TCM for Children with Chronic Medical Conditions Process Overview 11-24-09

1. Effective 11/30/09, Targeted Case Management (TCM) for Children with Chronic Medical Conditions is subject to Prior Authorization (PA) and ongoing Continued Stay Review (CSR) by APS Healthcare, on behalf of DHHS.

2. This PA process begins 11-30-09 for all current members in this service, as well as all new admissions.

3. Providers are required to complete a Prior Authorization request for service through the APS CareConnection System. Prior Authorization requests must include complete information about diagnoses, functional limitations and Initial Service Plan. Members are eligible for TCM for Children with Chronic Medical Conditions if they meet the eligibility criteria described in the MaineCare Benefits Manual, Chapter 2, Section 13.

4. Functional impairments in the required domains must be assessed by a licensed Occupational Therapist or other approved professional.

5. Prior Authorization approvals are authorized for up to 30 days and 60 units. If the client is in need of additional TCM service beyond 30 days, the provider must submit a Continued Stay Review to obtain authorization from APS Healthcare.

6. An authorization is required for the following code in order for the providers to bill Mainecare.
   The procedure code for TCM for Children with Chronic Medical Conditions is:
   T1017 UB Case Management Services for Children with Chronic Medical Care Needs
   The Billing Unit for this code is: 15 minutes.

7. The Prior Authorization length of time and units for this service is 30 days and 60 units.

8. The Continued Stay Authorization will be no more than 90 days.

If you have questions, please contact Kelly Bickmore, Operations Director at 1‐866‐ 521‐0027.

Provider Registration with APS Healthcare and Access to APS CareConnection: Providers who are not yet registered with APS Healthcare please contact Sara Godfrey at 1‐866‐521‐0027.