Utilization Management
Schaller Anderson Medical Administrators, Inc. (SAMAI) assumed responsibility for
review and authorization of certain clinical services on behalf of MaineCare.
The purpose of the Utilization Management program is to manage the use of health-care
resources so that members receive the most medically effective and cost-effective
health care, in the most appropriate setting, that will promote optimal health outcomes.
This responsibility requires the submission of the following services to SAMAI for
review:
In-state hospital admissions
- All acute care hospitals within the State of Maine must notify SAMAI of admissions
via a submission of a daily census.
- Management of the daily census results in concurrent review for inpatient admissions.
Out-of-state admissions
- Admission to an acute hospital or rehab facility requires prior authorization unless
an emergency.
- Many out-of-state hospitals submit notification of admission to SAMAI via a daily
census.
- Management of the daily census results in concurrent review for inpatient admissions.
Out-of-state outpatient services
- All out-of-state consultations and outpatient services require prior authorization.
Home health services
- SAMAI conducts concurrent review/utilization review of home health services for
adults and children as specified in Section 40 of the MaineCare Benefits Manual
- All active, new and recertification requests should be submitted within five (5)
working days of being opened.
Private duty nursing for children
- Private duty nursing for members up to 18 years of age as specified in Section 96
of the
MaineCare Benefits Manual
- All active, new and recertification requests should be submitted within 72 hours
of completion of assessment
- Request for recertification must be submitted prior to expiration of existing approval
Outpatient therapy for adults
- All requests, including the plan of care/treatment plan and any documentation supporting
the medical necessity and rehabilitation potential, should be submitted to SAMAI
within one (1) business day of evaluation
Certain podiatry procedures
- MaineCare requires prior authorization of targeted podiatry procedures
- See the Procedure Code Lookup at
http://oms.maine.gov for codes and coverage.
The member's in-state care provider is responsible for initiating and coordinating
a request for authorization. The requesting provider is responsible for complying
with MaineCare’s prior authorization requirements, policies and request procedures
and for obtaining an authorization number where necessary. Providers must verify
that any required authorization has been obtained before rendering service to a
recipient.
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