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Issue Corrected: Anesthesia Pain Management, CR 30025 - March 31, 2014
Code 01996 can now be entered as units. Below, is the original message we sent on March 8, 2014, explaining the issue that has now been corrected
Anesthesia Pain Management, CR 30025
Code 01996, Anesthesia Pain Management, was inadvertently set up in MIHMS as minutes-based instead of unit-based. Currently, the HIPAA 837 claims transactions require an MJ (minutes) qualifier in SV104 of the electronic transaction. As a result, these transactions are being rejected when submitted with the UN (unit) qualifier in SV104. The Direct Data Entry (DDE) portal for claims only allows minutes to be entered for this code. Units are then calculated directly from the minutes entered. As a work-around to the unit requirement for this code, providers can submit claims in the following manner for correct processing:
HIPAA 837 claims transactions: Submit Code 01996 as one minute using the MJ qualifier in SV104
DDE Portal: Submit Code 01996 as one minute; the portal will calculate this as a “0” unit, but will process correctly
Paper: Submit Code 01996 as one unit
We will inform you when the system can accept the UN qualifier in SV104.
Issue Corrected: Attention Alternative Residential Care Providers, TR 40134 - March 31, 2014
The system has been corrected allow claims submission via paper and 837 Electronic Transactions with an admit date for bill type 089X. Below, is the original message we sent on February 28, 2014, explaining the issue that has now been corrected:
Attention Alternative Residential Care Providers, TR 40134
MaineCare requires the date of admission on inpatient claims with the following bill types: 011X, 012X, 018X, 021X, 028X, 041X, 065X, 066X, 086X, and 089X. However, the system is not currently allowing claims submitted via paper and 837 I Electronic Transactions with an admit date for bill type 089X. As a result, transactions with this bill type are being rejected at the EDI Gateway in error when submitted with the admit date. Until this is corrected, these claims can be submitted using Direct Data Entry on the MyHealth PAS Portal. We will notify you when this issue has been corrected.
Issue Corrected: 270/271 Eligibility Inquiry Response Transactions, TR 40133 - March 31, 2014
Trading Partners submitting a 270 request for a specific services type code rather than the generic services type code ‘30’ will no longer receive confirmation of eligibility for members with unmet spenddown amounts when the eligibility should have been excluded.
Below, is the original message we sent on February 21, 2014, explaining the issue that has now been corrected:
270/271 Eligibility Inquiry/Response Transactions TR 40133
Trading Partners submitting a 270 request for a specific service type code rather than with the generic service type code ‘30’ could have received a confirmation of eligibility for members with unmet spenddown when that eligibility should have been excluded. Omitting the specific service type code will not report this member as eligible. We are working to correct this issue and will notify you once it is resolved. Contact the EDI Helpdesk at (866) 690-5585 (TTY: 711) for questions.
Issue Corrected: Attention Providers Billing Medicare Secondary Claims on Paper, TR 40131 - March 31, 2014
Co-insurance amounts from the Explanation of Medicare Benefits are now being populated in the claims processing system for paper claims.
Below, is the original message we sent on February 28, 2014, explaining the issue that has now been corrected:
Attention Providers Billing Medicare Secondary Claims on Paper, TR 40131
An issue was identified where the co-insurance amount from the Explanation of Medicare Benefits is not being populated in the claims processing system for paper claims. This issue only affects providers who are billing coordination of benefits on a paper claim form. As a result, paper claims with Medicare co-insurance amounts are requiring manual processing. We will notify you when this issue has been corrected. No provider action is needed.
Updates to the Prior Authorization (PA) Request Form, CR 39144 - April 1, 2014
Please use the updated PA Request form. You can access the new Prior Authorization Request form in the Authorizations and Referrals folder, on the Health PAS Online Portal.
Update to 2013 McKesson InterQual Criteria Sheets and Prior Authorization (PA) Changes, CR 37411 - April 1, 2014
Effective today, March 25, 2014, certain McKesson InterQual Criteria Sheets have been updated from the current version on the Health PAS Online Portal to the 2013 version and will be used as guidelines to approve or deny PA requests. Please note that for a short time, we will continue to accept PA requests with the older versions of the criteria sheets concurrent with the newer versions. We will notify you when we are no longer accepting the old forms.
With the adoption of the 2013 McKesson InterQual Criteria Sheets, MaineCare is also changing the process for submitting PAs. You no longer need to include the full criteria sheet in your submission to MaineCare. Instead, you must print, sign, date, and submit the first page of the criteria sheet, indicating the relevant clinical scenario number, and print only the completed clinical scenario sheet for the scenario that applies.
The 2013 McKesson InterQual Criteria Sheets can be accessed by logging into your Trading Partner Account on the Health PAS Online Portal and clicking on the Prior Authorization Document Library, and then on the Provider Prior Authorization Folder.
Reminder: There may be codes on McKesson’s InterQual Criteria Sheets that are not covered by MaineCare.
A new Prior Authorization Request form is also available. Please submit the new form with the criteria sheets. You can access the Prior Authorization Request form in the Authorizations and Referrals folder, on the Health PAS Online Portal.
If you have questions about the PA process, McKesson InterQual Criteria Sheets, or to verify what codes are covered, please contact Provider Services at: 1-866-690-5585.
Genetic Testing Reminder - April 9, 2014
MaineCare does not reimburse genetic testing services for treatment for psychological diagnoses/mental health issues as per the MaineCare Benefits Manual, Chapter 1:
1.06-5 Non-Covered Services
A. MaineCare will not reimburse for non-covered services. Providers may bill members for non-covered services only if, prior to the provision of the service, the provider has clearly explained to the member that MaineCare does not cover the service and that the member will be responsible for the payment. Providers must document in the member’s record that the member was told, prior to provision, that the service was not a MaineCare covered service and that the member is responsible for the payment.
B. The following services are considered non-covered services. Costs for these non-covered services are not reimbursable by MaineCare, or by the member unless the notification requirements described in Section 1.06-4(A) have been met.
MaineCare does not reimburse for:
- Services not described in the MaineCare Benefits Manual, or related Principles of Reimbursement;
Copayments Taken Multiple Times from Same Claim, TR 40909 - April 9, 2014
We have discovered an issue where copays were taken multiple times from the same claims submitted from 2/16/14 through 2/26/2014. This issue has been corrected and affected claims will be reprocessed in the upcoming weeks. No provider action is needed.
Issue Corrected: MaineCare Primary Claims Paying at Zero, TR 38415 - April 9, 2014
The issue where some claims were paying $0 when billing MaineCare for Part B services as the primary payer for a member who has Medicare Part A only has been corrected. Below, is the original message we sent on January 23, 2014, explaining the issue that has now been corrected:
MaineCare Primary Claims Paying at Zero, TR 38415
When billing MaineCare as primary payer, some claims are paying $0 in error. This issue is occurring when a member has Medicare Part A only, but the provider is billing Medicare Part B services to MaineCare. The claim is processing MaineCare as primary, but the system is not calculating the payment correctly. We will notify you when this issue is corrected and claims will be reprocessed. No provider action is needed.
Attn Optometrists: Corrected Rates for 92071 and 92072, CR 411140 - April 9, 2014
Effective April 1, 2014, the rates for 92071 and 92072 have been changed to the correct lower rate:
92071 is $18.87
92072 is $60.20
Issue Corrected: Bypass Edit 5031 for FQHC and RHC Claims, CR 39572 - April 9, 2014
FQHC and RHC claims should no longer deny when only one line on the claim denies.
Below, is the original message we sent on February 21, 2014, explaining the issue that has now been corrected:
Bypass Edit 5031 for FQHC and RHC Claims, CR 39572
Currently, FQHC and RHC claims are denying when only one line on the claim denies. These claims are identified in MIHMS with edit 5031, and the Remittance Advice reflects a Claims Adjustment Reason Code of 16 (Claim/service lacks information or has submission/billing error(s) which is needed for adjudication). We are working to correct this issue. Once corrected, claims will no longer deny when only one claim line denies. We will notify you once this issue is resolved.
MIHMS Eligibility Lookup Changes - April 14, 2014
When doing an Eligibility Verification on the secure part of the MyHealth PAS Online Portal, you will see that “Defined Benefits” is now called “Special Population with Limited Benefits.” You will also see this new term in the “MIHMS MaineCare Eligibility Document” found under the Definition of Benefits link, on the left menu of the Health PAS Online Portal. This document has been updated to include new sections of MaineCare policy.
If you have questions, please contact Provider Services, Monday through Friday, from 7:00 AM to 6:00 PM at: 1-866-690-5585 (TTY users dial 711) or MaineCareProvider@molinahealthcare.com.
Reduced Data-Entry Wait Time in Provider Enrollment and Maintenance Cases, CR 37387 - April 14, 2014
When using the Provider Enrollment Application (PEA) for provider enrollment or maintenance, the default setting is to save the entire application every time the user moves from one screen to another (auto-save). The application is also saved when the user clicks the ‘Save and Close’ button or ‘Submit’ button.
The auto-save feature reduces the chance that data will be unintentionally lost during a session. However, it substantially increases the amount of wait time between each screen.
This feature can be temporarily bypassed to allow users to move through the application much faster, making it easier to complete maintenance cases.
The following should be considered when deciding to turn off this feature:
If the internet connection is interrupted or the browser is closed before manually saving the information, all entered data will be lost.
Bypassing the auto-save feature is only good for the current application session. This feature must be turned off each time the PEA application is accessed.
To avoid losing data, the user must periodically manually save the application by clicking the “Save” button in the lower button bar.
To turn off the auto-save feature: 1. Start or re-open an enrollment or maintenance case. 2. Once past the login page, place the cursor in any field on the page and press the [Ctrl]+[Alt]+[S] keys at the same time. 3. A pop-up box will display a message indicating that the “Manual Save” feature is on and a new “Save” button will be displayed in the lower button bar to allow a manual save of the data. 4. Close the pop-up box to continue. To return to auto-save at any time in the application, press the [Ctrl]+[Alt]+[S] keys at the same time again.
If you need assistance, please contact the EDI Helpdesk, Monday through Friday from 7:00 AM to 6:00 PM, at: 1 (866) 690-5585, TTY users dial 711 or firstname.lastname@example.org
Code and Rate Additions, Deletions, and Corrections - April 14, 2014
We have recently created a “Code and Rate Additions, Deletions, and Corrections” spreadsheet that we will use to notify you of code and rate changes. You can view these spreadsheets on the Claims, Billing, and Enrollment webpage. When spreadsheets are added with new information, we will notify you via listserv message.
Primary Care Provider Incentive Payments (PCPIP) and Report Schedule - April 14, 2014
MaineCare is currently completing the PCPIP and PCPIP48 reports for the reporting period of 04/01/2012 - 03/31/2013.
The schedule is as follows:
The report will be mailed to eligible providers on Friday, 04/11/2014
The payment will be processed with the 04/16/2014 payment cycle
For any questions, please email PCP Network Services.
Attn Durable Medical Equipment (DME) Suppliers: Nebulizer Claims Denied in Error for MaineCare Members Under 21 Years of Age, CR 41322 - April 14, 2014
An issue was identified where nebulizer claims are being denied in error for MaineCare members under 21 years old. Currently, the system is configured to limit one (1) nebulizer per five (5) years for members under 21 years of age. We will notify you when this issue is corrected. Affected claims will be reprocessed.
Attn Section 21 Waiver Providers, CR 41382 - April 14, 2014
An issue was identified where Section 21 and 29 waiver service claims with code T2021 were denied in error.
You will see the following CARC (Claims Adjustment Reason Code) and/or RARC (Remittance Advice Remark Code) on a future Remittance Advice, and corresponding edits can be viewed on the MyHealthPAS Portal:
CARC - 119 - Benefit maximum for this time period or occurrence has been reached.
RARC N640 - Exceeds number/frequency approved/allowed within time period.
Edit 271-benefit restriction group validation failed
Edit 206 benefit visit limit exceeded.
We will notify you when this issue is corrected. Affected claims will be reprocessed and no provider action is needed.
New CMS 1500 Form, CR 35494 - April 14, 2014
As you know, Medicare began accepting the new CMS-1500 (2/12) claim form earlier this year and stopped accepting the old form as of 4/1/2014. MaineCare is currently accepting the new forms; however, we are only transferring the data that has previously been entered on the older form.
Box 14, DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP) – If two qualifiers are present, code 431 will be used
Box 15, OTHER DATE – If multiple qualifiers are present, code 439 will be used
Box 21, DIAGNOSIS OR NATURE OF ILLNESS OR INJURY – When submitting more than 4 diagnosis, only the first 4 will be captured
At this time, any new fields present or completed on the CMS-1500 (2/12) claim form will be disregarded. MIHMS is being updated to accept data from the new version CMS-1500 (2/12) claim form. We will continue to process both versions until then and will notify you when the older CMS-1500 version will no longer be accepted.