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.