Children's Behavioral Health Services

Children’s Residential Treatment Prior Authorization Process

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***It is important to note that this process must be followed during all new admissions and when a youth is being moved from one facility/building to another even if the facility/building is within the same agency.

  1. When there has been discussion within a child’s team about the potential of residential treatment for a child, the child’s case manager/caseworker must call the Office of Child and Family Services (OCFS) Mental Health Program Coordinator (MHPC).  At this time, the MHPC will discuss with the case manager/case worker the history leading up to the discussion around residential treatment.  This discussion will include a review of treatment services as well as use of natural supports.  The OCFS Mental Health Program Coordinator may request to attend a team meeting.
  2. If residential treatment appears indicated, the child’s case manager/case worker completes the Intensive Temporary Residential Treatment Application with the legal guardian(s) and collects the required clinical documentation referenced in the application packet.  The application and clinical documentation will be submitted to the OCFS Mental Health Program Coordinator. 
  3. Once a completed application with all required documentation is received by the Mental Health Program Coordinator, a review occurs to determine medical necessity utilizing the Mainecare Benefits Manual Chapter II, Section 97, Medical Eligibility Criteria for Residential Treatment.  This review may take up to 2 full State of Maine business days (if the application and clinical documentation are received after 3PM, it is considered received at the start of the next State business day).
    1. A.)  If it is determined that the child meets medical necessity for residential treatment, the child’s case manager/case worker will be notified by the OCFS Mental Health Program Coordinator by telephone and if there are e-mail addresses on the application there will be a brief e-mail sent simply stating that there has been authorization of residential treatment for the child (with the e-mail containing the child’s initials only) and the recommended residential programs.  The OCFS Clinical Care Specialist (CCS) will also send an authorization letter to the legal guardian(s) and case manager/case worker with recommendations of specific residential treatment programs included.  If there is disagreement by the community team about the recommended residential treatment provider(s), the MHPC must be contacted to pursue further discussion around this so that other recommendations can be made if appropriate.  There may be providers that are preferred by youth/family.  If preferred programs are full, the type of treatment provided doesn’t meet the need of the child, the ages of the other children at the program are too young/old, etc., the youth and family team must consider other residential treatment providers.  Move on to step #5 of this process. 
      OR
    2. If it is determined that the child does NOT meet medical necessity for residential treatment, the child’s case manager/case worker will be notified by the OCFS Clinical Care Specialist by telephone, and if there are e-mail  addresses on the application there will be a brief e-mail sent simply stating that residential treatment has not been authorized utilizing the child’s initials only. The OCFS Medical Director will also send a letter outlining the recommended treatment options and stating that the child does not meet medical necessity for residential treatment.  There will be appeal rights attached to this letter.  This process would end here.

  5. The legal guardian(s) along with assistance from the case manager/case worker as necessary will contact the recommended residential treatment provider(s) listed on the OCFS authorization letter.  The OCFS authorization letter and Residential Treatment Application along with any other required documentation that the residential treatment provider requires will be submitted directly to the residentia treatment agency by the legal guardian(s) and case manager/case worker.
  6. The proposed residential treatment provider will then review all documentation available and conduct a face to face interview as appropriate with the child and   family/guardian(s). 
  7. The residential treatment facility will contact the OCFC Clinical Care Specialist when they have determined that the child is clinically appropriate for their facility and the CCS will then give final authorization for the child to be admitted to the designated residential treatment provider via a faxed letter to the residential provider that identifies a Mental Health or Intellectual Disabilities/Pervasive Developmental Disorder designation and level I or II designation with rate.  If the residential treatment agency is in disagreement with the level designation/rate, the agency can appeal using the process specified in the Mainecare Benefits Manua Chapter I, Provider Appeals.
  8. The authorized residential treatment provider will contact the OCFS Clinical Care Specialist on the day of admission to the facility to request Prior Authorization be entered into the APS Care Connection system.  The Clinical Care Specialist will confirm with the provider what the correct Billing ID is.
  9. The OCFS Clinical Care Specialist will enter the child into APS Care Connection within 1 state business day of being informed of the admission date to the residential facility.  This entry into APS Care Connection is a Prior Authorization submission and will include the provider’s Billing ID, Location, room and borad code if appropriate, designation of level within residential treatment, and relevant clinical information used to make the level of care determination.
  10. The APS Care Manager will confirm the OCFS prior authorization, process the review, and assign the PA number from MIHMS.  The PA number will then appear in the Download Notification within APS Care Connection.
  11. An initial individualized treatment plan will be submitted to the OCFS Clinical Care Specialist by the residential treatment provider within the first 3 weeks post admission to the residential treatment facility.  The OCFS CCS will review the   treatment plan within 3 days of receiving it and may suggest changes to the agency.  The CCS is looking for the following in an initial treatment plan:
    1. Treatment focusing on the specific reason the child was approved for residential treatment.  Treatment modalities being used should be specified.
    2. Clear statement of why the child requires this level of care for treatment.
    3. Individual goals and objectives for the child, family goals and objectives, and who is responsible to deliver these services.
    4. Clear discharge criteria, including a tentative discharge date.
    5. Clear transition plan that notes how reintegration back into the community will occur over time with target dates (i.e. so many visits and treatment sessions at the program; so many day visits at home with treatment with clinician processing these visits, so many overnights with treatment with clinician processing these visits, etc.)
  12. The OCFS Clinical Care Specialist will be involved as needed once the child is admitted to the residential treatment facility with the purpose of assisting with difficult discharges which may be related to a variety of barriers. 
  13. APS Healthcare will be utilized for continued stay requests for any child in residential treatment.  When the first continued stay request is due, the residential treatment provider will extend off of the Case ID (PA) that OCFS created at the time of admission.
  14. The residential treatment provider is responsible for submission of any Continued Stay Requests and discharges in APS Care Connection.

General Information Related to this Process:

  • The OCFS decision making process for Prior Authorization of Residential Treatment may take up to 2 full state business days once a completed application with clinical documentation is received (if a completed application is received after 3PM, it is considered to be received on the next state business day).    
  • If an application is submitted to OCFS and there is insufficient clinical documentation making it impossible to make a medical necessity determination, a letter requesting more information will be sent to the guardian and case manager/caseworker.  This will allow the missing documentation to be submitted within 7 business days.  If the missing documentation is received within 7 business days, the application will be reviewed and a decision will be given.  If the missing documentation is not received within 7 business days, the application will be considered administratively denied, and a new application with documentation would need to be submitted in the future as appropriate.
  • If a child is authorized for residential treatment and the child does not enter residential treatment within 60 days of this authorization, a “Request for Extension of Approval of Intensive Residential Treatment Services” form (attached to all authorization letters sent out to legal guardian(s) and case managers/case workers) must be submitted to the OCFS Mental Health Program Coordinator.  This form must be faxed/post marked no later than 7 days prior to the end of the 60 days or OCFS may request a new application.  A decision will be made to either approve the request or require that a new application for residential treatment be submitted with attached updated clinical documentation.
  • Admission to a residential facility should never occur in the absence of this process.  Treatment and Room and Board funding are directly tied to being authorized through this process. 
  • All decisions for approval of residential treatment must be authorized by a Clinical Care Specialist.  In the event that the regional OCFS staff are unable to come to agreement on the most appropriate treatment option, the Clinical Care Specialist will present the case to the OCFS Medical Director who will review the case and make the final determination.  All decisions regarding a denial of residential treatment must be made by the OCFS Medical Director.   
  • The OCFS staff and APS Healthcare staff will be communicating around difficult situations/cases.
  • If there is a circumstance where increased staffing within a residential agency appears to be appropriate, the residential provider must contact the OCFS Clinical Care Specialist for potential prior authorization of the Temporary High Intensity Service within children’s residential treatment, and must follow the prior authorization and utilization review processes specific to this particular service.
  • The regional CBHS Team Leader should be contacted if concerns arise regarding this process.

OCFS Regional Contact Information:

Region 1 (Districts 1 & 2) –

Region 2 (Districts 3, 4, & 5) –

Region 3 (Districts 6, 7, & 8):