C.M.R. 10, 144, ch. 101, ch. IV, § 144-101-IV-1, subsec. 144-101-IV-1.03

Current through 2024-46, November 13, 2024

Subsection 144-101-IV-1.03 - DEFINITIONS

For purposes of this Section, the following definitions shall apply:

1.03-1Authorized Agent is the organization authorized by the Department of Health and Human Services (DHHS) to perform specified functions pursuant to a signed contract or other approved signed agreement.

1.03-2Educational Opportunities means the opportunities provided by DHHS or its Authorized Agent to discuss the member's pattern of health care utilization, in which discussion the member receives information on how to obtain or use appropriate health care services or receives a referral to an appropriate agency to obtain services for the identified utilization problem.

1.03-3Health Care Provider is an individual or entity that furnishes health care services or benefits to persons for which payment is reimbursable through the MaineCare Program.

1.03-4Health Care Services are all services covered under the Maine Medical Assistance Program. These services include, but are not limited to, primary care provider, pharmacy and hospital services.

1.03-5Lock-In is a federally authorized program specified in the Code of Federal Regulations ( 42 CFR § 431.54(e) ) that provides that a MaineCare member who has utilized MaineCare services at a frequency or amount that is not medically necessary may be restricted to designated health care providers that are enrolled as MaineCare providers. Lock-In will only be deemed necessary once the Member Review Team has determined that the member has exhausted all Educational Opportunities. The Team may enroll a member in a Lock-In corresponding to the type of Over-Utilization by the member. A member may be enrolled in more than one type of Lock-In. A Lock-In is a basis of denial for a claim for payment of services outside the terms of the Lock-In. Lock-In restrictions do not apply to emergency services, that is, stabilization of an emergency medical condition as defined in Section 1.02-4.B. &C. of Chapter I of the MaineCare Benefits Manual. There are four types of Lock-in:

A.Full Restriction (Lock-In type 1) - This Lock-In type requires a member to be restricted to the core providers of a Primary Care Physician, a Hospital, a Pharmacy and may include restrictions within additional provider types. Full restriction will occur when clinical review has identified Over-Utilization in any two of the core provider types.

B.Partial Lock-In (Lock-In type 2) - This Lock-In type restricts the member to a provider in one or multiple types of health care providers when clinical review has identified Over-Utilization in one or more types of health care providers but the standard of a Full restriction is not met.

C. Prescriber Lock-In (Lock-In type 3) - This Lock-In type restricts the member to one or more specific Prescribers for prescriptions when clinical review has indentified Over-Utilization in one or more types of prescriptions. The Member Review Team may designate multiplePrescribers for the member for differing types of prescriptions.

D. Pharmaceutical Restriction (Lock-In type 4) - This Lock-In type restricts the member from being able to obtain one or more specific drug categories (classes) when clinical review has identified Over-Utilization in one or more drug categories.

1.03-6 Maine Integrated Health Management Solution (MIMHS) - is the computer system that MaineCare Services of The Department of Health and Human Services (DHHS) uses to process provider claims for reimbursement as of March 2010.

1.03-7Medical Necessity is the use of health care services or benefits that are appropriate to, and not in excess of, the health care needs of the member, as determined by the Member Review Team through investigation and analysis of the medical record and claims history. Potential indicators of the lack of medical necessity include but are not limited to:

A. unusually frequent utilization of health care services;

B. inappropriate or excessive acquisition of drugs, especially drugs with addictive properties such as: tranquilizers, psychostimulants, narcotic analgesics, non-narcotic analgesics, sedative barbiturates and sedative non-barbiturates; and

C. duplicated services or prescriptions for the same or similar conditions.

1.03-8Members are recipients of MaineCare services.

1.03-9Member Review Team ("the Team") is the Department of Health and Human Services (DHHS) multidisciplinary team that participates in the surveillance of health care services and benefit utilization by MaineCare members and determines the existence of over-utilization and/or misuse. The Team shall consist of, at a minimum, a physician; a registered nurse or social worker; and a representative of Program Integrity. The Team may also include other consultants, such as a pharmacist and/or a representative from the Health Care Management unit of MaineCare services.

1.03-10Over-Utilization is the use of health care services and benefits in excess of medical necessity, as determined by the Member Review Team.

1.03-11Primary Care Provider (PCP) is a physician or other provider who practices primary care.

1.03-12Program Integrity Unit is the unit responsible for conducting a federally required monitoring plan that reviews all MaineCare services and expenditures.

1.03-13Prescriber is an M.D., D.O., nurse practitioner, physician assistant or resident in training who possesses a valid DEA number.

C.M.R. 10, 144, ch. 101, ch. IV, § 144-101-IV-1, subsec. 144-101-IV-1.03