C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-95, subsec. 144-101-II-95.04
Covered services are those services provided by podiatrists within the scope of their license and for which the Department may make payment. Covered services include those podiatric services provided directly by a podiatrist, laboratory and x-ray services furnished by the podiatrist's office and services that are specifically included in the Department's MaineCare Benefits Manual, Section 90, Physician Services. Some services require prior authorization by the Department or its Authorized Agent, and procedures requiring prior authorization are listed at: http://portalxw.bisoex.state.me.us/oms/proc/pub_proc.asp?cf=mm [File Link Not Available] . Services shall be covered only for members who meet the medical eligibility requirements in Section 95.02.
Covered services are limited to the following:
The diagnosis and treatment of problems of the foot, in an initial visit in a setting furnished with equipment appropriate to the practice of the profession.
Podiatric care will only be covered for members who meet the eligibility above in Section 95.02, Eligibility for Care.
Podiatrists may bill for an office visit, or for podiatric care, but not both for the same visit.
The Department requires some bunion surgery to be prior authorized in accordance with provisions defined in Section 90.05-1, Restricted Services, of the MaineCare Benefits Manual, Chapter II, Section 90, Physician Services.
MaineCare may reimburse a podiatrist in private practice for laboratory and x-ray services provided in his or her office, using the podiatrist's equipment and supplies. To be eligible for reimbursement, a laboratory and/or x-ray unit must comply with the regulations set forth in Section 55, Laboratory Services and/or Section 101, Medical Imaging Services, in Chapter II of the MaineCare Benefits Manual.
MaineCare reimbursement is available to podiatrists in private practice for those orthotic devices covered by MaineCare that are prescribed or utilized within the scope of practice. Podiatrists providing this equipment must inform members of their freedom of choice to obtain these items from other suppliers. MaineCare will not reimburse podiatrists for supplying durable medical equipment to the member unless the durable medical equipment is otherwise unobtainable. MaineCare will not cover orthotics that can be bought off-the-shelf, including those that can be molded. 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 specialty supplies and/or equipment during the office visit. MaineCare will not reimburse podiatrists for basic medical supplies that are available through providers enrolled as Medical Supplies and Durable Medical Equipment providers. Podiatrists must consult the most recent version of the Current Procedural Terminology (CPT) and the HealthCare Common Procedure Coding System (HCPCS) books for appropriate billing codes. Providers may also consult the Office of MaineCare Services' web site for access to the current procedure codes at: http://www.maine.gov/dhhs/oms/providerfiles/billing_instructions.html .
The provider's charges must not exceed acquisition cost. It is also the provider's responsibility to verify that the services and procedure codes are covered by MaineCare. Claims must be submitted according to current Departmental billing instructions. Limits and prior authorization requirements on orthotic services apply as defined in the MaineCare Benefits Manual, Chapter II, Section 60, Medical Supplies and Durable Medical Equipment.
Podiatric care as described above, and/or diagnostic and treatment services provided to a resident of a nursing facility may be reimbursed only when the member meets the medical eligibility requirements set forth in Section 95.02, and a covered service (refer to Section 95.04) is ordered in writing by the member's attending physician, physician assistant, or advanced practice nurse as allowed by the licensing authority and scope of practice.
Interpreter services for members who are deaf/hard-of-hearing, or who need language interpreters are to be provided in accordance with the guidelines specified in Chapter I of the MaineCare Benefits Manual.
MaineCare will cover supplies and materials used by a podiatrist for non-routine services needed in performing office procedures that are above and beyond what is usually used in a normal office visit. Examples of supplies and materials are: strapping, padding or compression dressings, plaster, and surgical trays. MaineCare does not cover dressings used following routine podiatric care. MaineCare reimburses acquisition cost only. Claims must be submitted according to current Departmental billing instructions.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-95, subsec. 144-101-II-95.04