C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-71, subsec. 144-101-II-71.07

Current through 2024-51, December 18, 2024

Subsection 144-101-II-71.07 - REIMBURSEMENT AND BILLING INSTRUCTIONS

71.07-1Reimbursement Methodologies

The following reimbursement methodologies set the rates for each session and performance payment:

A.Session Rate. The allowed amount for each National DPP LCP session is 100% of Medicare's current total reimbursement for all sessions without weight loss included in the MDPP divided by the total number of sessions required by the most current version of the DPRP Standards.

B.Performance Payment. The allowed amount for each performance payment is 100% of Medicare's current maximum reimbursement for additional payments related to weight loss in the MDPP divided by two (2).

Specific reimbursement rates for each session and performance payment are listed on a fee schedule, which is posted on the MaineCare Health PAS Online Portal in accordance with 22 MRS § 3173-J(7).

71.07-2Sessions

Providers shall bill 0403T for each in-person session and bill 0403T with the GT modifier for sessions delivered through telehealth, e.g. online and distance learning sessions, as defined in the DPRP Standards. In accordance with the number of required National DPP LCP sessions, Providers may bill 0403T for each participating member up to twenty-two (22) times within the rolling calendar year that starts from date of the first National DPP LCP session they attend. Providers that accept a transfer participant from another program may submit a prior authorization to exceed the annual limit by the number of additional sessions the member must attend to complete the program.

71.07-3Performance Payments

Providers are eligible for two performance payments for each participating member. Providers shall record all weight measurements and HbA1c test results that justify performance payments in the member's record.

A.First Performance Payment. Providers may bill G9880 once for the first performance payment for each member who achieves one of the following:

1. At least 5% weight loss from the first recorded weight compared to the weight recorded at any session during months seven (7) to eleven (11); or

2. At least a 0.2% reduction in HbA1c achieved at any point during months seven (7) to eleven (11) as compared to the HbA1c level indicated by a test taken no more than twelve (12) months prior to the date of the first session.

B.Second Performance Payment. Providers may bill G9880 once for a second performance payment for each member who achieves one of the following:

1. At least 5% weight loss from the first recorded weight compared to the weight recorded at the twelfth month session; or

2. At least a 0.2% reduction in HbA1c achieved at any point during the twelfth month as compared to the HbA1c level indicated by a test taken no more than twelve (12) months prior to the date of the first session.

The twelfth month performance payment is billable regardless of whether the member met the minimum 5% weight loss or the minimum 0.2% reduction in HbA1c required for the first performance payment in months 7-11. Providers may bill both performance payments regardless of the number of sessions members attend, as long as the weight loss or HbA1c reduction is achieved during the applicable program month(s).

71.07-4Billing Instructions

Providers must bill in accordance with the Department's billing instructions on the MaineCare Health PAS Online Portal.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-71, subsec. 144-101-II-71.07