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    • 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:

      1. 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 mainecaresupport@molinahealthcare.com

         

    • 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.

      Please Note:

      • 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.

         

    • Prior Authorizations for CT and PET Scans: Age Requirement and Default Units (Pathways), CR 40069 - April 22, 2014

      Prior Authorizations (PA) entered into the MIHMS Health PAS Online Portal for Computed Tomography (CT) and Positron Emission Tomography (PET) Scans will be affected by the following changes:

      • The age restriction criteria, has been reconfigured for members under the age of 21 and over the age of 65 who do not require PA submission. Previously the age was rounding up to 65 when the member was 64 years old. The system has been corrected to recognize the day of the member’s 21st birthday until the day of their 65th birthday.

      • Previously, the system would default to two (2) units when none were entered. The system will now default to one (1) unit when a PA request is entered with no units.

      If you have questions, please contact Provider Services at: 1-866-690-5585 (TTY: 711) Monday – Friday 7:00 AM EST until 6:00 PM EST.

         

    • Benefit Lookup by Procedure Codes/Service Codes on the MyHealthPAS (MHP) Online Portal, CR 40069 - April 22, 2014

      On December 19, 2013, we notified you that the “Procedure Codes/Service Codes” lookup functionality was no longer available. This lookup functionality will be updated beginning Monday, April 21, 2014 and will be back online for your reference.

      You will notice the following changes:

      • Enhanced disclaimer language

      • A new hyperlink to the MaineCare Eligibility Document v2.0 with more details about plans and programs

      • All available benefits are now displayed to include used unit information.

      When a Procedure Code has been entered, the search returns all situations where the procedure code is potentially covered. In situations where policy-set limits have been met, additional units that may be available with prior authorizations are also displayed.

      This update includes additional detail that was not previously available. When there are situations where services can be provided without PAs or with PAs when limits have been met, multiple lines will now be returned, indicating all possible covered scenarios. An example is displayed below. One (1) Adult Prophylaxis service is allowed per rolling six (6) months without a PA. Once the limit is met, additional services can be prior authorized.

      In the example below, the following four (4) scenarios would be returned:

      A. Dental Services without PA; the used units displayed for these three lines represent the same unit allowed by policy.

      • D1110 Dental Services – Adult Prophylaxis W/O PA FQHC/RHC is the one allowed unit per rolling six months if delivered in a Federally Qualified Health Center or a Rural Health Center.

      • D1110 Dental Services – Adult Prophylaxis W/O PA is the one allowed unit per rolling six months if delivered in routine dental settings.

      • D1110 Dental Services – Adult Prophylaxis W/O PA is the one allowed unit per rolling six months if delivered in a Hospital setting (as specifically defined by policy). B. Dental Services with PA.

      • D1110 Service Covered, No Limit information Found which does require a PA, identifies those situations where the limit of (one) 1 service per rolling six (6) months has been met.

      If you have any questions about the information being presented, you must consult the MaineCare Benefits Manual.

      When doing procedure code lookups, please remember the following:

      • Members with Qualified Medicare Beneficiaries (QMB) Program eligibility participate in the Medicare Buy In Plan where MaineCare and Medicare participate in cost sharing. Procedure codes will show as covered. However, this coverage is only for MaineCare’s’ cost sharing portion. This does not apply to members with QMB Plus who are covered by full MaineCare.

      • Used units information only refers to visit limits set by MaineCare policy as opposed to units available under PAs. PA information can be viewed at the PA Status Screen.

      • Claims for services that are limited by MaineCare policy might be submitted by another provider prior to your claim. This can result in your claim being denied if all units have been used on the prior claim.

      If you have questions, please contact Provider Services at: 1-866-690-5585 (TTY: 711) Monday – Friday 7:00 AM EST until 6:00 PM EST.

         

    • Claims with Code J1050, CR -40731 - April 22, 2014

      Claims previously billed with J1050 for NDC codes 59762453802 and 00781932785 were denied because the NDC files do not contain those NDC codes. You can now bill for J1050 with these two codes for dates of services on or after 01/01/2013. Affected claims will be reprocessed and no provider action is needed.

      You can identify these claims on your Remittance Advice (RA) by the following reason codes:

      • CARC - 16 - Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

      • RARC - M119 - Missing/incomplete/invalid/deactivated/withdrawn National Drug Code (NDC).

      Please note: If you billed one unit, we are unable to reprocess your claims and you will need to rebill with the NDC code.

      Please contact your Provider Relations Specialist with questions related to timely filing.

         

    • Attn APRN and Optometrists: Claims Denied in Error, CR 41181 - April 22, 2014

      An issue was discovered where some independent Advance Practice Registered Nurse (APRN) and Optometrist contracts were end dated in error, causing claims to deny. This issue has now been corrected. Affected claims will be reprocessed and no provider action is needed.

         

    • Issue Corrected: Attn Durable Medical Equipment (DME) Suppliers: Nebulizer Claims Denied in Error for MaineCare Members Under 21 Years of Age, CR 41322 - April 22, 2014

      Nebulizer claims are now being processed correctly for MaineCare members under 21 years of age.

      Below, is the original message we sent on April 11, 2014, explaining the issue that has now been corrected:

      Attn Durable Medical Equipment (DME) Suppliers: Nebulizer Claims Denied in Error for MaineCare Members Under 21 Years of Age, CR 41322

      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.

         

    • Reprocessing Denied Durable Medical Equipment (DME) Services Sales Tax, TR 27389 - April 22, 2014

      On 12/13/2013, we notified you via listserv that an issue with DME services sales tax was corrected.

      This issue occurred when a claim was submitted with multiple DME lines where some lines paid while others denied and the sales tax line paid the full amount billed. Since the sales tax corresponds to both the paid and denied lines, the sales tax lines were overpaid.

      We will now begin to reprocess affected claims.

         

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