Attention Section 67, Nursing Facility Services: Bariatric Care Reimbursement
MaineCare is issuing this guidance to nursing facilities regarding the process for facilities to request durable medical equipment (DME) and/or authorization for reimbursement to meet extra staffing needs for residents with bariatric care needs.
To request reimbursement for extra staffing for bariatric care needs, the facility must submit a prior authorization (PA) request via the HealthPAS online portal, or by fax at 1-866-598-3963, or U.S. Mail: PA Unit, Office of MaineCare Services, 11 State House Station, Augusta, ME 04333. The request must include a supporting letter of medical necessity and clinical documentation from the treating provider. The letter of medical necessity must document:
1) The extent of the member's ability to participate in their own care (e.g. can the member weight-bear or perform any of their own activities of daily living independently or with assistance).
2) Whether the member requires a one-, two-, or three-person assist and why this level of assist is necessary.
3) The unique physical characteristics of the member that require the additional assistance (e.g. distribution of member’s weight).
4) The hourly rate being requested, including documentation of employee type and anticipated wages and labor hours that justify the requested rate.
To request DME to meet a resident’s bariatric care needs, nursing facilities should contact a DME provider. If providers need assistance finding a DME dealer, contact the DME Provider Relations Specialist Shannon Beggs by email or phone at (207) 624-4012. The DME provider will submit a PA request to MaineCare via the HealthPAS online portal, or by fax at 1-866-598-3963, or U.S. Mail: PA Unit, Office of MaineCare Services, 11 State House Station, Augusta, ME 04333. MaineCare may approve bariatric equipment for a member residing in a Nursing Facility at an amount higher than the facility’s rate of reimbursement if the member meets the two criteria below. Any DME that MaineCare approves for a resident is that resident’s property.
1) The member meets the definition of being bariatric size specific to the requested equipment.
2) The DME provider can demonstrate that the requested equipment meets medical necessity requirements for the member.
For more information, please contact Provider Relations Specialist Bruce Cosgrove.