14-193 C.M.R. ch. 40, § 3 - Procedures

Current through 2022-14, April 6, 2022

1. Notwithstanding any other provisions herein, DMHMRSAS shall act on applications for prior authorization for specialized out-of-state services with reasonable promptness and shall adjust the time periods specified herein as circumstances require in order to do so. In cases of an emergency, the prior authorization process will be completed as expeditiously under the circumstances as necessary to alleviate the emergency.
2. All requests for Departmental funding for specialized out-of-state mental health treatment shall be directed to the appropriate Regional Mental Health Team Leader. All requests for funding in excess of $5000 must be accompanied by the completed application form and substantiating documentation to demonstrate eligibility as described in Section 2, above. The Team Leader, who will function as coordinator for processing the request, will review the request for completeness and will notify the party making the request, within three (3) working days of receipt, that it is complete or that specific information is missing. For purposes of the foregoing, an application transferred from the Department of Human Services (DHS) shall be deemed received three (3) working days after the referral is sent by DHS to DMHMRSAS. Such transfer shall be accompanied with a notice of the transfer to the applicant and the provider, such notice being sent by DHS in the form of a denial letter, together with the name and telephone number of the contact person at DMHMRSAS (the Team Leader) who will be responsible for processing the application. For purposes of this Protocol and any application form implementing it, an application shall be deemed complete if the attending physician addresses each of the criteria with an opinion accompanied by a reasonable amount of supporting information.
3. The applicant shall make a reasonable effort to submit to DMHMRSAS the information requested within thirty (30) calendar days from the date that notice is received that the application is incomplete, failing which the application may be considered abandoned. Any notice that an application is incomplete sent out by DMHMRSAS more than thirty (30) calendar days from the date the original application was filed or deemed filed with DMHMRSAS shall be considered an adverse action by DMHMRSAS and shall be accompanied with a statement advising the applicant of an opportunity for a fair hearing to challenge the determination that the application is incomplete. In the case of a notice of incompleteness given more than sixty (60) calendar days from the date the original application was filed or deemed filed, the statement shall advise the applicant of an opportunity for a fair hearing to determine not only whether the application is complete, but, in the event it is deemed so, whether DMHMRSAS should be ordered to take final action on the application within ten (10 ) calendar days. Any such order by the fair hearing officer shall provide that the request shall be considered authorized if a decision is not made within such ten (10) day period. Any denial of requested services, in whole or in part, shall be accompanied by a statement advising the applicant of a right to a fair hearing. If an applicant chooses to request a hearing, the request shall be made no later than thirty (30) calendar days from the date of receipt of the notice and DMHMRSAS shall forward such requests to the Maine Department of Labor Division of Administrative Hearings (or its successor) within 24 regular business hours (that is, by the next working day) and a hearing shall be held within 7 working days thereafter.
4. When the Team Leader determines that the request is complete, the Team Leader will convene a team which shall include at minimum the regional Medical Director and the Regional Director to review the documentation and make a recommendation about the appropriateness of the request for funding. This recommendation will be completed within two weeks of the notification to the party making the request that the application is complete.
5. Once the request has been approved on the regional level, the Team Leader shall forward a written recommendation to the Associate Commissioner for Operations (or designee) with completed application form and supporting documentation for consideration.
6. The Associate Commissioner (or designee) shall make a final determination within two weeks of receipt of the regional recommendation. The determination shall include specific length of stay and terms for concurrent review of treatment progress.
7. Requests for approval of funding for specialized out-of-state treatment shall be finally acted upon within four (4) calendar weeks of the date the application is complete or determined as a result of a fair hearing to be complete. Applications still pending after this four (4) calendar week period shall be deemed approved.

Notes

14-193 C.M.R. ch. 40, § 3

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