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 III - Allowances for Services › Section 144-101-III-45 - HOSPITAL SERVICES › Subsection 144-101-III-45.02 - GENERAL PROVISIONS

Current through 2024-29, July 17, 2024
45.02-1
Inflation
For purposes of determining inflation, unless otherwise
						specified, the economic trend factor from the most recent edition of the
						"Healthcare Cost Review" from IHS Mark it is used.
45.02-2
Third Party Liability
					 (TPL)
When a member is admitted to a hospital, it is the
						hospital's responsibility to identify all coverage available and perform all
						procedural requirements of that identified coverage to assure proper
						reimbursement. The Department will remove claims data from the MaineCare paid
						claims history when the TPL reimbursement for that claim is equal to or exceeds
						MaineCare reimbursement. Please see Chapter I Section
						1.07 of the
MaineCare Benefits Manual
for detailed definitions applicable
						to Third Party Liability. Providers must adhere to the procedures outlined in
						that Section. Any MaineCare claims data submitted by a hospital may only be
						withdrawn within one hundred twenty (120) days of the date of the remittance
						statement.
45.02-3
Interim and Final Cost Settlements
At interim and final settlements, the hospital will
						reimburse the Department for any overpayments within thirty (30) days of
						receipt of the settlement report, or the Department will reimburse the amount
						of any underpayment to the hospital. Each Interim and Final Cost Settlement
						Report must be treated separately for purposes of remitting checks for
						overpayment and underpayment. If no payment is received within thirty (30)
						days, the Department may offset prospective interim payments, if permitted by
						federal and state law. Any caps imposed on Prospective Interim Payments (PIPs)
						are not applicable to the determination of settlement amounts.
The final settlement will not be performed until the
						Department receives the Medicare Final Cost Report. If the Medicare Final Cost
						Report has been received by the Department prior to the issuance of the Interim
						Cost Settlement Report, the Department will issue only a Final Cost Settlement
						Report.
Pursuant to
						PL
						2007, P & S Law, Chapter 19, when carrying out
						final and interim settlements of payments, the Department shall pay all final
						settlements for hospital fiscal years 2003 and earlier prior to paying interim
						settlements for services for hospital fiscal years 2005 and later. This does
						not limit the Department's authority to:
1. Make ongoing MaineCare payments for
					 services being rendered during the current fiscal year; or
2. Provide partial settlements for hospital
					 fiscal years 2004 and later to certain hospitals in need of such relief in
					 order to relieve financial hardship. Financial hardship is determined by the
					 Department and includes consideration of such factors as a high settlement
					 amount due as a percent of total patient revenue, significant negative
					 operating margins and/or negative cash flow as reflected on audited financial
					 statements.
The provider must submit a written request for a hardship
						waiver to the DHHS Commissioner sixty (60) days from the due date for the
						hospital's MaineCare cost report. All supporting documentation must be
						submitted with the request. The Department will not make a determination of
						financial hardship until resources are available to issue interim or final
						hospital audit settlements. The Department may request additional information
						to support the provider's claim of financial hardship before making a
						determination.