C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-4, subsec. 144-101-II-4.07

Current through 2024-51, December 18, 2024

Subsection 144-101-II-4.07 - REIMBURSEMENT

Reimbursement for covered services shall be made as described below. The reimbursement rate is an all-inclusive rate and covers the facility costs described in 4.04(A).

4.07-1Reimbursement is based on a fee schedule. The fee schedule reimburses at the lower of

A. 100% of the lowest amount allowed by the Maine Medicare Part B carrier based on current Medicare rates; or

B. the provider's usual and customary facility charge.

In accordance with Chapter I of the MaineCare Benefits Manual, it is the responsibility of the provider to seek payment from any other resources that are available for payment prior to billing the MaineCare Program.

4.07-2Reimbursement for Multiple Procedures

When multiple procedures are performed in the same operative session, MaineCare will pay for the procedure that has the highest payment amount as final payment for all procedures performed. For purposes of this Section, an operative session is an ambulatory surgical visit in which one or more of the covered surgical procedures are performed.

4.07-3 Reimbursement of Physician Services for Covered Services in an ASC

Physician services for covered surgical procedures will receive separate payment under MaineCare Benefits Manual, Section 90, Physician Services. The reimbursement rate for services delivered with ASC as the Place of Service (POS) will receive the facility rate set forth in the physician fee schedule located at: https://mainecare.maine.gov/.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-4, subsec. 144-101-II-4.07