Penguin Health
Maine · MaineCare · Adaptive behavior services
Maine's audit was so bad the state rewrote the rule
HHS-OIG audited MaineCare's autism services and found at least $45.6 million improperly paid, with session notes scored deficient in 94 of 100 sampled enrollee-months and billed time exceeding the notes in 92. Maine committed to repayment and statewide postpayment reviews, then repealed the audited rule and replaced it on April 29, 2026 with a new Section 28 that enumerates the progress note. The matching rule set lives in the rules library in the Penguin Health app.
At least, for CY2023, in audit A-01-24-00006 (January 2026).
With billed time exceeding the notes in 92, per the potentially-improper findings.
Section 28, Adaptive Behavior Services for Children, replacing the audited rule.
All four audit recommendations remain open.
The audit, then the rule
What OIG found, and what the new rule requires
The audit's biggest buckets were documentation: missing or unsigned assessments, session notes that failed the rule's own element list, notes missing entirely, units exceeding the time on the note, and non-therapy time (lunch, naps, breaks) billed straight through. Maine's response was structural: a new Section 28 whose stated purpose includes fixing "outdated, ambiguous, and inaccurate provisions," with the progress note enumerated in section 28.08-4. These rules cite the new rule; the audit is why it exists.
- Name, signature, and credentials of the delivering staff; the date, time, location, and staff-to-member ratio; the level of family participation (who, the nature of their involvement, and its duration); the treatment interventions provided; and the member's response, including progress and barriers against the ITP goals.
- No services between 8:00 p.m. and 6:00 a.m. without clinical justification and Department approval.
- Primarily academic, recreational, religious, vocational, or custodial services; family-delivered services; respite. The audit's non-therapy-time finding lives here.
- ABA direct care staff hold BHP or RBT certification; supervisors are BCBAs or licensed psychologists with behavior-analytic training.
- Within 30 days, reviewed every 90, with dated signatures of involved staff and the legal guardian.
- Community providers electronically verify service, member, date, location, provider, and start/end times.
The checklist
What a MaineCare ABS note has to show
Each item below names its section in the new rule and the Penguin rule that checks it. Maine sets no note-completion deadline, so none is claimed.
| The note shows | What that means in practice | Source | Rule |
|---|---|---|---|
| Name, signature, and credentials of the delivering staff | Who delivered the service, signed, with credentials. | §28.08-4 | ME-1 |
| Date, time, location, and staff-to-member ratio matching the billing | The ratio element is distinctive to Maine: the note states how many staff to how many members. | §28.08-4 | ME-2 |
| The family-participation block | Which family members were involved, how, and for how long, or that none participated. | §28.08-4 | ME-3 |
| The treatment interventions provided | Named interventions, not activity in the abstract. | §28.08-4 | ME-4 |
| Response, progress, and barriers against the ITP | How the member responded and where they stand against plan goals. | §28.08-4 | ME-5 |
| No unjustified night-hours billing | Billed time between 8:00 p.m. and 6:00 a.m. needs documented clinical justification. | §28.06 | ME-6 |
| No academic, recreational, or custodial content, no continuous non-therapy time | The audit's biggest potentially-improper bucket. An activity passes when the note names the therapeutic technique applied during it. | §§28.06, 28.10 | ME-7 |
| Units supported by the documented time | Billed time exceeded the notes in 92 of 100 sampled months; this is that check. | §28.08-4; ch. 1 records rules | ME-8 |
OIG also found identical notes across enrollee-months.
The assessment within 30 days with the supervisor's dated signature; the ITP within 30 days, reviewed every 90.
Adaptive behavior services bill under HCPCS codes (for example H2021) rather than the 9715x family.
In the rules library
Eight Maine rules, ready to turn on
Open the rules library in the Penguin Health app, choose MaineCare Adaptive Behavior Services, and click Add to organization. Rules your organization already has are left alone, so adding the set twice only fills gaps. After adding, edit any rule or add your own alongside them.
Each rule runs only on notes billed to MaineCare payers. Penguin checks the CentralReach payer name, so a Maine rule never fires on a commercial note in the same organization, and the payer and code matches get confirmed against your real billing strings when the set is added.
Penguin reads signed session notes from CentralReach, read-only, after signature and before the claim, and runs the set on every note. Deterministic rules compare record fields. AI rules are read by the AI, which returns a pass or fail with a one-sentence reason.
Eight rules for the new Section 28: the progress-note elements including family participation and staff ratio, the night-hours window, non-covered content, and units support.
- reviewed
- Oct 20, 2026
- runs on
- Notes billed to MaineCare payers
- sources
- 10-144 C.M.R. ch. 101, ch. II, §28, effective Apr 29, 2026
- watching
- The adopted-rule file and the Nov 19, 2026 OIG status update
Every failure ships with QA guidance for that program code: an educational email, numbered action steps, and a QA email pre-filled with the date of service and a link to the note. Each reviewer action is written to a write-once audit log with seven-year retention, which is the record you hand the postpayment reviewer Maine committed to sending. Billing Medicaid in more than one state? The rules library covers sixteen, including Massachusetts and New York.
Maintained by Penguin
We watch MaineCare so the rules never go stale
Maine replaced its rule once already this year, and all four OIG recommendations are still open. The Maine set is tied to the adopted rule, not to a template written once.
The Section 28 adopted-rule file and the OIG recommendation tracker. Penguin fetches the sources on a schedule and archives every revision.
We rewrite the affected rule, cite the filing that changed it, and date the review. The set shows its sources and review date in the library.
An updated rule runs in the next scheduled validation and on demand against notes you have already reviewed, so a changed requirement shows you exactly which past notes it touches.
- OIG issues A-01-24-00006
At least $45.6M improper; 100 of 100 sampled months carried improper or potentially improper lines; Maine commits to repayment and statewide postpayment reviews.
- An emergency eligibility rule
A level-of-care threshold added ahead of the full rewrite.
- The new Section 28 takes effect
Adaptive Behavior Services for Children: enumerated progress notes, the night-hours window, credential requirements, EVV.
LibraryME-1 through ME-8 are built against this rule.
- Maine set reviewed
Checked against the adopted rule. Current.
- WatchingNovember 19, 2026
The expected OIG recommendation-status update. When MaineCare amends the rule or issues documentation guidance, the set is updated and every organization using it gets the change.
Next step
Run a month of MaineCare notes through Penguin
Bring one month of adaptive behavior services notes. We add the Maine set from the rules library, run it, show every finding beside the rule section it maps to, and hand your QA lead the fix for each one. Or get a demo account and click through Penguin on your own time first.