
Miscellaneous DME, including those billed under the Healthcare Common Procedure Coding System (HCPCS) code E1399 or any other DME billed under another code which contains the phrase "miscellaneous," "accessories," "not otherwise specified," or "not otherwise classified" in its description when the MaineCare allowed amount exceeds $99.99, requires PA.
DME parts for member-owned DME previously supplied and covered under MaineCare require PA. For example, a part related to a wheelchair that previously required PA would also require PA. DME parts that fall under warranty will not be covered.
The Department is not responsible for the cost of parts for rented DME.
Repairs to member-owned DME with a total cost (parts and labor) exceeding sixty percent (60%) of replacement cost require PA, at which time the Department will decide if replacement of the DME is appropriate.
PA is required for any repair if replacement parts, labor, or the combination are over $699.00 to repair medically necessary DME. The Department reserves the right to request documentation necessary to validate medical necessity before PA is granted.
Reimbursement is not allowed for repair of any DME that is still under warranty.
The Department is not responsible for the costs associated with repairs to rented DME.
To qualify for PA, information on the Department's approved PA form or the appropriate CMN must indicate that the same warranty is offered on used equipment as on new equipment. The equipment being reconditioned shall not exceed the expense for new equipment.
Some items subject to coverage limitations may be covered in excess of the limitation under limited circumstances when prior authorized by the Department. These items can include power operated vehicles and wheelchairs, hospital beds, standard mattresses for hospital beds, prosthetic devices to allow functional mobility, nebulizers, respiratory suction pumps, and CPAP and Bi-Pap devices and supplies.
The following exceptions apply to MaineCare PA requirements:
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-60, subsec. 144-101-II-60.07