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

Effective Date:

8 Approval Date: from their Primary Care Provider for those covered MaineCare services designated as ‘managed services’. For those MaineCare covered services that do not require PCP authorization members may self-refer or seek prior authorization, as is noted below.

2. Prior Authorization – 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). All services requiring prior authorization are reviewed for medical necessity. Prior authorization for 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.

3. Utilization Review – Ongoing monitoring of health care received by MaineCare members is provided by staff of the Program Integrity Unit within the Bureau of Medical Services. Ongoing sampling is conducted to review the utilization of care and services received by MaineCare members and also to evaluate necessity, quality, quantity and timeliness of services provided to MaineCare members.

4. Member Restriction – Member restriction is an administrative procedure established for MaineCare members with a history of over utilization of benefits. Participants must receive their primary medical care from one (or multiple specified providers). Primary purposes for restricting members to specified provider(s) are: 1) to decrease and control over utilization and/or abuse of covered health care services/benefits and to minimize medically unnecessary and addictive drug usage; 2) to establish a method of monitoring non-emergency health care services for members who have utilized health care services or benefits at a frequency or amount that is not medically necessary; and 3) to assist members through education and referral towards appropriate health care service and benefit use.

5. Utilization Report/Primary Care Physician Incentive Payment Report – Member utilization is also measured through preventive/quality indicators presented in the Utilization Report and Primary Care Physician Incentive Payment Report which are provided to MaineCare primary care providers at least twice a year. The Utilization Report contains 22 performance measures centered on well-child care, utilization of emergency services, potentially avoidable hospitalizations for chronic/serious medical conditions, and other disease prevention