Updates to MaineCare’s 1135 Waiver Provisions  

Updates to MaineCare’s 1135 Waiver Provisions  

We have updated guidance on temporary changes to the medical and behavioral health authorization processes as they relate to the COVID-19 public health emergency and MaineCare’s 1135 waiver. This information can be found online and is also outlined below.  

Reinstatement of Kepro’s Utilization Review Process, Effective February 1, 2021 

Due to the ongoing public health emergency, and through the authority of our 1135 waiver, the Office of MaineCare Services (OMS) has authorized Kepro to automatically extend service authorizations due to expire between on or before January 31, 2021 for an additional 30 days.  

Effective February 1, 2021, providers will be required to submit requests for service authorization via Kepro’s Atrezzo portal. Services will no longer be automatically extended after January 31, 2021. 

Providers will continue to have 31 days in advance of the authorization start date and five days after the authorization start date to submit authorization requests. Kepro will not backdate requests for late submissions.  

Providers will continue to have flexibility through February 28, 2021 to use existing clinical assessments and/or documents if they are unable to obtain new ones. Beginning March 1, providers will be expected to have current clinical documentation for review in their prior authorization requests and continued stay reviews. Requirements regarding signatures will continue to be waived per the 1135 waiver.  

For questions regarding the Kepro process, please contact ProviderRelationsME@kepro.com. For billing questions, please contact your designated MaineCare Provider Relations Specialist. 

Physician-Administered Drugs  

Effective March 1, 2021, the following provision related to physician-administered drugs will be rescinded:   

Prior Authorizations for Continuation of Treatment: For members who have active authorizations for specific medications, providers will need to submit only the authorization request itself. The Department will waive the requirement for providers to submit clinical documentation demonstrating efficacy of treatment and will approve an authorization for a period of three months. At the end of the three-month period, providers will need to submit the clinical documentation demonstrating efficacy of treatment for services to continue.   

For the drug OPDIVO: Providers can submit the J-Code form with diagnosis, NDC, and provider signature only. MaineCare will waive submission of clinical documentation and approve for three months.  

For the continuation of the drugs Tysabri and Ocrevus: Providers can submit just the PA form without the clinical documentation. MaineCare will waive submission of clinical documentation and approve for three months. At the end of the three-month period, providers will need to submit the clinical documentation for services to continue.  

Prior Authorizations for Radiology Services  

As announced September 29, 2020, radiology services no longer require prior authorization, effective October 1, 2020.