Children's Behavioral Health
Children’s Residential Treatment Prior Authorization Process
Prior Authorization Process (Word*)
***It is important to note that this process must be followed during all new admissions, including for youth who are currently in a residential program. Treatment and Room and Board funding will not be available without authorization through this process.
When there is a discussion within a youth's team regarding Residential Treatment, the case manager/caseworker will review/explore minimally the following (see Residential Treatment Consultation Guide).
If the youth's team decides to further pursue Residential Treatment, the child's case manager/caseworker must call the Office of Child and Family Services (OCFS) Mental Health Program Coordinator (MHPC). In cases where the youth is currently in a residential program, the call would be made to the Clinical Care Specialist (CCS) and they will be the point person through the process. The discussion will include a review of information on the Residential Treatment Consultation Guide. The MHPC/CCS may request to attend a meeting either in person or by phone. If the MHPC/CCS does attend a team meeting, the case manager/case worker supervisor must also be in attendance.
If residential treatment appears indicated, the youth's case manager/caseworker completes the Residential Treatment application with the legal guardian(s) and collects the required clinical documentation referenced in the application packet. The case manager/case worker will review the entire application and clinical documentation with the legal guardian(s), youth (14 and older - if younger as appropriate) and case manager/case worker supervisor. Then the application will be signed and submitted to the MHPC/CCS within 5 business days from the decision of the team to submit an application.
After the complete application is received, 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 after the day of receipt. If more information is requested, a letter will be sent specifying what information is needed. The guardian/case manager will have 7 business days to provide the information. If the information is not received, an administrative denial will be issued.
A.) If medical necessity is met, the child's case manager/case worker and identified contacts listed on application will be notified by phone and/or a password protected prior authorization letter via email or fax. A hard copy will also be mailed to the guardian.
B) If it is determined that medical necessity is not met, the child's case manager/case worker and identified contacts listed on the application will be notified by the OCFS Clinical Care Specialist by phone and/or a password protected email when email addresses are available. A letter to the guardian and case manager/caseworker will follow in the mail regarding treatment recommendations and appeal rights.
If OCFS Determines that your child meets eligibilty criteria:
- The case manager/case worker will review the eligibility letter and recommended programs with the family and decide which programs to pursue.
- The case manager/case worker will contact the residential treatment provider(s). Within two business days of receiving the eligibility letter, the case manager/case worker will send the OCFS eligibility letter, Residential Treatment application packet and agency specific documentation to the family's choice of residential providers.
- Within 7 business days of receiving the referral materials, the residential treatment provider will review all documentation and conduct a face to face interview as necessary. If the residential treatment provider can meet the youth's treatment needs, they will contact the Clinical Care Specialist (CCS) to give notice of acceptance, name of residential treatment location, and potential admission date. The Clinical Care Specialist will send a final authorization letter which will include the level designation.
- If the residential treatment provider can meet the youth's treatment needs, admission shall occur with in 7 business days of acceptance.
- On the day of admission, the residential provider must contact the CCS to request prior authorization (PA) be submitted to APS. The CCS will submit a PA with in 1 business day of receiving a phone call from the residential provider. The prior authorization and payment will begin on the day that the Clinical Care Specialist is notified that admission has occurred. Notification can be in the form of an email or voicemail and can be left at any time of day. The Clinical Care Specialist will then enter the PA within 24 business hours of the notification being received. If OCFS does not receive notification on the day of admission, the PA and respective payment will not begin until the date they are notified.
- APS 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 for the residential provider to access..
OCFS Regional Contact Information:
Mental Health program Coordinators
Richard Meagher - All youth in Sagadahoc & Oxford County, and DOC involved youth in Androscoggin &Franklin County
39 Western Ave South Paris, Me 04281
Phone: (207) 743-3924,
FAX: (207) 743-5219,
Marjorie Kosalski - All youth in Waldo, Knox, & Lincoln County and DOC involved youth in Somerset & Kennebec County
320 Water St., 180 State House Station, Augusta, ME 04338
Phone: (207) 287-3575,
FAX: (207) 287-5299,
Jeffrey Leonard - All youth in Washington County and DOC involved youth in Hancock, Piscataquis, Penobscot & Aroostook County
DOC Juvenile Services, 10 Franklin Street, Bangor, ME 04401
Phone: (207) 941-3140,
FAX: (207) 941-3132,
Clinical Care Specialists:
- Mental Health Program Coordinators:
- Clinical Care Specialists:
updated May, 2013