Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-9 - INDIAN HEALTH SERVICES › Subsection 144-101-II-9.06 - BILLING INSTRUCTIONS

Current through 2024-29, July 17, 2024
09.06-1.
Early and Periodic Screening, Diagnosis and Treatment Services
					 (EPSDT)
An Indian Health Center must bill using designated codes
						when providing Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
						services as described in Section 94 of the MaineCare Benefits Manual. EPSDT
						codes for use by Indian Health Center can be found at
http://brightfutures.aap.org/pdfs/Coding%20for%20preventive%20care_1pdf.pdf
.
The Indian Health Center must be enrolled as a provider
						under Section 94 of the MaineCare Benefits Manual and must follow all
						requirements outlined in that Chapter (including submission of the Bright
						Futures form) to bill under these codes. If the Indian Health Center provides
						EPSDT services and other medical services to the same individual as part of the
						same visit, the Center must bill only the EPSDT code. When immunizations are
						provided, the appropriate immunization and administration codes shall be noted
						on the CMS-1500 billing form, but no additional reimbursement shall be
						available. Diabetes education and asthma self-management shall also be billed
						using distinct codes found at
http://maa.dshs.wa.gov/download/Memos/2002Memos/02-61maa%20Asthma-Diabetes.pdf
.
09.06-2.
Same Day
					 Visits
A second, same day visit may be billed if it is medically
						necessary and could not have been anticipated by the Center's professional
						staff as documented in the members' record or when the first encounter is a
						medical visit and a second visit is a mental health visit. Billing codes for
						additional, same day visits must incorporate the appropriate code and/or
						modifier.
09.06-3.
Billing for Non-Tribal Members
In order to ensure appropriate federal financial
						participation, non-tribal members must be identified on the CMS 1500 claim
						form.
09.06-4.
Fee-for-service and reimbursement for Pharmacy and Ambulance
					 Services
Indian Health Centers have the option of obtaining a
						separate National Provider Identification (NPI) number for the limited purpose
						of fee-for-service billing and reimbursement for pharmacy, ambulance or any
						other ambulatory services in the State's Medicaid Plan, not covered under this
						Section. Such services must be provided in accordance with all applicable
						sections of the MaineCare Benefits Manual and will be reimbursed in accordance
						with those sections.
09.06-5.
Enrollment as a Federally
					 Qualified Health Center (FQHC)
Indian Health Centers may choose to enroll as Federally
						Qualified Health Centers (FQHCs) or Ambulatory Care Clinics. For purposes of
						billing Medicaid, each center may choose only one designation. Centers may
						remain FQHCs for the purposes of billing Medicare, while enrolling as
						Ambulatory Care Clinics under Medicaid. If permitted by a ruling from federal
						authorities, Indian Health Centers may bill retroactively as Ambulatory Care
						Clinics as allowed under that ruling. As a condition of enrollment Indian
						Health Centers must provide a copy of their contract with the Indian Health
						Services.
09.06-6.
Co-payment Exemptions
Section 5006(a) of the American Recovery and Reinvestment
						Act of 2009 (Recovery Act), Public Law 111-5 amends sections 1916 and 1916A of
						the Social Security Act, to preclude States from imposing Medicaid premiums or
						any other Medicaid cost sharing on Indian applicants and members served by
						Indian health providers and to assure that Indian health providers and
						providers of contract health services (CHS) under a referral from an Indian
						health provider, will receive full payment. A tribal member who is presently or
						has previously been eligible for CHS or to receive services through an I/T/U
						will be exempt from co-payments (onetime documentation is necessary to provide
						proof of present or previous I/T/U or CHS eligibility).