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State of Maine |
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MAINECARE
HOME HEALTH PAYMENT RESEARCH FORM
Date: ________
Home Health Agency
Name: __________________________
Address: ______________________ Phone#: __________________________
______________________ Fax#: __________________________
Contact Person:
__________________________
Member Name: __________________________
MaineCare #: __________________________
Social Security: __________________________
1. Initial
Certification Payment Issue
Start of Care Date: _______________
Admit/Discharge sent:____________
Initial Certification Period: From_________
to _________
Payment Dates in Question: From_________
to _________
Disciplines billing for:
Explain Problem:
2. Prior Authorization
Payment Issue
Prior Authorized Period: From_________
to _________
Referral Date: _______________
Assessment Date: _______________
Payment Dates in Question: From_________
to _________
Disciplines billing for:
Explain Problem:
Please submit copies of
start of care, admit/discharge form and other pertinent information to support
your request. DO NOT send copies of rejected claims. Fax to 287-9231
3. BEAS RESPONSE Date:_____________
o
No admit/discharge on file. Please submit admit/discharge form for this
consumer.
o
PA required for this discipline. Please make referral to Goold for prior
authorization.
o
No Section 17 document for exemption received. Please submit Section 17.
o
Other ___________________________________________________________
MAINECARE
HOME HEALTH PAYMENT RESEARCH FORM
INSTRUCTIONS
Use this form when payment issues arise for consumers you serve under MaineCare Home Health. Fill in the top section with the date, your agency name, address, phone and fax numbers, and the contact person who is most familiar with this payment issue.
Fill in the consumer’s name, MaineCare and Social Security numbers.
Please submit copies
of start of care, admit/discharge form and other pertinent information to
support your request. DO NOT send copies of rejected claims. Fax to 287-9231
1. Initial
Certification Payment Issue: This block is for
payment issues that occur during the consumer’s initial certification period.
Include the start of care date, the date you sent the Admit/Discharge form to
BEAS, the initial certification dates and the payment dates which are in
question. List the disciplines that are being billed for during this initial
certification period. Explain the payment issue, giving any additional
information necessary to research this issue.
Start of Care Date: _______________
Admit/Discharge sent:____________
Initial Certification Period: From_________
to _________
Payment Dates in Question: From_________
to _________
Disciplines billing for:
Explain Problem:
2. Prior Authorization
Payment Issue: This block is for payment issues that occur during a
consumer’s certification period that has been prior authorized through an
assessment from Goold. Include the eligibility period as noted on the outcome
of the assessment, the referral date of that assessment, the assessment date,
and the payment dates which are in question. List the disciplines that are
being billed for during this certification period. Explain the payment issue,
giving any additional information necessary to research this issue.
Prior Authorized Eligibility Period: From_________ to _________
Referral Date: _______________
Assessment Date: _______________
Payment Dates in Question: From_________
to _________
Disciplines billing for:
Explain Problem:
3. BEAS RESPONSE: This block will be used by BEAS in
responding to this payment research form.
Date:_____________
o
No admit/discharge on file. Please submit admit/discharge form for this
consumer.
o
PA required for this discipline. Please make referral to Goold for prior
authorization.
o
No Section 17 document for exemption received. Please submit Section 17.
o
Other ___________________________________________________________