ME ASO Hospital Requirements - 1/1/09

The Following Hospitals are Subject to the Requirements of the Maine BH ASO:

• Hospitals that provide service to MaineCare members under Section 46 of the MaineCare Benefits Manual, including for non-compensated adults.

• Hospitals with a dedicated psychiatric or substance abuse unit, that provide service to MaineCare members under Section 45 of the MaineCare Benefits Manual.

• Hospitals that do not have a dedicated psychiatric or substance abuse unit are not subject to the requirements of the Maine Behavioral Health ASO.

Hospital ASO Requirements:

• These requirements apply only to hospitals subject to the requirements of the Maine BH ASO, as noted above.
• Hospitals are not required to obtain or submit a MECMS PA Billing number for claims submissions.

Requirements for the Hospital UR Process:

Hospitals are required to submit the following reviews to APS Healthcare for MaineCare members:

• Initial Registration
• Continued Stay Review (may be multiple reviews, depending on LOS)
• Discharge Review

Use of APS CareConnection® for the UR Process

Please submit reviews to APS Healthcare via APS CareConnection®.

• Hospitals may use APS CareConnection® to verify MaineCare member eligibility.
• The Hospital can use APS CareConnection®  to view the status of the authorization request, to submit a continued stay review and to download the authorization information for clinical and billing purposes, on a 24/7 basis.

Reconciliation of Authorizations at DHHS Cost Settlement

Authorization records will be reported to DHHS and reconciled with submitted claims.  Non authorized services will not be reimbursed during the cost settlement process.

Hospital Average Occupancy Report

The Hospital Average Occupancy Report can be used by both hospitals and APS Healthcare to ensure that registrations, continued stay requests and discharges are timely.

Hospital UR Process

Initial Registration Review:

• The hospital will submit an Initial Registration Review to APS Healthcare within 1 business day of admission for all admissions of MaineCare members.

• The initial APS authorization for inpatient hospital admissions is three (3) days.

• When Service is authorized by APS:

• APS Healthcare will convey to the provider, authorization start and end dates and an authorization number.

• The authorization number is the same number as the “APS Case ID” in APS CareConnection®.

• The authorization number is kept in hospital records, but is not submitted to MaineCare for billing.

• Authorization information will be conveyed to the provider within 24 hours of the Initial Registration Review submission.

Continued Stay Review:

These reviews are required if the hospital assesses that continued treatment beyond 3 days is medically necessary.  Another Continued Stay Review is required each time the hospital assesses that continued treatment is necessary, for an existing episode of treatment.  In other words, the hospital may submit multiple Continued Stay Reviews, depending on the length of stay.

• APS Healthcare strongly encourages hospitals to use APS CareConnection® to both submit reviews and to download authorization data.

• The provider must submit the Continued Stay Review to APS Healthcare no later than the last day of the existing authorization.

• See the Continued Stay Review form for data requirements. 

• Authorization length will vary according to member clinical need.

Discharge Review:

Within one (1) business day of the day that the member is discharged from the facility, the hospital must submit a discharge review to APS.  The discharge must be submitted if a member has been registered for admission, whether or not a continued stay review was submitted.

Spring Harbor & Acadia Hospitals Only; Non-compensated Inpatient Adults:

• Submit a de-identified Initial Courtesy Review within one (1) day of admission.  

• Please complete member information screen according to the process attached below.  Important:  Enter each data element as described in the attached process (e.g. DOB is always 01/01/2001).

• If the length of stay extends beyond the Initial Courtesy Review authorization end date, a Courtesy Continued Stay Review must be submitted.  Continue to submit Courtesy Continued Stay Reviews as long as the person remains inpatient.

• Within one (1) business day of discharge, submit a Discharge Review by choosing and completing a “discharge” in the “Search Services” screen in APS CareConnection®.

For the Two IMD’s Only:  Acadia and Spring Harbor Hospitals:

• Process to Submit De-Identified Courtesy Reviews in Care Connection for Non-Compensated Adults