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    • Tobacco Cessation Services - August 5, 2014

      Effective August 1, 2014, there were a number of substantial changes to MaineCare coverage of tobacco cessation services. These changes result from a combination of state and federal legislation (LD 386, An Act to Reduce Tobacco-Related Illness and Lower Health Care Costs in MaineCare, and the Affordable Care Act, respectively) promoting access to these benefits. MaineCare providers should be aware of these changes and of increased member eligibility for tobacco cessation products and services.

      As of August 1, 2014, tobacco cessation pharmacological products, including patches, inhalers, sprays, gum, lozenges, and oral medications, will be available to all MaineCare members, as well as to participants in Maine’s Drugs for the Elderly (DEL) program. No co-payments may be collected for these products, and no annual or lifetime limitations will be imposed.

      Effective August 1, 2014, those annual limits will be eliminated, and the service will be reimbursable for all members.

      Prior to August 1, 2014, tobacco cessation counseling was reimbursable for some members up to a limit of three sessions per year. The following sections of the MaineCare Benefits Manual will be updated to eliminate the limitations:

      • Section 9, Indian Health Services;
      • Section 31, Federally Qualified Health Centers;
      • Section 90, Physician Services;
      • Section 103, Rural Health Centers; and,
      • Section 25, Dental Services (one per year)

      Effective August 1, 2014, in addition to full coverage of tobacco cessation products, MaineCare will now cover tobacco cessation counseling for all MaineCare members. Tobacco cessation counseling will now be covered under Section 65, Behavioral Health Services. No co-payments or other cost-sharing may be imposed on these services. There will no longer be limitations placed on the number of annual tobacco cessation counseling sessions available to MaineCare members.

      The following codes may be used:

      • S9453: Smoking cessation classes, non-physician provider (Section 9, Indian Health Services; Section 31, Federally Qualified Health Centers; and Section 103, Rural Health Clinics);
      • 99406: Smoking and tobacco use cessation counseling visit; intermediate, greater than three (3) minutes and up to 10 minutes (Section 90, Physician Services; Section 65, Behavioral Health Services);
      • 99407: Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (Section 90, Physician Services; Section 65, Behavioral Health Services);
      • 99411: Preventive medicine, group counseling; 30 minutes (Section 65, Behavioral Health Services);
      • 99412: Preventive medicine, group counseling; 60 minutes (Section 65, Behavioral Health Services); and,
      • D1320: Tobacco Counseling for the Control and Prevention of Oral Disease (Section 25, Dental Services)
         

    • Laboratory Testing Reminder - August 6, 2014

      Laboratory testing should only be ordered and performed when medically necessary in accordance with policy as noted below:

      55.04 COVERED SERVICES

      55.04-1 General Provisions

      A covered service is a service for which payment can be made by the Department.

      Laboratory services which are specifically defined in the Department's Allowances for Physician Services Chapter III, Section 90, and are medically necessary for diagnosis and control of a medical condition, are covered services. These services must be ordered by a physician or other licensed practitioner authorized to order lab services within the scope of his or her license and be consistent with good medical practice.

      55.04.2 Bundling or Grouping of Laboratory Tests

      Included in the Allowances for Laboratory Services is a list of tests that are frequently done as a group (profile) on automated equipment. For any combination of these tests, the provider shall use the code which correctly designates the number of tests included in the profile. The provider shall not “unbundle” and bill separately for tests included as part of a group (profile or panel) that pay at a lower rate. Use the Physicians’ Current Procedural Terminology (CPT) Manual Codes for the proper Automated, Multichannel Tests, and for the proper Organ or Disease Oriented Panels.

      Some examples of unnecessary testing include, but are not limited to, the following:

      • Ordering quantitative testing for drugs in lieu of qualitative screening may not be medically necessary.
      • When the result of a qualitative screening test is negative, a quantitative follow-up test may not be necessary.
      • A confirmatory quantitative test may be unnecessary for a drug the member is not prescribed. (For example, if a patient is not prescribed diazepam and a screening panel is done for other reasons, a confirmatory quantitative test for diazepam may not be medically necessary.)
      • If a patient is prescribed hydrocodone and the qualitative test is positive, then it may not be medically necessary to perform a quantitative test when the patient is clinically stable.

      One way to help prevent ordering medically unnecessary tests is to avoid writing standing orders for customized panels and auto-reflex testing created by laboratories. In this case, medically unnecessary tests may be run under your approval even though you may not have felt it was necessary.

      If a CPT code is assigned to a panel, then these tests should be run together. When a laboratory creates its own panel and there is no corresponding CPT, then the tests may not be accepted as medically necessary or cost effective. The ordering provider may be held accountable for tests that are not medically necessary.

         

    • Attention: Maine Administrative Services Organization (ASO) Provider of Intensive Outpatient (IOP) Services - August 8, 2014

      Effective August 1, 2014, the service length for IOP Prior Authorizations (PA) with APS Healthcare will increase from fourteen (14) calendar days to thirty (30) calendar days.

      The APS CareConnection web portal will default the “Units” field for PAs and Continued Stay Requests to one unit. Providers will be able to adjust the “Units” field to match the service length requested based on the member’s needs.

      What does this mean for providers?

      When a PA is requested, a provider will be able to request up to thirty (30) calendar days (an increase from 14 calendar days) for IOP services. Weekly continued stay reviews will begin following this initial thirty (30) calendar day service period. Providers may contact APS Provider Relations with questions at 1-866-521-0027, Option 1, or via email at MaineCare-Prov@apshealthcare.com .

      What does this mean for members?

      With this change, a member may be able to receive IOP services for up to thirty (30) calendar days (an increase from 14 calendar days). Members may contact the APS Member Liaison with questions at 1-866-521-0027, Option 3, or via email at rlavigne@apshealthcare.com.

         

    • Attention: Providers of Adult Behavioral Health Homes - August 8, 2014

      APS Healthcare has updated the required fields in CareConnection to align with Section 17 Service required fields in order to capture information for Consent Decree reporting requirements. Effective August 1, 2014, the Contact For Service Notification (CFSN) process and Adult Mental Health Enrollment/ Individual Service Plan (ISP) Resource Data Summary (RDS) will be required for Behavioral Health Home submissions. The CFSN is not a requirement for members who do not have MaineCare.

      Instructions to assist providers in submitting accurate RDS/ISP data across all service areas are attached and can also be found on the APS website.

      What does this mean for providers?

      Providers will be required to follow the CFSN process and complete the ISP section for members in Adult Behavioral Health Homes. Providers may contact APS Provider Relations with questions, at 1-866-521-0027, Option 1, or via email at MaineCare-Prov@apshealthcare.com .

      What does this mean for members?

      This update does not change any process for a member in an Adult Behavioral Health Home. Members may contact the APS Member Liaison with questions, at 1-866-521-0027, Option 3, or via email at rlavigne@apshealthcare.com.

         

    • Official ICD-10 Implementation Date - August 11, 2014

      The Centers for Medicare & Medicaid Services (CMS) recently issued a final rule stating that October 1, 2015 will be the official compliance date for ICD-10 implementation. Please click here to access their press release regarding the implementation date.

      Now that the final rule has been issued, it is critical that providers continue preparing for ICD-10 in order to be ready for the transition.

      As we noted in the July 25, 2014 listserv, MaineCare will continue preparing for implementation to enable a successful transition. You will see an increase in MaineCare’s ICD-10 activity in February 2015 so we can complete all tasks required prior to implementation.

      Pilot Testing:

      Given the ICD-10 compliance delay, pilot testing is now targeted for the spring of 2015. Please watch our listserv this winter for information about pilot testing.

      For more information, please see our MaineCare ICD-10 website, our Frequently Asked Questions page or contact us through the ICD-10 Email Box.

         

    • New Placement of the Self-Attestation Form for MaineCare’s 2013/2014 Primary Care Rate Increase - August 11, 2014

      The Self-Attestation form for MaineCare’s 2013/2014 Primary Care Rate Increase has moved. The form, along with instructions, is now available on MaineCare’s Provider Resource webpage, under the Affordable Care Act (ACA) section.

      If you have questions, please call Provider Services, Monday through Friday, from 7:00 AM to 6:00 PM at: 1-866-690-5585 (TTY users dial 711).

         

    • Attention Provider of Rehabilitation and Community Support Services - August 11, 2014

      Effective August 15, 2014, APS Healthcare will implement a new process for members who:

      1. Are eligible for Section 28, Community-Based Services,
      2. Have identified a preferred provider, and
      3. Are on the waitlist for Section 28 services.

      A member’s guardian will receive a 60-day notification letter when they have been waiting for a preferred provider for sixty (60) days or more. This letter will outline the family choice process as well as a notification of providers who may be able to serve the family within a shorter timeframe. With outreach through the sixty (60) day notification letter, the intent is to educate families on available resources in their community and decrease wait times for eligible members.

      APS Healthcare has been matching children for Section 28 services based on date of referral. It is the expectation that children will be served based on the time they are on the waitlist (on a first come, first serve basis).

      It is important to note that we are researching ways to also decrease waitlist time for members who have been determined eligible for Section 28 Community-Based Services and have not identified a preferred provider.

      What does this mean for members?

      Members who are eligible for services and have identified a preferred provider, will receive a notification letter when they are on a preferred waitlist for (sixty) 60 days or more. The guardian may stay on the waitlist or may access other resources in the community that are able to serve them. Members may contact the APS Healthcare Member Liaison with questions at 1-866-521-0027, Option 3, or via email at rlavigne@apshealthcare.com.

         

    • Planned Disaster Recovery Test from 12:00 Noon Saturday August 16 to 6:00 AM Monday, August 18 - August 12, 2014

      The MIHMS Health PAS Online Portal will be unavailable from 12:00 PM on Saturday, August 16, 2014 through 6:00 AM Monday, August 18. MaineCare will perform a scheduled Disaster Recovery Test on the system during this time.

      We do not anticipate any impact to the payment processing cycle for the weeks before or after the Disaster Recovery Test.

      During the test period, the maintenance page will be up and the Health PAS Online Portal will be unavailable. Providers and billing agents cannot: - Submit Direct Data Entry (DDE) or electronic claims - View any portal documents - Retrieve a PDF RA or 835 - Perform a new provider enrollment or submit a maintenance case for an existing enrollment - Use any portal functionality (Including 837, 270 or 271 submissions)

         

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          • Tobacco Cessation Services - August 5, 2014

            Effective August 1, 2014, there were a number of substantial changes to MaineCare coverage of tobacco cessation services. These changes result from a combination of state and federal legislation (LD 386, An Act to Reduce Tobacco-Related Illness and Lower Health Care Costs in MaineCare, and the Affordable Care Act, respectively) promoting access to these benefits. MaineCare providers should be aware of these changes and of increased member eligibility for tobacco cessation products and services.

            As of August 1, 2014, tobacco cessation pharmacological products, including patches, inhalers, sprays, gum, lozenges, and oral medications, will be available to all MaineCare members, as well as to participants in Maine’s Drugs for the Elderly (DEL) program. No co-payments may be collected for these products, and no annual or lifetime limitations will be imposed.

            Effective August 1, 2014, those annual limits will be eliminated, and the service will be reimbursable for all members.

            Prior to August 1, 2014, tobacco cessation counseling was reimbursable for some members up to a limit of three sessions per year. The following sections of the MaineCare Benefits Manual will be updated to eliminate the limitations:

            • Section 9, Indian Health Services;
            • Section 31, Federally Qualified Health Centers;
            • Section 90, Physician Services;
            • Section 103, Rural Health Centers; and,
            • Section 25, Dental Services (one per year)

            Effective August 1, 2014, in addition to full coverage of tobacco cessation products, MaineCare will now cover tobacco cessation counseling for all MaineCare members. Tobacco cessation counseling will now be covered under Section 65, Behavioral Health Services. No co-payments or other cost-sharing may be imposed on these services. There will no longer be limitations placed on the number of annual tobacco cessation counseling sessions available to MaineCare members.

            The following codes may be used:

            • S9453: Smoking cessation classes, non-physician provider (Section 9, Indian Health Services; Section 31, Federally Qualified Health Centers; and Section 103, Rural Health Clinics);
            • 99406: Smoking and tobacco use cessation counseling visit; intermediate, greater than three (3) minutes and up to 10 minutes (Section 90, Physician Services; Section 65, Behavioral Health Services);
            • 99407: Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (Section 90, Physician Services; Section 65, Behavioral Health Services);
            • 99411: Preventive medicine, group counseling; 30 minutes (Section 65, Behavioral Health Services);
            • 99412: Preventive medicine, group counseling; 60 minutes (Section 65, Behavioral Health Services); and,
            • D1320: Tobacco Counseling for the Control and Prevention of Oral Disease (Section 25, Dental Services)
               

          • Official ICD-10 Implementation Date - August 11, 2014

            The Centers for Medicare & Medicaid Services (CMS) recently issued a final rule stating that October 1, 2015 will be the official compliance date for ICD-10 implementation. Please click here to access their press release regarding the implementation date.

            Now that the final rule has been issued, it is critical that providers continue preparing for ICD-10 in order to be ready for the transition.

            As we noted in the July 25, 2014 listserv, MaineCare will continue preparing for implementation to enable a successful transition. You will see an increase in MaineCare’s ICD-10 activity in February 2015 so we can complete all tasks required prior to implementation.

            Pilot Testing:

            Given the ICD-10 compliance delay, pilot testing is now targeted for the spring of 2015. Please watch our listserv this winter for information about pilot testing.

            For more information, please see our MaineCare ICD-10 website, our Frequently Asked Questions page or contact us through the ICD-10 Email Box.

               

          • New Placement of the Self-Attestation Form for MaineCare’s 2013/2014 Primary Care Rate Increase - August 11, 2014

            The Self-Attestation form for MaineCare’s 2013/2014 Primary Care Rate Increase has moved. The form, along with instructions, is now available on MaineCare’s Provider Resource webpage, under the Affordable Care Act (ACA) section.

            If you have questions, please call Provider Services, Monday through Friday, from 7:00 AM to 6:00 PM at: 1-866-690-5585 (TTY users dial 711).

               

          • Attention Provider of Rehabilitation and Community Support Services - August 11, 2014

            Effective August 15, 2014, APS Healthcare will implement a new process for members who:

            1. Are eligible for Section 28, Community-Based Services,
            2. Have identified a preferred provider, and
            3. Are on the waitlist for Section 28 services.

            A member’s guardian will receive a 60-day notification letter when they have been waiting for a preferred provider for sixty (60) days or more. This letter will outline the family choice process as well as a notification of providers who may be able to serve the family within a shorter timeframe. With outreach through the sixty (60) day notification letter, the intent is to educate families on available resources in their community and decrease wait times for eligible members.

            APS Healthcare has been matching children for Section 28 services based on date of referral. It is the expectation that children will be served based on the time they are on the waitlist (on a first come, first serve basis).

            It is important to note that we are researching ways to also decrease waitlist time for members who have been determined eligible for Section 28 Community-Based Services and have not identified a preferred provider.

            What does this mean for members?

            Members who are eligible for services and have identified a preferred provider, will receive a notification letter when they are on a preferred waitlist for (sixty) 60 days or more. The guardian may stay on the waitlist or may access other resources in the community that are able to serve them. Members may contact the APS Healthcare Member Liaison with questions at 1-866-521-0027, Option 3, or via email at rlavigne@apshealthcare.com.

               

          • Planned Disaster Recovery Test from 12:00 Noon Saturday August 16 to 6:00 AM Monday, August 18 - August 12, 2014

            The MIHMS Health PAS Online Portal will be unavailable from 12:00 PM on Saturday, August 16, 2014 through 6:00 AM Monday, August 18. MaineCare will perform a scheduled Disaster Recovery Test on the system during this time.

            We do not anticipate any impact to the payment processing cycle for the weeks before or after the Disaster Recovery Test.

            During the test period, the maintenance page will be up and the Health PAS Online Portal will be unavailable. Providers and billing agents cannot: - Submit Direct Data Entry (DDE) or electronic claims - View any portal documents - Retrieve a PDF RA or 835 - Perform a new provider enrollment or submit a maintenance case for an existing enrollment - Use any portal functionality (Including 837, 270 or 271 submissions)

               

           

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