C.M.R. 10, 144, ch. 101, ch. I, § 144-101-I-1, subsec. 144-101-I-1.11

Current through 2024-51, December 18, 2024

Subsection 144-101-I-1.11 - PAYMENT PROCESS

1.11-1Payments

The Office of the State Treasurer issues all payments. A Remittance Advice (RA) is generated with each payment showing the payment or denial of specific claims. Payment will be made by Electronic Fund Transfer (EFT), unless the provider is unable to accept payment in this manner. In those cases the Office of the State Treasurer shall provide an alternative method of payment.

1.11-2National Correct Coding Initiative Edits

A. MaineCare will perform National Correct Coding Initiative (NCCI) Edits on all outpatient UB-04 and 1500 claims forms. There are two (2) types of NCCI edits:

1. Procedure-to-Procedure (PTP) Edits define pairs of HCPCS and CPT codes that should not be reported together.

2. Medically Unlikely Edits (MUEs) define the maximum units of service for each HCPCS and CPT code that a provider would generally report for a single patient on a single date of service.

B. MaineCare will reject claims not in conformity with NCCI requirements.

1.11-3Rejected Invoices

If the claim is rejected due to invalid or incomplete information, no reimbursement is made. Rejected claims will be identified either during the claim submission process or on the RA and will include a reason for the rejection. A correct claim must be resubmitted within the time limits previously stated in Section 1.10-2 before payment will be considered.

If a covered service was denied payment, or an incorrect amount was paid due to a billing or processing error, providers must follow appropriate billing instructions issued by the Department (see Section 1.12).

1.11-4Payments and Denials for all Third Party Payers, Including Medicare

Providers shall bill the appropriate third party payer, including Medicare, for those MaineCare members also covered by the third party payer. Providers are to comply with the most current billing instructions as made available by the Department.

C.M.R. 10, 144, ch. 101, ch. I, § 144-101-I-1, subsec. 144-101-I-1.11