MaineCare General E-Message - June 17, 2016

Section 17 Community Support Services: Establishing Prior Authorization

Effective July 1, 2016, APS Healthcare, in coordination with the Office of MaineCare Services, will conduct prior authorization reviews for the following MaineCare Benefit Manual Chapter II, Section 17 services:

• Daily Living Skills (DLS)
• Day Supports
• Skills Development

These reviews are consistent with the prior authorization reviews currently conducted for other Section 17 services.

Procedures for New MaineCare members becoming eligible for DLS, Day Supports, and Skills Development services:

• The provider will submit a registration for the member and a 30 day service authorization.
• At day 31, MaineCare members will be required to meet medical necessity criteria based on current policy.  Providers will then submit documentation to support medical necessity via a Continued Stay Request in the CareConnection system for continued authorization of services.
• If a clinical letter supporting medical necessity criteria is required, please fax the letter on the same day that the Continued Stay Review is entered into the APS CareConnection system. The letter may be faxed to APS Healthcare at 1-866-325-4752. Please include the following in the letter:

• Date when clinical support letter was written
• Service being requested  (Community Integration, Assertive Community Treatment or ACT, Community Rehabilitation Services or CRS)
• APS case ID number
• MaineCare member’s name, date of birth, and social security number if grant funded
• Signed clinical opinion from an approved clinician regarding mental health risk factors

• If the member meets clinical criteria, they will receive approval from APS Healthcare for a 90 day service authorization. Continued Stay Reviews will be conducted every 90 days, at which time the member’s eligibility will again be reviewed.

Procedure for MaineCare members currently receiving DLS, Day Supports, and Skills Development services:

• Eligibility for services and medical necessity will be reviewed at the member’s next 90 day Continued Stay Review.
• Effective July 1, 2016, documentation of medical necessity for the member’s current services will be examined at the time of the Continued Stay Review. 
• Continued Stay Review requests should be entered into the APS CareConnection system.
• If a clinical letter supporting medical necessity criteria is required, please fax the letter on the same day that the Continued Stay Review is entered into the APS CareConnection system.  The letter may be faxed to APS Healthcare at 1-866-325-4752. Please include the following in the clinical letter:

• Date when clinical support letter was written
• Continued service requested (DLS, Day Supports, Skill Development)
• APS case ID number
• MaineCare member’s name, date of birth, and social security number if grant funded
• Signed clinical opinion from an approved clinician regarding mental health risk factors

• Please note that, per policy, substance abuse inpatient treatment, and involvement in the criminal justice system due to substance use/abuse, does not support medical necessity.

APS Healthcare may be contacted with questions about utilization review at 1-866-521-0027. MaineCare’s Policy Division may be contacted for policy-related questions at 207- 624-4050.