C.M.R. 10, 144, ch. 101, ch. VI, 144-101-VI-01, subsec. 144-101-VI-01.04

Current through 2024-46, November 13, 2024

Subsection 144-101-VI-01.04 - MANAGED SERVICES

Managed services are the services defined in the categories listed below, and are described in Chapter II of this Manual. Any future policy revisions to the service categories described in this Section will automatically be included as part of Section 1.04 unless specifically exempted by rule. These services are payable by MaineCare only when provided by the member's PCP or his or her designee, or by other MaineCare providers with a referral by the member's PCP or his or her designee. Reimbursement for the provision of managed services is made in accordance with the policies set forth in Chapters I, II, and III, of this Manual. Unless otherwise exempt, MaineCare members enrolled in Primary Care Case Management are subject to co-payments for all MaineCare services that require co-payments.

Certain services that fall within the service categories described in Section 1.04, may be accessed directly by members and do not require a referral by the member's PCP. Please see Section 1.05 for a description of these services.

All claims for managed services must have the PCP's referral number in the appropriate block on the claim form regardless of whether the services were delivered by the member's PCP or his or her designee, or another provider to whom an authorized referral was made.

The following services, described in Chapters II or V of the MaineCare Benefits Manual, are managed:

1.04-1Ambulatory Surgical Center Services, Section 4.

1.04-2Advanced Practice Registered Nursing Services, Section 14, with the exception of those services which do not require referral by the PCP, as described in Section 1.05-1 and those services provided by an Advanced Practice Registered Nurse serving as the member's PCP.

1.04-3Chiropractic Services, Section 15.

1.04-4Clinic Services: Section 3, Ambulatory Care Clinics (with the exception of school-based health centers); Section 31, Federally Qualified Health Centers; and Section 103, Rural Health Clinics.

1.04-5Prevention, Health Promotion and Optional Treatment Services, Section 94.

1.04-6Hearing Aids and Services, Section 35.

1.04-7Home Health Services, Section 40.

1.04-8Hospital Services, Section 45, with the exception of those services that do not require referral by the PCP, as described in Section 1.05.

1.04-9Medical Supplies and Durable Medical Equipment, Section 60.

1.04-10Occupational Therapy Services, Section 68.

1.04-11Vision Services, Sections 75 and 90. Members may, however, self-refer for routine annual eye examinations. See Section 1.05-1.

1.04-12Physical Therapy Services, Section 85.

1.04-13Physician Services, Section 90.

1.04-14Podiatric Services, Section 95.

1.04-15Speech and Hearing Services, Section 109.

C.M.R. 10, 144, ch. 101, ch. VI, 144-101-VI-01, subsec. 144-101-VI-01.04