C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-94, subsec. 144-101-II-94.03
In Appendix 1, MaineCare has adopted the most recent version of the Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents of the American Academy of Pediatrics (http://brightfutures.aap.org) (hereinafter "Bright Futures") as the standard of care expected at health assessment visits for MaineCare members under the age of 21. There are nineteen (19) separate age appropriate MaineCare Bright Futures health assessment forms that delineate the age-specific guidelines for each required visit.
See Appendix 1 for the MaineCare Bright Futures periodic health assessment schedule that begins with a neonatal examination and continues up to the age of 21.
In order to do health assessments under the Bright Futures guidelines, a provider must:
If one or more components of a health assessment visit are performed elsewhere (e.g. by another provider because of a referral, by a Head Start agency or by a school), the results of the procedure(s) done by others must be recorded on the MaineCare Bright Futures health assessment form before a provider may request payment for the health assessment visit. In all cases, each component of the health assessment must be addressed.
Providers may meet these documentation requirements by retaining completed copies of the MaineCare Bright Futures health assessment forms in each child's consolidated health record; and
MaineCare children are at significantly higher risk for lead exposure than other children and have higher lead levels according to MaineCare data.
As part of the Bright Futures health assessment visit done at one and two years of age, providers must test the blood for lead levels. MaineCare will pay MaineCare physicians, physician's assistants, and advanced practice registered nurses who are in private practice an enhanced reimbursement for venous and capillary blood draws when they are done for blood lead testing.
MaineCare will reimburse the Maine Department of Health and Human Services, Centers for Disease Control and Prevention for environmental investigations of a child's home or primary residence when the child has been diagnosed as having an elevated blood lead level. MaineCare will not pay for testing of substances such as soil, dust, paint or water which are sent to a laboratory for analysis.
As part of the Bright Futures health assessment visit, providers must evaluate the member's immunization history and bring him or her up to date on all required immunizations. If immunizations are needed but cannot be administered at the time of a health assessment visit, the provider should recall the member to give the immunizations at a more appropriate time.
MaineCare recommends that providers use the Maine Department of Health and Human Services, Centers for Disease Control and Prevention, guidelines for provision of age appropriate immunizations. The Centers for Disease Control and Prevention uses the Federal Centers for Disease Control and Prevention guidelines. These guidelines may be obtained by contacting the Centers for Disease Control and Prevention Immunization Program.
When children need health assessments outside of the normal schedule, providers must use the age appropriate MaineCare Bright Futures health assessment form for the age closest to the child's chronological age to document the visit.
When children have behavioral health issues, any treatment provider or individuals outside of the health care system can request an examination off the periodic health assessment schedule with the consent of the child and/or the child's parent(s) or guardian(s). Individuals outside of the health care system include, but are not limited to, teachers, school nurses, and day care providers.
The provider must initiate medically necessary follow-up treatment identified as needed during a health assessment visit, including but not limited to treatment for defects in vision, hearing and dental care, at the earliest practical date commensurate with the needs of the child. Generally, this should happen within six months from the date of the health assessment visit.
Billing for follow-up treatment for health care needs identified during the health assessment visit must be done using the appropriate Evaluation and Management Current Procedural Terminology (CPT) codes. Do not use the MaineCare Bright Futures health assessment form when billing for follow-up treatment services.
Members enrolled in MaineCare managed care may need a referral from their primary care provider if the needed follow-up treatment is a "managed service."
One or more components of a health assessment visit may be omitted if any of the following circumstances exist. If any of the following circumstances exist and a component of the health assessment visit is not performed, the provider must record the appropriate reason on the MaineCare Bright Futures health assessment form.
In some circumstances the member's behavior may be such that a procedure is impossible to perform. In the interest of providing comprehensive health assessments for all children, the provider should arrange another appointment with the member and attempt the procedure(s) again before submitting a claim for the health assessment visit.
Some procedures, especially immunizations, are contrary to the religious beliefs of some members/caretakers and may be refused on that basis.
Members/caretakers occasionally may ask that specific procedures not be done. These personal requests may be granted, but should be distinguished from religious exemptions when possible.
The provider may omit a procedure if, in his/her professional judgment, the procedure is not medically necessary or is medically contraindicated.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-94, subsec. 144-101-II-94.03