Guidance for Psychiatric Hospitals Seeking Prior Authorization (PA) for Mental Health Intensive Outpatient Services​

Jun 14, 2023

Psychiatric Hospital providers seeking to bill for Mental Health Intensive Outpatient (MH-IOP) Services under MaineCare Benefits Manual (MBM) Ch. II, Section 46.05-3 will be asked to submit PA requests through Atrezzo. Acentra Health (formerly Kepro) will review these requests in accordance with the substantive standards for MH-IOP services adopted in the November 9, 2022, revision of MBM Ch. II, Section 65 (Behavioral Health Services). Specifically, Section 65.05-5 now details MH-IOP service and staff requirements, including delivery of services for at least three hours per day, three days per week, under the direction of a physician or psychiatrist, and consistent with Evidence-Based Practices. The rule specifies staff training and credentialing requirements, as well as service-specific member eligibility criteria for the different categories of IOP services.     

Once Acentra Health has issued its PA, Section 46 providers will continue to be able to bill for MH-IOP services under their current enrollment, without the need to obtain a Mental Health Agency license or enroll as a Section 65 provider. This approval process is consistent with past practice and with current provisions of MBM Section 46, which allows psychiatric hospitals to deliver outpatient services, defined as "a planned combination of diagnostic, treatment and rehabilitative services provided to mentally or emotionally disturbed members in the hospital setting on a less than twenty-four (24) hour a day basis." See 46.01-7. Section 46.03-3 further specifies that "For outpatient services to be covered by MaineCare the member must need treatment similar to or more active or inclusive than is available through a weekly visit to a mental health agency, psychologist or psychiatrist, but not need partial or full-time hospitalization”. See also 46.05-3, describing Outpatient Services and noting that reimbursement is available only as documented in the treatment plan for an individual member, subject to approval and Utilization Review by the Department and its Authorized Agent. Further information regarding reimbursement for outpatient services can be found in MaineCare Benefits Manual (MBM) Ch. II, Section 45.09-1(B).  

The Department’s preference is for MH IOP providers to enroll and bill under Section 65; however, given that current rule language as cited above allows for provision under Section 46 and reimbursement under Section 45, and given the need to expand access to these services, the Department will continue to allow provision under Section 46 and billing under Section 45 until such time as we update those rules. We will apply the criteria included in Section 65 for these services as part of the approval and utilization review process called for in Section 46 and have the PA process run through Atrezzo to ensure consistency of substantive standards across provider types.   

The Department will issue further guidance when the Atrezzo portal is ready to receive these PA requests. 

For questions, please reach out to Provider Relations Specialist Tiffany Norton.