Review of Concurrent Services: Effective 4/1/08

Review Process Concerning Concurrent Provision of Services

Overview:

APS is committed to ensure that only clinically appropriate services are authorized.
“Concurrent Services” are services that are provided at the same time to the same member.
“Non-concurrent services” are services that cannot be provided at the same time to the same member unless there is specific clinical justification as per MaineCare rules.
MaineCare rules define which services can be provided concurrently, and which services cannot, without a specific clinical justification.
When more than one service is provided or requested, APS will decide which service(s) will be authorized and which service(s) will be considered the “non-concurrent” service(s).
The decision about which service is considered “non-concurrent” will be based on MaineCare rules and the service(s) that best fits the clinical needs of the member.
If the service is already being provided, APS will issue a 30 day authorization to the service(s) considered to be the “non-concurrent” service(s).
The provider of the “non-concurrent” service is responsible to clinically justify the continued need for the service, as per MaineCare rules.
If the non-concurrent service is not clinically justified as per MaineCare rules, then the service will not be authorized.
If the request is for a new service authorization that could result in the authorization of a non-concurrent service, then APS either approves or denies the request based on the clinical appropriateness of the service.

Process:

For Every PA and Continued Stay Request, APS Care Managers will review all concurrent services that the member is also authorized for. If the member is authorized for a non-concurrent service, the following will occur:

1. For the service that is most clinically appropriate: APS will notify the provider that a non-concurrent service is also being provided to the member, and request that the services coordinate their care with each other and the member and examine whether the need for the non-concurrent service is clinically justified and consistent with MaineCare rules.

Example: Member is authorized for Outpatient services (Z4217) with APS and a request for 65M Child Behavioral Health Treatment is submitted. Provider Note from APS in the 65M provider’s download notification will state: “Please follow up with member and family. Member is currently receiving non-concurrent outpatient services.”

2. For the service that is not the most clinically appropriate: APS will notify the provider that the existing authorization date has been changed, so that the authorization is 30 days in length. The provider will be asked to coordinate with the member and other providers to do one of the following:

Use the 30 day authorization to appropriately discharge the member
Submit a Continued Stay Request that justifies continuing with non-concurrent service, consistent with MaineCare rules.
Transition the member to an inactive status, (do not discharge the member with APS); when the member is ready to transition from the other service back to the non-concurrent service, submit a Continued Stay Request to APS.

Example: Section 65M service is authorized with above provider note appearing in the download notification. 65M provider is expected to follow up with member and outpatient provider to coordinate care. APS Care Manager will change the end date of the existing outpatient authorization to 30 days from the submission date of the new 65M authorization. Provider note to the outpatient provider in the download notification will state: “Care Manager authorized with changes. Member has been authorized for 65M services. Per MaineCare rule http://www.maine.gov/sos/cec/rules/10/144/ch101/c2s065.doc outpatient is a non-concurrent service. Outpatient authorization LCD changed to X/X/X. Please coordinate care with member and other providers to determine if transition to inactive status, discharge, or Continued Stay request is appropriate.”