This section of Maine's MaineCare Benefits Manual governs Developmental and Behavioral Evaluation Clinics, which provide multidisciplinary developmental/behavioral evaluations, child abuse evaluations, and Foster Care Comprehensive Health Assessments (CHAs) for members from birth through age 20. Operators must ensure services are delivered by appropriately licensed staff under physician supervision, maintain complete clinical records for each member, and bill in accordance with Department instructions and the MaineCare fee schedule. The regulation sets eligibility criteria, covered and non-covered services, staffing qualifications, and reimbursement rates for these clinic-based evaluation services.
View official sourceTABLE OF CONTENTS PAGE 23.01 DEFINITIONS. 1 23.01-1 Developmental and Behavioral Evaluation Clinic 1 23.01-2 Approved Staff Members 1 23.02 ELIGIBILITY FOR CARE 1 23.02-1 Birth through age twenty (20) 1 23.02-2 Children in the care and custody of the Department 1 23.03 DURATION OF CARE 1 23.04 COVERED SERVICES 1 23.04-1 Developmental and Behavioral Evaluation 2 23.04-2 Child Abuse Evaluation 2 23.04-3 Foster Care Comprehensive Health Assessment (CHA) 3 23.05 NON-COVERED SERVICES 7 23.05-1 Academic 7 23.05-2 Vocational 7 23.05-3 Socialization & Recreational Services 7 23.06 POLICIES AND PROCEDURES 8 23.06-1 Setting 8 23.06-2 Professional Staff 8 23.06-3 Member’s Record 8 23.06-4 Program Integrity 8 23.07 REIMBURSEMENT 9 23.08 BILLING INSTRUCTIONS. 9 23.01 DEFINITIONS -6032501397000 23.01-1 Developmental and Behavioral Evaluation Clinic means a clinic that provides Developmental and Behavioral Evaluations, Child Abuse Evaluations, or Foster Care Comprehensive Health Assessments for members aged birth through twenty (20) years. A Developmental and Behavioral Evaluation Clinic may operate as a sub-unit of an existing agency and shall be licensed by the Department of Health and Human Services (DHHS or Department) to provide outpatient therapy services. 23.01-2 Approved Staff Members means licensed professional staff who are employed directly by a Developmental and Behavioral Evaluation Clinic, as well as appropriate licensed professionals providing covered services by consultant arrangement, subcontract, or cooperative agreement with a Developmental and Behavioral Evaluation Clinic. Foster Care Comprehensive Health Assessment Services may be provided by Approved Staff Members or by other qualified professionals in accordance with this Section. 23.02 ELIGIBILITY FOR CARE Members must meet the basic eligibility criteria as set forth in Part 2 of the MaineCare Eligibility Manual, 10-144 CMR Chapter 332. 23.02-1 Birth through age twenty (20). Members aged birth through twenty (20) are eligible for Developmental and Behavioral Evaluations and Child Abuse Evaluations as set forth in this section. 23.02-2 Children in the care and custody of the Department. Members aged birth through eighteen (18) who enter the care and custody of the Department are eligible for Developmental and Behavioral Evaluations, Child Abuse Evaluations, and a Foster Care Comprehensive Health Assessment (CHA) as set forth in this Section. 23.03 DURATION OF CARE Each member is eligible for covered services which are medically necessary and are provided within the maximum number of reimbursable evaluations as stated in this Section. The Department reserves the right to request additional information to evaluate medical necessity. 23.04 COVERED SERVICES The following services are covered when provided by Approved Staff Members of a Developmental and Behavioral Evaluation Clinic and billed by that clinic. The Foster Care Comprehensive Health Assessment is covered when provided by Approved Staff Members or otherwise qualified professionals in accordance with this Section. 23.04 COVERED SERVICES (cont.) Covered services must be provided under the direction of a physician. 23.04-1 Developmental and Behavioral Evaluation is a Multidisciplinary Evaluation of social interaction, communication, stereotyped patterns of behavior and includes evaluation of other associated developmental and behavioral problems. The evaluation is conducted by a multidisciplinary team that consists of a Psychiatrist and either a Licensed Psychologist or a Psychological Examiner. If a Licensed Psychologist is not part of the team, the team must also include a Licensed Clinical Social Worker or Licensed Clinical Professional Counselor. The Developmental and Behavioral Evaluation components may include a Psychosocial Assessment, a Psychological Evaluation and testing, clinically appropriate interviews and observations scales to assess for Autism Spectrum Disorders, and a Psychiatric Evaluation. The Developmental and Behavioral Evaluation may, at times, also include, speech/language, occupational therapy, and physical therapy assessments. The Developmental and Behavioral Evaluation team consults to summarize the member’s functional strengths and limitations to establish diagnosis(es) and to prepare recommendations for treatment or service. The Developmental and Behavioral Evaluation team communicates its findings to the parent or guardian and if clinically appropriate, the member. The findings are also summarized in a written report provided to the parent or guardian. Developmental and Behavioral Evaluations are limited to two (2) per member per year. Each Developmental and Behavioral Evaluation is limited to fourteen (14) hours/units per evaluation. 23.04-2 Child Abuse Evaluation means an expert forensic evaluation of a member which is conducted under the direction of a board certified pediatrician who is a trained specialist in child abuse assessment. The purpose of the Child Abuse Evaluation is to evaluate the existence and extent of any child abuse or neglect and the emotional, physical, and behavioral effects of such abuse or neglect. The Child Abuse Evaluation is a multidisciplinary evaluation. The Child Abuse Evaluation must be performed by the following licensed professionals: child abuse pediatrician; nurse practitioner or an equivalent provider; and licensed clinical social worker or an equivalent provider. The Child Abuse Evaluation must include a detailed psychosocial intake including contact with the Department, Law Enforcement, and the member’s Primary Care Physician (PCP), detailed medical examination as appropriate, clinical interview with the member and parent, medical history, and psychological testing if necessary, and review of medical records. There shall 23.04 COVERED SERVICES (cont.) be a final team meeting(s) to determine diagnosis, finalize conclusions regarding abuse and neglect and make recommendations regarding care, treatment, and safety plans. In addition to aiding in the provision of medically necessary services to the member, the purpose of the Child Abuse Evaluation is to produce a diagnosis and treatment recommendations that may be introduced into evidence in a child protective, criminal, or other court proceeding. Child Abuse Evaluations are limited to two (2) per member per year. The Department shall submit to CMS and anticipates approval for a State Plan Amendment for this provision: 23.04-3 Foster Care Comprehensive Health Assessment (CHA) is a medically based, interdisciplinary comprehensive health evaluation of a child in the Department’s care. CHA Provider Requirements CHAs may be provided within a Developmental and Behavioral Evaluation Clinic or by other qualified providers who are not practicing in a Developmental and Behavioral Evaluation Clinic. A Board-certified pediatrician, family physician, physician assistant, or pediatric or family nurse practitioner must complete the medical exam component of the CHA. A licensed psychologist, licensed clinical social worker, or a licensed clinical professional counselor must complete the psychosocial evaluation component of the CHA. Providers of the CHA must: Be licensed professionals acting within the scope of their licensure; Have at least one (1) year of documented experience providing comprehensive, trauma-informed care for infants, children and adolescents; and Must have at least one (1) year of documented experience in one (1) or more of the following areas: Child abuse, child neglect, and sexual abuse of children; 23.04 COVERED SERVICES (cont.) Developmental and behavioral issues of infants, children, and adolescents; Family dynamics and their effects on children; or The effects of foster care placement on children and families. B. CHA Components CHAs include the following five (5) components: Intake Intakes must include the following: Incorporating Departmental records into the member’s medical records; Scheduling the CHA appointment, including the medical exam and psychosocial evaluation, to occur within fourteen (14) calendar days of the referral unless there are unforeseen and uncontrollable circumstances, such as inclement weather or illness, that prevent the appointment from occurring. If the appointment occurs after fourteen (14) business days from the referral, the provider must document the justification for the delay in the member’s record; Providing information about the CHA to the child’s caregiver; and Notifying the Department about the date and time of the CHA. 2. Medical Exam Component The medical exam component must include the following: An in-person, face-to-face examination of the child; Review of the child’s records concerning reasons for entering the care and custody of the Department, including but not limited to the preliminary protection order, medical records, mental health records, and school records; Review of all available medical records, including past medical history, current medical needs and dental problems, medications, 23.04 COVERED SERVICES (cont.) allergies, and immunizations, as well as health history of acute or chronic health concerns; d. Compilation and review of the member’s medical information, concerns, and needs from the member’s caregiver. If the provider determines it appropriate, the provider may interview the member’s birth parent(s) to obtain relevant medical history; and A written medical exam report that includes the following: Findings from the medical exam, including the dates of administered and recommended laboratory, oral health, hearing, and vision screenings; recommendations for medical or remedial interventions and related follow up treatment; and a summary of the child’s past medical history. 3. Psychosocial Evaluation Component The length of the psychosocial evaluation is dependent upon the age of the child and number of caregivers interviewed. The psychosocial evaluation must include the following: i. An in-person, face-to-face interview with the child regarding, as clinically appropriate, history of trauma, social and educational functioning, family and/or caregiver relationships. The provider may conduct the psychosocial evaluation virtually if it is for the benefit of the child, and providers must document the justification in the member’s record. Providers cannot conduct a virtual psychosocial evaluation for their own benefit or convenience. The maximum time for the interview for the child and foster parent(s) is two (2) hours; Review of the child’s records, including early intervention services, education, and mental health records, as applicable; Appropriate screenings and assessments as determined by the evaluator; and A written psychosocial evaluation report that includes the following: the child’s strengths; assessments performed with dates administered and scores; past and current psychosocial information gathered through interviews listed in this section; 23.04 COVERED SERVICES (cont.) and recommendations for treatment and/or further evaluations, if determined appropriate by the evaluator. The psychosocial evaluation may include the following: Interviews with birth parent(s) when appropriate. The maximum time for the interview with birth parents is two (2) hours. These interviews may be completed in conjunction with the medical provider; A trauma screening or assessment to determine the impact of abuse and neglect experienced by the child; and Cognitive, adaptive, academic skills assessments and cognitive testing. In determining whether to include these components in the psychosocial evaluation, the evaluator shall take into account the age of the child and current concerns about the child’s medical and psychosocial health. 4. CHA Final Report Those providers who complete the medical and psychosocial components of the CHA must jointly discuss the member’s needs at a child team meeting and complete a final written report. The report must be submitted to the Department no later than twenty-one (21) calendar days after the CHA is complete. The report must include: The child’s medical records used in the medical exam and psychosocial evaluation; The medical exam report, including summaries of all components of the evaluation identified in this section; The psychosocial evaluation report, including summaries of all components of the evaluation identified in this section; and Recommendations informing the child’s foster parents, caregiver(s), providers, and DHHS caseworker(s) about trauma-informed care to enhance the child’s adjustment and development. 23.04 COVERED SERVICES (cont.) Strategies may include developmental and behavioral treatment and interventions. 5. Follow-up Evaluation Providers must conduct follow-up medical and psychosocial evaluations for members who remain in the care and custody of the Department between six (6) and eight (8) months after the initial CHA. The follow-up medical examination may only be conducted virtually if the findings from the initial examination indicate that a virtual follow-up is appropriate. After the follow-up evaluations, providers must submit reports to the Department that include the following: Results from a medical exam, which includes a review of records since the initial medical examination; Results from an updated psychosocial evaluation, the psychosocial portion of which is limited to a maximum reimbursement of five (5) hours; The member’s medical and psychosocial needs; and Recommendations for treatment that will be shared with the Department and the member’s caregiver. 23.05 NON-COVERED SERVICES 23.05-1 Academic. Any programs, services, or components of services provided to members which are academic in nature are not reimbursable by MaineCare. Academic services are those traditional subjects such as science, history, literature, foreign languages, and mathematics. 23.05-2 Vocational. Any programs, services or components of service provided to members of which the basic nature is to provide a vocational program not reimbursable by MaineCare. Vocational services are organized programs directly related to the preparation of individuals for paid or unpaid employment, such as vocational skills training, sheltered employment. 23.05-3 Socialization & Recreational Services. Any programs, services, or components of services of which the basic nature is to provide opportunities for socialization or recreation are not reimbursable under the MaineCare Program unless such services are provided as part of the member's service plan 23.05 NON-COVERED SERVICES (cont.) for which the specific goals and objectives must be specifically identified in that plan. These non-covered services include, but are not limited to picnics, dances, ball games, parties, field trips, and social clubs. 23.06 POLICIES AND PROCEDURES 23.06-1 Setting. The services described in this Section must be provided in settings which are appropriate to the member's needs. 23.06-2 Professional Staff. Developmental and Behavioral Evaluations, Child Abuse Evaluations, and CHAs are reimbursable services when provided by appropriately licensed providers acting within the scope of their licensure. Providers shall collect and retain copies of current licenses of professional staff and shall produce them for purposes of enrollment. 23.06-3 Member's Records. The Developmental and Behavioral Evaluation, Child Abuse Evaluation, and CHA services must be performed under the direct supervision of a physician and that fact must be documented in the member's record. There shall be a specific record for each member which shall include but not be limited to: A. The evaluation components provided, the provider(s) of each component, the goal(s) of the evaluation, and the method(s) or action(s) to achieve that goal. B. Complete results of all Developmental and Behavioral Evaluations, Child Abuse Evaluation, and CHA services, including reports of each individual assessment and reports of any consultations held. C. A closing summary signed and dated by the physician who supervised the Developmental and Behavioral Evaluation, Child Abuse Evaluation, and CHA service. The closing summary shall contain, at minimum: (1) reason for referral, (2) medical considerations, (3) functional strengths and limitations, (4) diagnosis(es), (5) recommendations. 23.06-4 Program Integrity A. The Division of Program Integrity monitors the medical services provided and determines the appropriateness and necessity of the services. 23.06 POLICIES AND PROCEDURES (cont.) B. The Department and its professional advisors regard the maintenance of adequate clinical records as essential for the delivery of quality care. In addition, providers should be aware that clinical records are key documents for post-payment audits. In the absence of proper and complete clinical records, no payment will be made, and payments previously made may be recovered in accordance with Chapter I of this Manual. C. Upon request, the provider must furnish to the Department, without additional charge, the clinical records, or copies thereof, corresponding to and substantiating services billed by that provider. D. The Department requires the clinical records and other pertinent information shall be transferred upon request with the member's signed release of information to other clinicians involved in the member's care. 23.07 REIMBURSEMENT The Department shall submit to CMS and anticipates approval for a State Plan Amendment related to this provision. A. Specific reimbursement rates are listed in the table below and on the MaineCare Provider Fee Schedule that is posted on the Department’s website in accordance with 22 MRS §3173-J(7). Covered Service Unit of Service 7/3/24 Rate Developmental and Behavioral Evaluation Per Hour $91.34 Child Abuse Evaluation Per Hour $209.48 CHA Initial Assessment Per Assessment $1,462.48 CHA Follow-up Evaluation Per Evaluation $357.01 B. In accordance with 22 MRSA §3173-J (2)(D)(3), every rate that did not receive a rate adjustment within the past twelve months will receive an annual cost-of-living-adjustment equal to the annual increase in the Consumer Price Index for Urban Wage Earners and Clerical Workers (CPI-W), for the Northeast Region, or its successor index, as published by the United States Department of Labor, Bureau of Labor Statistics or its successor agency, every July 1st. 23.08 BILLING INSTRUCTIONS Providers must bill in accordance with the Department's billing instructions for the CMS1500 claim form. 23.08 BILLING INSTRUCTIONS (cont.) CHA Billing Instructions 1. CHA Initial Assessment Bundled Payment Providers may bill for the CHA initial assessment once they submit the CHA final report. The bundled payment for the CHA initial assessment includes reimbursement for the medical exam component and the CHA final report. 2. CHA Follow-up Evaluation Bundled Payment Providers may bill for the CHA follow-up evaluation once they complete the follow-up evaluation and submit reports to the Department. The bundled payment for the CHA follow-up evaluation includes reimbursement for the medical exam component and the medical report. 3. CHA Psychosocial Evaluation Component Reimbursement Providers must deliver and bill for the services that make up the psychosocial component of the CHA in accordance with the applicable section of the MBM. Billing instructions are available upon request or from the Department’s website at: https://mainecare.maine.gov/Billing%20Instructions/Forms/Publication.aspx APAO ACCESSIBILITY CHECK: January 7, 2026 (no issues detected by agency of jurisdiction)