Maine CDC Breast and Cervical Health Program (MBCHP)


Provider Billing - Frequently Asked Questions...


 

1. If I provide a non-covered service to a MBCHP client, can I bill the woman for the service?

  • Before a MBCHP provider performs a non-covered service on a MBCHP member, the provider must explain to the patient that they will be financially responsible for the non-covered service. The MBCHP member may only be charged for a non-covered service.
  • Providers participating in the MBCHP network are required to accept as payment in full, the reimbursement rate established by MBCHP for covered services.
  • Members cannot be billed for any portion of a MBCHP covered service.
  • Providers may not submit claims to Collection Agencies for MBCHP covered services.
  • Any provider or billing agency with questions should call MBCHP before processing bills.

2. If I have a billing issue for a MBCHP member, what should I do?

  • First, please call the MaineCare Provider line to check on the status of claim or client eligibility:
  • Second, if you have a specific claims issue, please fax a copy of the claim, including Remittance Advice (RA) and Explanation of Medical Benefit (EOB) to the MBCHP with a brief description of the issue on the fax cover sheet:
    • MBCHP fax number: 207-287-4100
    • MBCHP fax number: 207-287-8944
  • If you wish to speak with MBCHP regarding a billing issue, please contact us at 1-800-350-5180 extension 76285.

3. How do I handle a covered service claim for a MBCHP member who has private or group insurance benefits?

  • MBCHP is the payor of last resort. It is the responsibility of the provider to determine from each MBCHP member whether there are any other resources (private or group insurance benefits, etc.) that are available for payment of the service and to seek payment from such resource prior to billing MBCHP.
  • Once the claim has been processed by the third-party insurer, a copy of the Explanation of Benefits (EOB) must be attached to the MBCHP claim and submitted to:
    • For Professional claim (1500 form)
      • MaineCare claim processing, M-500, Augusta, ME 04332
    • For Institutional claim (UB-04 form)
      • MaineCare claims processing, M-100, Augusta, ME 04332

4. I submitted a claim to MBCHP and I am not seeing the claim in the portal; what should I do?

  • If you submitted a claim via paper and you are not seeing it on the claims portal, please contact MBCHP at 1-800-350-5180 extension 76285 or Molina Provider Services at 1-866-690-5585 or MaineCareProvider@molinahealthcare.com.
  • If you submitted a claim electronically through a billing agent or clearinghouse, please contact the Molina EDI helpdesk at 1-866-690-5585 or MaineCareSupport@molinahealthcare.com.

5. I have a claim that was submitted for MBCHP services that has denied. I am unsure of the denial reason that was given. Who should I contact?

  • If you require a further explanation of a denied claim or a denial reason please contact MBCHP at 1-800-350-5180 extension 76285.
  • Some common reasons for MBCHP claims being denied:
    • 1500 - Claim line has CPT code that requires a modifier and the claim is missing the modifier (TC or 26)
    • 1500 - Member has insurance and claim comes in without an EOB
    • UB-04 - Claim line has a Revenue Code that is not one MBCHP uses (see billing-information)
    • UB-04 - Claim line is for "facility charges" for the overhead expenses associated with furnishing the professional service itself. MBCHP fee schedule includes these charges in the payment for professional services. We cannot break down the "facility charges" or overhead expenses from the professional fee at this time.
  • The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides federal funding for MBCHP and provides annual guidelines on allowable procedures and relevant CPT codes the program can reimburse for.
  • Currently, MBCHP is specifically not allowed to reimburse for:
    • ANY Computer Aided Detection (CAD) in breast cancer screening or diagnostics or;
    • ANY Magnetic Resonance Imaging (MRI) in breast cancer screening or diagnostics

6. Are there specific revenue codes, CPT codes, and diagnosis codes for MBCHP billing?

  • Yes. MBCHP has specific Revenue Codes, CPT Codes, and Diagnosis Codes for MBCHP claims. For a complete list of covered MBCHP codes see billing-information.

7. Is there a specific way an RHC/FQHC must bill MBCHP?

  • Yes. An RHC/FQHC should bill services on a UB-04 form utilizing the Revenue/CPT code combinations that are covered by MBCHP. For MBCHP billing, "T" codes are not required. For additional information contact the MBCHP Medical Care Coordinator at 1-800-350-5180 extension 76285.

8. What is the MBCHP timely filing limit?

  • MBCHP claims have a timely filing limit of 180 days from date of service.

9. How are MBCHP office visits reimbursed?

  • The reimbursement rate for an office visit from MBCHP is all inclusive. MBCHP includes: room fees, Clinical Breast Exam (CBE), pelvic exam, and Pap test into one reimbursement rate. MBCHP reimburses an office visit as a professional fee. To bill the professional fee to MBCHP you can do one of two things:
    • Bill on a 1500 using the MBCHP approved E/M codes; or,
    • E/M codes can be billed on UB-04 using the professional fee Revenue Code (0960).
  • If you have questions on which way you should bill your office visit, please contact the MBCHP Medical Care Coordinator at 1-800-350-5180 extension 76285.
  • MBCHP does not pay a facility charge separate from professional fee. As stated above, MBCHP reimbursement is all inclusive. The rate is higher than the fee schedule rate for a service performed in a facility setting as it includes the overhead expenses. Please note that this may not be the same way you would bill your straight MaineCare claims. MBCHP has different billing and reimbursement requirements as it is a Maine Center for Disease Control & Prevention program funded by a federal grant and not a MaineCare (Medicaid) program.

Updated June 10, 2014