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Model Application Template for the State Children’s Health Insurance Program

Effective Date:

30 Approval Date: members per year). The report also contains a listing of the particular MaineCare members on the PCP’s panel currently hospitalized with the identified conditions.

MaineCare managed care members in need of treatment by specialists may access care through referral from the member’s Primary Care Provider for those covered MaineCare services designated as ‘managed’ services. For those MaineCare services that do not require PCP authorization, members may self-refer or seek prior authorization from the Bureau.

Prior authorization is required for certain MaineCare covered services obtained in-state and all MaineCare covered services provided out-of- state (with the exception of emergency services and services furnished by providers located within 15 miles of the New Hampshire border and 5 miles of Canadian border who are treated as in-state providers). Prior authorization for covered services rendered out-of-state is provided only when a member’s continuity of care must be preserved for medical reasons and only after it is determined that the needs of the member cannot be met in the State of Maine.

Another management tool developed and used by the Bureau to monitor and manage MaineCare members with chronic pain is the Pain Management Program. Members receiving 3-5 narcotics from different prescribers or 6+ different narcotics are invited to voluntarily join the program. Under the program, members are matched with one physician responsible for managing all medication use by the member with patient safety as a primary focus

7.2.4 Decisions related to the prior authorization of health services are completed in accordance with state law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR 457.495(d))

Prior authorization of health services are completed in accordance with MaineCare requirements.