C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-90, subsec. 144-101-II-90.04
A covered service is a service for which the Department may make payment. The Department covers those reasonably necessary medical and remedial services that are provided in an appropriate setting and recognized as standard medical care required for the prevention and/or treatment of illness, disability, infirmity or impairment and which are necessary for health and well-being.
The Department will not give additional reimbursement to providers who are salaried by a hospital for services billed by the hospital and whose payment is included in the hospital cost report for services provided while a member is hospitalized as an inpatient or receiving outpatient services.
When a non-MaineCare provider covers the practice for a MaineCare provider and performs services, MaineCare will only reimburse the MaineCare billing provider. The MaineCare billing provider must maintain adequate records to document the actual rendering provider. The MaineCare billing provider is responsible for reimbursing the non-MaineCare provider.
Providers should direct any questions about coverage of particular services to the Provider Relations Unit prior to provision of the service.
The Department covers anesthesiology services when personally performed or medically directed by a rendering provider appropriately licensed or certified in the state in which he or she is practicing. All anesthesiology providers must practice only within the scope of his or her licensure or certification, and qualified to deliver treatment under this Section.
The physician shall not direct more than four (4) anesthesia patients concurrently and shall not perform any other services while he or she is directing the single or concurrent services so as to not violate Section 90.04-1(A)(2)(a) above.
MaineCare covers anesthesiology services by computing a price based on a basic value for each procedure, with time unit values added to administer the procedure. The Department assigns a basic value to specific procedures that require anesthesia. Time required to administer the anesthetic is then billed in one (1) minute units.
Billable anesthesia time starts when the anesthesia provider begins to prepare the patient for anesthesia services and ends when the anesthesia provider is no longer furnishing anesthesia services to the member, that is, when the member may be placed safely under postoperative care. Providers may include the time spent administering regional and local injections and placing catheters and other monitoring devices in billable time for the delivery of the anesthesia services. Providers should bill these procedures separately only when they are performed independently and not in conjunction with an anesthesia service.
MaineCare requires providers to use the latest HCPCS and Current Procedural Technology (CPT) procedure codes when billing for anesthesia services. These codes already have associated values assigned for each procedure and available modifiers to describe unusual situations. Providers should add the appropriate modifier identified in billing instructions.
MaineCare will reimburse a physician who is overseeing a CRNA at fifty percent (50%) of the amount allowed for physician services. This is in addition to the CRNA reimbursement.
MaineCare will reimburse anesthesia performed by certified registered nurse anesthetists (CRNAs) at seventy-five percent (75 %) of the amount allowed for physician services.
When billing for anesthesia for all non-surgical diagnostic, medical services, or dental services, providers should bill the appropriate code for the procedure, with the appropriate anesthesia modifier to indicate that anesthesia was provided for a procedure not usually requiring anesthesia.
MaineCare will make no allowance for topical anesthesia, local infiltration, or digital block anesthesia administered by the operating surgeon. When the surgeon provides regional or general anesthesia, the Department will reimburse for the basic anesthesia value without added time units.
Ophthalmologic procedures for diseases of the eye are covered when billed with appropriate CPT codes. Vision services must meet the guidelines detailed in MBM, Section 75, Vision Services.
Allowances for laboratory procedures apply to lab services provided by physicians or by independent laboratories. Providers must be willing to participate in proficiency testing. Tests that produce an index or ratio based on mathematical calculations using two (2) or more separate results may not be billed as separate tests, i.e., A/G ratio, free thyroxine index, etc.
MaineCare reimburses for tests that are frequently done as a group (panel) on automated equipment as a group under a single code in its reimbursement rate. For any combination of these tests, providers must bill the appropriate CPT code that correctly designates the tests included in the panel. MaineCare will reimburse no more than the price of the most appropriate panel for any tests performed individually on the same day.
Please refer to MBM, Chapter II, Section 55, Laboratory Services, regarding services provided in a physician's office and referrals for laboratory services.
MaineCare reimburses for obstetric services provided to a woman who is pregnant only when provided by a provider appropriately licensed or certified in the state in which he or she practices, practicing within their scope of that licensure or certification, and qualified to deliver services under this Section. Providers are expected to engage in collaborative management of individual members with appropriate consultation, referrals, and transfers of care including, but not limited to, transfer of care for the purpose of specialized treatment and admission to an approved MaineCare hospital, with such treatment including maternity services.
Obstetrical care services include antepartum care, delivery, postpartum care, and other services normally provided in uncomplicated maternity care. Antepartum care includes usual prenatal services (e.g., initial and subsequent history, physical examination, recording of weight, blood pressure, fetal heart tones, maternity counseling, etc.).
Delivery includes management of labor and vaginal delivery (with or without episiotomy, with or without forceps), or cesarean section, and resuscitation of newborn infant when necessary. Postpartum care following vaginal or cesarean section delivery includes hospital and office visits, including routine postpartum care and family planning education.
MaineCare covers treatment of medical complications of pregnancy (e.g., toxemia, cardiac problems, neurological problems, etc.) or other problems requiring additional or unusual services and requiring hospitalization.
When a non-MaineCare provider covers the practice for a MaineCare provider and performs obstetrical services, MaineCare will only reimburse the MaineCare billing provider. The MaineCare billing provider must maintain adequate records to document the actual rendering provider. The MaineCare billing provider is responsible for reimbursing the non-MaineCare provider.
MaineCare provides two methods for maternity care billing, global charge basis or per service charge basis. Providers may choose only one (1) of the two (2) methods for each delivery as set forth below:
MaineCare covers behavioral health services as defined below when provided by an individual appropriately licensed or certified in the state in which he or she practices, practicing within the scope of that licensure or certification, and qualified to deliver treatment under this Section.
The Department reimburses for behavioral health services as defined below. When the same provider performs two (2) services for the same member on any one day, MaineCare will reimburse for only one (1) service, at the higher payment rate of the two (2) services.
Providers must use appropriate CPT codes when providing psychotherapy services. MaineCare members receiving psychotherapy services under this section of the MBM are ineligible to receive comparable or duplicative services, during the same time period, except as otherwise noted in MBM, Chapter II, Section 14, Advanced Practice Registered Nursing (APRN) Services, Chapter II, Section 45, Hospital Services, Chapter II, Section 65, Behavioral Health Services, or Chapter II, Section 46, Psychiatric Hospital Services.
MaineCare reimburses for the following services:
Providers must keep clinical records that include, but are not limited to: the member's name, address, attending physician, other providers, and the member's history, diagnosis, and treatment plan, treatment documentation, and any discharge/closing summaries. The provider of the therapy service shall sign all entries.
Hospital admission is the initial hospital visit, comprehensive and complete diagnostic history, physical examination, preparation of hospital records, and initiation of diagnostic and treatment services.
Daily Care is the interval history, examination and treatment of members in an inpatient hospital setting. MaineCare will reimburse for as many inpatient hospital visits per week as are medically necessary.
Providers must include a personalized plan of care in the medical record that itemizes the type of behavioral health services needed; how the service can best be delivered; short and long-range goals; and a discharge plan.
Psychometric testing includes the administration of the test; the interpretation of the test; and the preparation of test reports. Providers do not have to include preliminary diagnostic interviews or subsequent consultation visits in the limits or rates for psychological testing.
MaineCare limits reimbursement for psychological testing sessions to no more than four (4) hours for each test, except for the following:
Chapter II, Section 101, of the MBM further details Medical Imaging Services, which are comprised of two parts:
MaineCare reimburses Computerized Axial Tomography (CAT) scans of the head and full body. MaineCare does not reimburse for repeat x-ray examinations of the same body part for the same condition required because of technical or professional error in the original x rays.
Drugs and biologicals must meet all the general requirements for coverage of items as incidental to a provider's services. MaineCare does not cover the dispensing of prescription and nonprescription drugs and biologicals to members.
To be reimbursable, a drug or biological administered by other than oral method in the office setting must meet all of the following criteria:
Providers must bill following the Department's billing instructions when billing for these codes. Although drugs must have an assigned J code to be eligible for reimbursement, providers must also indicate National Drug Code (NDC) codes on the claim in order to be reimbursed. MaineCare will not reimburse claims without both a valid J code and NDC.
MaineCare will not reimburse for provider administered drugs that are not rebateable under Section 1927 of the Social Security Act ( 42 U.S.C.A. § 1396r-8(a)) and implementing CMS regulations ( 42 C.F.R. § 447.500et seq.) unless the provider obtains Prior Authorization (PA). PA procedures can be found in Chapter 1 of the MBM. PA will not be granted for non-rebateable, provider administered drugs for which there are therapeutically equivalent alternatives that are rebateable. Instructions for billing, a crosswalk of J codes and a list of rebateable NDC codes are available on the MaineCare Services website at https://mainecare.maine.gov. Providers must bill acquisition cost only, excluding shipping and handling.
The Department shall submit to CMS and anticipates approval for a State Plan Amendment related to these provisions.
A "physician administered drug" must satisfy the criteria set forth in 90.04-7(A), but in addition, could include drugs administered orally in an office or other outpatient clinical setting.
If a physician-administered drug has an FDA-approved biosimilar equivalent that the Department has identified as more affordable, providers shall use the biosimilar drug. Annually, the Department shall identify drugs that have a more affordable FDA-approved biosimilar equivalent on the Biosimilar Preferred Drug List on the MaineCare Health PAS Online Portal. Physicians shall submit a PA request in order to administer the original drug.
Some physician-administered drugs may require PA to ensure members meet age, clinical, or other requirements.
More information on the PA process is in MaineCare Benefits Manual, Chapter I, Section 1. The MaineCare Health PAS Online Portal contains a complete list of physician-administered drugs that require PA and corresponding PA criteria sheets. Providers must make requests for PA on the Department's approved form and get approval prior to the date of service.
MaineCare covers orthopedic shoes when prescribed by a provider, but they may not be billed under physician services. The provision and billing of shoes must comply with the guidelines of MBM, Chapter II, Section 60, Medical Supplies and Durable Medical Equipment.
Providers may bill for those supplies needed in performing office procedures that are above and beyond what is usually used in a normal office visit. MaineCare reimburses acquisition cost only, excluding shipping and handling.
MaineCare reimburses for certain medical and durable medical equipment (e.g., essential prosthesis, braces, intermittent positive pressure breathing (IPPB) machines, oxygen, etc.) when prescribed. Providers providing this equipment must inform members of their freedom of choice to obtain these items from other suppliers. MaineCare shall not reimburse providers for both prescribing and supplying durable medical equipment to the same member unless the durable medical equipment is otherwise unobtainable or the item typically requires no maintenance or replacement during the period used by a member. If these circumstances do exist, reimbursement to the prescribing provider for also supplying an item shall be on the basis of the reasonable acquisition cost of the item to the provider.
Providers must maintain documentation of acquisition cost, including receipts and a copy of the original invoice, and make such documentation available to the Department upon request. Providers must also maintain documentation supporting the necessity of providing the supplies and/or equipment during the office visit. MaineCare shall not reimburse physicians for on-going medical supplies that are obtained through providers enrolled as Medical Supplies and Durable Medical Equipment Providers.
Residents with a medical license, locum tenens, and temporaries must enroll as rendering providers under a physician's group or as a hospital based professional in order for their services to be reimbursed by MaineCare.
MaineCare reimburses for preventive and routine physical examinations for children and adults. MaineCare does not cover physical exams performed solely for the purpose of school, sports, disability benefits, life or health insurance coverage, Workers' Compensation, the Driver Education and Evaluation Program (DEEP), work, or any other reason not related to medical necessity.
Except when medically contra-indicated, immunization(s) must be given at time of examination(s) as appropriate for age and health history.
MaineCare reimburses certain preventive services when using the following guidelines:
MaineCare covers Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services for children and young adults up to the age of twenty-one (21) when performed in accordance with the Bright Futures Guidelines for Preventive Child Health Supervision. Providers who elect to enroll as an EPSDT provider must also comply with MBM, Chapter II, Section 94, Early and Periodic Screening, Diagnosis and Treatment Services.
MaineCare covers initial and periodic comprehensive health histories and examinations for adults age twenty-one (21) and older. The frequency of routine physicals for adults must not exceed one time per twelve-month (12) period. Covered screening services include, but are not limited to, those recommended by the United States Preventive Service Task Force.
Providers should bill the preventive medicine evaluation and management procedure codes.
MaineCare reimbursement is available for physician services provided to a child under age twenty-one (21) only when the provider meets at least one of the following criteria:
Diabetes Self-Management and Training (DSMT) services for members with diabetes (any form) can be rendered by qualified organizations in Maine that have current National DSMT site recognition/accreditation, and have a current DSMT Letter of Understanding (LOU) with the DHHS, Maine CDC, Chronic Disease Prevention and Control Program. These rendering qualified provider organizations will be reimbursed when a provider furnishes these services to a MaineCare member whose physician has prescribed these services for the management of the member's diabetes.
The services consist of any/all diabetes education and support services outlined within the most current American Diabetes Association (ADA) - National Standards for Diabetes Self-Management Education and Support and Clinical/Medical Care Standards for people with diabetes (any form). See http://care.diabetesjournals.org.
DSMT cannot be reimbursed on the same day as Medical Nutrition Therapy services.
Medical Nutrition Therapy (MNT) services consist of nutritional assessments and interventions in accordance with nationally-accepted dietary or nutritional protocols. These services provided by rendering providers will be reimbursed when a provider furnishes these services to a MaineCare member whose physician has prescribed these services. Providers must be appropriately licensed or certified in the state in which he or she practices, practicing within the scope of that licensure or certification, and qualified to deliver treatment under this Section.
MNT cannot be reimbursed on the same day as DSMT services.
When employed in a physician's practice, services provided by the following professionals practicing within the scope of their certification and licensure are reimbursable:
Advanced Practice Registered Nurse (APRN); Audiologist; Certified Clinical Nurse Specialist (CNS); Certified Nurse Midwife (CNM); Certified Nurse Practitioner (NP); Certified Registered Nurse Anesthetist (CRNA); Dental Hygienist; Licensed Clinical Professional Counselor (LCPC); Licensed Clinical Psychologist; Licensed Clinical Social Worker (LCSW); Licensed Dietician; Licensed Marriage and Family Therapist (LMFT); Licensed Master Social Worker (LMSW); Licensed Professional Counselor (LPC); Nurse Practitioner (NP); Occupational Therapist (OT); Physician Assistant (PA); Physical Therapist (PT); Registered Nurse First Assist (RNFA).The following criteria must be met prior to reimbursement of these services:
Rendering providers must be an integral part of the physician's practice, and must be based within the setting/facility.
Please see MBM, Chapter 1, Section 1.06-2 for the requirements for Interpreter services.
MaineCare covers face-to-face medical conferences by a physician or rendering provider with an interdisciplinary team of health professionals or representatives of community agencies to coordinate activities of patient care when the member is not present.
MaineCare does not cover conferences between staff of the same clinic or agency or team conferences by telephone.
MaineCare covers counseling and treatment for tobacco dependence to educate and assist members with smoking cessation.
Effective August 1, 2014, with retroactivity contingent upon the provider's compliance with MBM, Chapter I, Section 1.10-2 and 42 C.F.R. § 447.45 regarding the timely submission of claims, tobacco cessation treatment shall be a covered service for all MaineCare members who currently use tobacco products and who wish to cease the use of tobacco products. Tobacco cessation treatment includes both counseling and products. These services are provided to educate and assist members with tobacco cessation. During counseling, providers must educate members about the risks of tobacco use, the benefits of quitting and assess the member's willingness and readiness to quit. Providers should identify barriers to cessation, provide support, and use techniques to enhance motivation to quit for each member. These services may be provided in the form of individual or group counseling. Both forms of counseling may be provided by licensed practitioners within the scope of licensure as defined under State law and who are eligible to provide other coverable services in Section 90.
In addition to counseling, tobacco cessation treatment services include the provision of all pharmacotherapy approved by the Federal Food and Drug Administration for tobacco dependence treatment. Tobacco cessation products are "Covered Drugs," reimbursable pursuant to Chapter. II, Section 80.05 of the MBM. MaineCare members are not required to participate in tobacco cessation counseling to receive tobacco cessation products. Members shall be provided with tobacco cessation treatment services with no annual or lifetime dollar limits, and no annual or lifetime limits on attempts to cease tobacco use.
Providers may bill these services alone or in addition to other outpatient evaluation/management services provided on the same date of service. MaineCare only reimburses separately for these additional services when used for the express purpose of counseling and/or risk factor reduction directed at tobacco addiction, and only when used in conjunction with an appropriate tobacco use disorder documented in the medical record.
Any prescriber who has an individual DEA number must use that identifier when writing prescriptions, rather than a number assigned to an institution. Physicians should refer to Section 80, Pharmacy Services, of the MBM, for prescribing policies and procedures. For the most current and accurate prescribing criteria, please refer to MaineCare's Preferred Drug List at www.mainecare.pdl.org.
Providers may not bill separately for services commonly carried out as an integral part of a total service (e.g., dipstick urinalysis). However, providers may bill separately for independent service not immediately related to other services.
MaineCare distinguishes a consultation from a referral. A consultation includes services rendered by a provider whose opinion or advice is requested by another provider for the further evaluation and or management of the member.
If the consulting provider assumes responsibility for the continuing care of the member, any subsequent services rendered by this provider are not considered to be consultation.
A referral is the transfer of the total or specific care of a member from one provider to another.
When provided as part of an examination and/or treatment, MaineCare will reimburse for the services described below in addition to the office visit. However, when the only service provided is immunization, therapeutic injection, or hyposensitization the rate is all-inclusive.
Providers should bill for administration of vaccines distributed by the Maine CDC in accordance with MaineCare Services billing instructions.
Providers administering immunizations to children ages birth through age eighteen (18) years of age, must participate in the Vaccines for Children (VFC) program. Providers who would like more information or would like to enroll in the VFC program should contact the Maine CDC's
Immunization Program or visit their website at:
http://www.maine.gov/dhhs/mecdc/infectious-disease/immunization/index.shtml.
Providers should direct any questions about the administration of State supplied vaccines to the Maine CDC.
When not supplied by the Maine CDC, providers should bill therapeutic injections and immunizations using the proper NDC code. The charged amount for the therapeutic and immunological material must reflect the acquisition cost of the material to the provider. Providers must keep copies of invoices in their files. Any vaccine that could be obtained by distribution from the Maine CDC is not reimbursable, e.g., Measles, Mumps and Rubella (MMR)
MaineCare will only reimburse the provider fee for the administration of such a vaccine.
The Maine CDC, Health and Environmental Testing Laboratory has specimen kits available for use in submitting certain specimens to the State laboratory for analysis. Providers must purchase these kits from the State laboratory. When a provider uses a kit to collect a specimen from a MaineCare member, providers should notify the State laboratory of the name and MaineCare ID number of the member for whom the kit was used. The State laboratory will then bill the kit to MaineCare. A replacement kit will be sent to the provider.
MaineCare reimburses all covered surgical procedures as global packages with post-operative periods of 0-, 10- or 90-days and according to the MaineCare Global Surgery Fee Schedule available at https://mainecare.maine.gov.
Allowances for surgery include payment for the following all-inclusive global- packaged services:
Some services are not included in the global surgical package and may be paid for separately. These include, but are not limited to, initial consultation or evaluation to determine the need for surgery for major surgical services, visits unrelated to the diagnosis for which the surgical procedure is performed or for complications of the surgery, diagnostic tests and procedures, clearly distinct surgical procedures during the post-operative period that are not re-operations or treatment for complications, and some critical care services unrelated to the surgery.
MaineCare requires use of standard CPT codes and modifiers. Providers should consult current CPT and HCPCS publications for these modifiers. The following are examples of situations that often arise in regard to surgical procedures. Special CPT modifiers may be required for these situations:
However, when such a procedure is carried out as a separate entity, not immediately related to other services, the procedure will be covered. (e.g., cystoscopy in conjunction with bladder surgery does not warrant additional payment; cystoscopy in conjunction with hysterectomy is an independent procedure.)
Providers of oral and temporomandibular joint (TMJ) surgery must also comply with all applicable rules of MBM, Chapter II and III, Section 25, Dental Services, including but not limited to, urgent care guidelines and prior authorization. All TMJ surgeries require prior authorization.
Chiropractic services must be performed as detailed in MBM, Chapter II, Section 15, Chiropractic Services. Providers should also see instructions for documenting rehabilitation potential in Section 90.05-3.
Occupational therapy services must be performed as detailed in MBM, Chapter II, Section 68, Occupational Therapy Services. Providers should also see instructions for documenting rehabilitation potential in Section 90.05-3.
Physical therapy services must be performed as detailed in MBM, Chapter II, Section 85, Physical Therapy Services. Providers should also see instructions for documenting rehabilitation potential in Section 90.05-3.
Speech and hearing services must be performed as detailed in MBM, Chapter II, Section 109, Speech and Hearing Services. Providers should also see instructions for documenting rehabilitation potential in Section 90.05-3.
Application of topical fluoride varnish is covered up to four (4) times per calendar year for members under the age of 21. These limitations apply across qualified providers, including dental providers. Qualified providers shall bill using CPT code 99188.
MaineCare covers oral health risk assessments for members who do not have a dental home and/or have not seen a dentist in the past year. The provider must:
MaineCare will cover two (2) evaluations per calendar year across all qualified providers, but no more than once every 150 days. Additional information is available in MBM, Chapter III, Section 25, Dental Services.
For members under three (3), providers shall bill using dental code D0145. For members three (3) and over, providers shall bill using D0191.
Physicians and rendering providers will be reimbursed for providing MaineCare covered services to treat a member with gender dysphoria, as prescribed by a physician or other referring medical professional. Coverage for surgical services related to gender dysphoria will require a prior authorization pursuant to Section 90.05, Restricted Services.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-90, subsec. 144-101-II-90.04