Attention Section 31, Federally Qualified Health Centers (FQHCs): New Rates Implemented

As of May 10, 2023, new rates resulting from the Department’s rate determination for Section 31, FQHCs are now available for billing in MIHMS. The new rates are retroactive to March 1, 2023.  

Last week, the Department provided billing guidance to FQHCs to prepare them for the updated payment methodology and rates, including how to bill for services that are now outside the encounter rate and to allow for easier adjustment of claims by providers and the Department after implementation. Please see below for further guidance. 

MaineCare Adjustments: for the following services that were reimbursed at the encounter rate and have now moved to Fee-For-Service (FFS), MaineCare will adjust claims that providers submitted for services delivered on or after March 1st, billed with a charge equal to or greater than the new FFS rate: 

  • Injectable drugs for treatment of Opioid Use Disorder (OUD) (under Section 90)  

  • Services for and associated with Dental Crowns and Dentures (under Section 25) 

Provider Adjustments: Providers will need to adjust FFS claims originally billed with a $0 charge. The charge on the adjustment claim will need to be equal to or greater than the new FFS rate. Providers have 120 days from the date of this notice or 120 days from the date of the paid Remittance Advice (RA) (whichever is greater) to adjust affected claims. Providers should focus on the oldest paid claims first.  

If you billed for services that are reimbursed outside of the encounter rate, and the charges were at or above the final rates, MaineCare will adjust your claims and no action is needed. 

Reminder: Providers must deliver and bill all services according to the requirements outlined in relevant sections of the MBM unless otherwise noted in Section 31. E.g., all dental services must meet requirements outlined in Section 25, Dental Services.  

Please contact Shannon Beggs, Provider Relations Specialist, with any questions.  

Rate Letters: Effective May 12th, you can access the updated Calendar Year (CY) 2023 FQHC rate letters on the Health PAS Online Portal. You can view them by logging into your Trading Partner Account and following this pathway: File Exchange > Reports > Rate Setting Letters.    

If you have questions about accessing the letters, please contact Provider Services at: 1-866-690-5585. If you have questions about the content of the letters, please contact Rate Setting directly using the contact name and phone number on the letters.