C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-68, subsec. 144-101-II-68.09

Current through 2024-51, December 18, 2024

Subsection 144-101-II-68.09 - POLICIES AND PROCEDURES

68.09-1Qualified Professional Staff are:

Occupational Therapist, Registered, Licensed (OTR/L);

Occupational Therapy, Licensed (OT/L);

Certified Occupational Therapy Assistant, Licensed (COTA/L); and

Occupational Therapy Assistant, Licensed (OTA/L).

All professional staff must be conditionally, temporarily, or fully licensed as documented by written evidence from the appropriate governing body. All professional staff must provide services only to the extent permitted by licensure. An OTR/L or an OT/L may be self-employed or employed by an agency or business. Agencies or businesses may enroll as a provider of service and bill directly for services provided by qualified staff. A COTA/L or an OTA/L may not enroll as an independent billing provider.

68.09-2Member's Records

Providers must maintain a specific record for each member, which shall include, but not necessarily be limited to:

1. Member's name, address, birth date, and MaineCare ID number;

2. The member's social and medical history, and medical diagnoses indicating the medical necessity of the service or services;

3. A personalized plan of service including (at a minimum):

A. Type of occupational therapy needed;

B. How the service can best be delivered, and by whom the service shall be delivered;

C. Frequency of services and expected duration of services;

D. Long and short range goals;

E. Plans for coordination with other health service agencies for the delivery of services;

F. Any medical supplies for which a Practitioner of the Healing Arts' order is necessary; and

G. Practitioner of the Healing Arts' orders including, for adults, their documentation of the member's rehabilitation potential.

The physician or primary care provider must review, sign and date the member's plan of care at least once every three (3) months for adult members (age twenty-one (21) and over). The plan of care must be kept in the member's record and is subject to Departmental review along with the contents of the member's record.

4. Written progress notes shall contain:

A. Identification of the nature, date and provider of any service given;

B. The start time and stop time of the service, indicating the total time spent in delivering the service;

C. Any progress toward the achievement of established long and short range goals;

D. The signature of the service provider for each service provided; and

E. A full account of any unusual condition or unexpected event, including the date and time when it was observed and the name of the observer.

Entries are required for each service billed. When the services delivered vary from the plan of care, entries in the member's record must justify why more, less, or different care than is specified in the plan of care was provided.

68.09-3Utilization Review

The Department or its authorized agent has the right to perform utilization review. If at any point of an illness or disabling condition, it is determined that the expectation for measurable functionally significant improvement will not be realized, or if they are already realized and no more services are needed, the services are no longer considered reasonable and necessary, and will not be covered

68.09-4Program Integrity

Requirements for Program Integrity are detailed in Chapter I of the MaineCare Benefits Manual.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-68, subsec. 144-101-II-68.09