reglab/statecodes huggingface dataset:
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-109 - Speech and Hearing Services › Subsection 144-101-II-109.02 - DEFINITIONS

Current through 2024-29, July 17, 2024
109.02-1
Audiology Services
means those services requiring the application of theories, principles and
					 procedures related to hearing and hearing disorders for the purpose of
					 assessment and treatment.
109.02-2
Augmentative and Alternative Communication Devices (AACD)
are
					 electronic or non-electronic aids, devices, or systems and related components,
					 accessories and supplies that assist in overcoming or ameliorating the
					 communication limitations that preclude or interfere with meaningful
					 participation in current and projected daily activities.
109.02-3
Augmentative and Alternative
					 Communication Services (AACS)
are services provided to assist the
					 individual in meeting the full range of his/her communication needs. The goal
					 of AACS is to overcome or ameliorate the communication limitations that
					 preclude or interfere with meaningful participation in current and projected
					 daily activities.
109.02-4
Hearing Aid Services
: The hearing aid benefit is described in
					 Chapter II, Section
					 60, "Medical Supplies and Durable
					 Medical Equipment".
109.02-5
Practitioner of the Healing Arts
: physicians and all others
					 registered or licensed in the healing arts, including, but not limited to,
					 nurse practitioners, podiatrists, optometrists, chiropractors, physical
					 therapists, occupational therapists, speech therapists, dentists, psychologists
					 and physicians' assistants.
109.02-6
Rehabilitation
					 Potential
is a documented expectation by the member's physician or PCP
					 (Primary Care Provider for members receiving MaineCare Primary Care Case
					 Management Services) that the member's condition will improve significantly in
					 a reasonable predictable period of time as a result of the prescribed treatment
					 plan. The physician or PCP's documentation of rehabilitation potential must
					 include the reasons used to support the physician or PCP's
					 expectation.
109.02-7
Speech
					 and Hearing Agency
is a facility that offers, at a minimum, both
					 speech-language pathology services and audiology services by qualified
					 professional staff who are employees of the speech and hearing agency.
					 Contracted staff are not considered employees.
109.02-8
Speech-Language Pathology
					 Services
are those services requiring the application of theories,
					 principles and procedures related to the development and disorders of speech,
					 voice, language, and oral pharyngeal and related functions, for purposes of
					 assessment and treatment.
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-109 - Speech and Hearing Services › Subsection 144-101-II-109.03 - ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
Members must meet the financial eligibility criteria as
						set forth in the
MaineCare Eligibility Manual
.Some members may
						have restrictions on the type and amount of services they are eligible to
						receive. It is the responsibility of the provider to verify a member's
						eligibility for MaineCare, as described in Chapter I, prior to providing
						services.
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-109 - Speech and Hearing Services › Subsection 144-101-II-109.04 - SPECIFIC ELIGIBILITY FOR CARE

Current through 2024-29, July 17, 2024
Services for members of all ages must be medically
						necessary and ordered by a practitioner of the healing arts as allowed by the
						respective licensing authority and his or her scope of practice. The Department
						or its authorized agent has the right to perform medical eligibility
						determination and/or utilization review to determine if services are medically
						necessary.
Adult members (age twenty-one (21) and over) must have an
						initial evaluation by a physician or PCP documenting that the member has
						experienced a significant decline in his/her ability to communicate
						orally/visually, safely swallow or masticate, and that the member has
						rehabilitation potential; or that the member may suffer a significant
						deterioration in ability to communicate orally/visually, safely swallow or
						masticate that would result in an extended length in stay or placement in an
						institutional or hospital setting. This requirement will not apply to members
						with Medicare coverage or other third party health insurance until the coverage
						for speech therapy services by the other payer has been
						exhausted.
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-109 - Speech and Hearing Services › Subsection 144-101-II-109.05 - DURATION OF CARE

Current through 2024-29, July 17, 2024
A. Each Title XIX
					 and XXI member is eligible for as many covered services as are medically
					 necessary as determined by the Department of Health & Human Services. The
					 Department reserves the right to request additional information to determine
					 medical necessity; and
B. Members
					 aged twenty-one (21) and older, who receive speech therapy services, must
					 obtain a re-evaluation of their progress in speech therapy by a speech-language
					 pathologist every six (6) months. The report of the speech-language
					 pathologist's progress and prognosis for improved speech, oral/visual
					 communication, swallowing or chewing functioning must be sent to a physician or
					 PCP, who must in turn, determine if the member meets the criteria described in
					 Section
					 109.04, "Specific
					 Eligibility for Care". Services will be covered only as long as the member
					 meets the eligibility requirements in 109.04.
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-109 - Speech and Hearing Services › Subsection 144-101-II-109.06 - SETTING

Current through 2024-29, July 17, 2024
MaineCare will reimburse speech and hearing services when
						provided in appropriate settings. Approved settings for these services are the
						practitioners' office, speech and hearing agencies, members' homes, and schools
						for members under age 21.
Services may be provided in an alternative setting at the
						practitioner's discretion when the following conditions are met:
1. The services are medically
					 necessary.
2. The setting is
					 conducive to the services being provided.
For speech and hearing services provided in a nursing
						facility or an ICF-MR by a speech-language pathologist or audiologist, refer to
						Chapter II, Section
						67, "Nursing Facility Services",
						or Section
						50, "ICF-MR Services".
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-109 - Speech and Hearing Services › Subsection 144-101-II-109.08 - LIMITATIONS

Current through 2024-29, July 17, 2024
109.08-1
Audiology Evaluation
If such an evaluation has already been performed by
						another audiologist within the previous four (4) months, prior authorization
						(PA) by the Department is required. Refer to Section 109.09-5, below, for
						procedure to request PA.
109.08-2
Adult Speech-Language
					 Pathology Services
The member must also receive an initial evaluation by a
						speech-language pathologist that supports the physician or PCP's determination
						that the member meets the eligibility criteria described in Section
						109.04, "Specific
						Eligibility for Care". If speech-language pathology services are to be
						continued beyond a period of six (6) months, a re-evaluation by a
						speech-language pathologist must be completed every sixth month from the
						initial determination of rehabilitation potential, in order to determine that
						eligibility continues to exist. A report of the results of the speech-language
						pathologist's six-month re-evaluation must be sent to the member's physician or
						PCP, who will use that information to decide if eligibility continues to exist.
						If the physician or PCP agrees in writing that eligibility continues to exist,
						the member may continue to receive speech-language pathology services for an
						additional six (6) month period.
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-109 - Speech and Hearing Services › Subsection 144-101-II-109.09 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
109.09-1
Records
The provider will maintain an individual record for each
						member eligible for MaineCare reimbursement, including but not limited
						to:
A. Name, birthdate, MaineCare ID
					 Number.
B. Referral from a
					 practitioner of the healing arts as allowed by the respective licensing
					 authority and his or her scope of practice, made in writing or by telephone
					 prior to the delivery of service. Written referral confirming a telephone
					 referral must be included in the record within thirty (30) days of the original
					 order.
C. Pertinent medical
					 information, as available, regarding the member's condition.
D. Appropriate hearing and/or speech-language
					 evaluation and diagnosis.
E. A plan
					 of care which includes identified problems, treatment in relation to the
					 problems, and obtainable goals. This plan shall be updated in relation to the
					 member's progress in reaching the goals.
F. Documentation of each visit, showing the
					 date of service, the service performed, the start time and stop time of the
					 service, indicating the total time spent in delivering the service, and the
					 signature of the individual performing the service.
G. Progress notes written regularly (at least
					 quarterly), which state the progress which the member has made in relation to
					 the plan of care.
H. A discharge
					 summary with a copy sent to the referring practitioner of the healing
					 arts.
I. Copies of prior
					 authorization or any other pertinent information concerning the member.
Members' records will be kept current and available to
						the Department as documentation of services included on invoices.
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-109 - Speech and Hearing Services › Subsection 144-101-II-109.10 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
The maximum amount of payment for services rendered is
						the lowest of the following:
A. The
					 provider's usual and customary charge,
B. The amount listed in Chapter III, Section
					 109 of the
MaineCare
					 Benefits Manual
,
C. The
					 lowest amount allowed by Medicare Part B, when applicable.
In accordance with Chapter I of the
MaineCare
						Benefits Manual
, it is the responsibility of the provider to seek
						payment from any other resources that are available for payment of the rendered
						service prior to billing MaineCare.
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-109 - Speech and Hearing Services › Subsection 144-101-II-109.11 - COPAYMENTS

Current through 2024-29, July 17, 2024
109.11-1
Copayment Amount
A. A copayment will be charged to each
					 MaineCare member receiving speech pathology services, with the exception of
					 those exempt, as specified in the
MaineCare Eligibility
Manual, such as children. The amount of the copayment shall not exceed $2.00
					 per day for services provided, according to the following schedule:
MaineCare Payment for Service
Member Copayment
$10.00 or less
$ .50
$10.01 - 25.00
$1.00
$25.01 or more
$2.00
B. The member shall be responsible for
					 copayments up to $20.00 per monthwhether the copayment has been paid or not.
					 After the $20.00 cap has been reached, the member shall not be required to make
					 additional copayments and the provider shall receive full MaineCare
					 reimbursement for covered services.
C. No provider may deny services to a member
					 for failure to pay a copayment. Providers must rely upon the member's
					 representation that he or she does not have the cash available to pay the
					 copayment. A member's inability to pay a copayment does not, however, relieve
					 his/her liability for a copayment.
Providers are responsible for documenting the amount of
						copayments charged to each member (regardless of whether the member has made
						payment) and shall disclose that amount to other providers, as necessary, to
						confirm previous copayments.
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-109 - Speech and Hearing Services › Subsection 144-101-II-109.12 - BILLING INFORMATION

Current through 2024-29, July 17, 2024
Providers must bill in accordance with the Department's
						"Billing Instructions for the CMS1500 Claim Form."
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-113 - Non-Emergency Transportation (NET) Services › Subsection 144-101-II-113.02 - NON-EMERGENCY TRANSPORTATION REGIONS

Current through 2024-29, July 17, 2024
Brokers oversee NET services on a regional basis. Each
						Broker is responsible for arranging all NET services for eligible Members that
						reside in its assigned region(s). The Broker may not coordinate transportation
						for Members who reside outside its region(s) except when: (1) coordination
						between Brokers is necessary to adequately and timely ensure a Member's access
						to NET services; or (2) the Member resides out-of-state for medical reasons.
When a MaineCare Member resides out-of-state for medical
						reasons, as approved by the Department, NET services shall be provided by the
						Broker located in the region most geographically proximate to the Member's
						out-of-state residence. Geographic proximity is defined as the shortest
						straight line distance between the Member's out-of-state residence and any
						point along the border of the state of Maine.
On a monthly basis, the Department will provide each
						Broker with a list of approved Members residing out-of-state who are assigned
						to the Broker's region(s). This list is subject to change between the
						Department's monthly reporting to the Broker. The Broker may not use the
						absence of a Member's name on the list as the sole reason to deny NET services
						to the Member.
The following map details the regional boundaries.
Click to
						view image
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-113 - Non-Emergency Transportation (NET) Services › Subsection 144-101-II-113.03 - ELIGIBILITY FOR SERVICES

Current through 2024-29, July 17, 2024
Members who meet the financial, residency and
						eligibility criteria found in the MaineCare Eligibility Manual qualify for
						Non-Emergency Transportation (NET) Services. Some Members may have restrictions
						on the type and amount of underlying services they are eligible to receive. It
						is the responsibility of the Broker to verify a Member's eligibility for
						MaineCare services, as described in the MaineCare Benefits Manual (MBM),
						Chapter I, General Administrative Policies and Procedures,
prior to
						providing services
. All Members who receive services under waivers are
						eligible to receive services under Section 113.
Refusal to cooperate and provide requested documents by
						the Member may be cause for the denial of services. Members must have no other
						means to reach the covered service, therefore requiring the Department's
						transportation services.
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-113 - Non-Emergency Transportation (NET) Services › Subsection 144-101-II-113.04 - COVERED TRANSPORTATION SERVICES

Current through 2024-29, July 17, 2024
113.04-1
Covered Transportation services include:
A.
Non-emergency transportation to
					 covered MaineCare services.
The Broker must ensure the availability of
					 wheelchair-accessible vehicles. The Broker may utilize wheelchair van
					 companies, taxis, other agency vehicles, or family, friends or volunteers with
					 vehicles that meet wheelchair accessibility standards and the individual
					 Member's mobility needs.
B.
Transportation to a pharmacy to
					 obtain MaineCare covered medication.
C.
Related travel expenses, such as
					 meals and lodging.
In addition to the provision and reimbursement of
					 transportation services, the Broker, at its sole expense, must cover and
					 reimburse related travel expenses in providing NET services. However, the
					 Broker shall not reimburse related travel expenses when NET services are
					 provided to transport a Member to a medical service that requires prior
					 authorization in writing by the Department, and for which prior authorization
					 was either not obtained or denied.
D.
Minor Traveling with Adult
					 Members:
There may be times when an adult Member requests to allow a
					 minor to accompany the Member to an appointment, not as an Escort, but because
					 the Member does not have alternate childcare available. If there is room or an
					 available seat, the Broker will allow a child or children to be transported
					 with the adult Member who requires the MaineCare
					 service
.
E.
Inpatient minors:
A parent, foster parent or guardian is eligible
					 to be transported to visit his or her MaineCare or Member minor child (age 17
					 or younger) who is an inpatient of a hospital, whether or not the parent is
					 MaineCare eligible him or herself. These trips are limited to the child's
					 period of hospitalization. Transportation of individuals who are not MaineCare
					 Members should be reported under the minor child's MaineCare eligibility
					 number. Transportation to visit an inpatient adult MaineCare Member is not
					 covered.
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-113 - Non-Emergency Transportation (NET) Services › Subsection 144-101-II-113.05 - NON-COVERED SERVICES

Current through 2024-29, July 17, 2024
Non-Emergency Transportation (NET) services do not
						include:
A. Ambulance Services:
					 Ambulance Services are covered in the MaineCare Benefits Manual, Section 5
					 (Ambulance Services);
B.
					 Transportation for individuals residing in Nursing Facilities and for
					 individuals residing in Intermediate Care Facilities for individuals with
					 Intellectual Disabilities or Pervasive Developmental Disorders (ICF-IIDs)
					 unless there is a written request from the facility to the Department that it
					 is unable to supply the transportation for good cause, the transportation is
					 for medically necessary medical service, and that written request has been
					 prior approved by the Department;
C. Transportation to visit a sick infant or
					 child or critically ill/injured spouse, except as allowed above for visits by a
					 parent, foster parent, or guardian to his or her children admitted to a
					 hospital under an inpatient status. Transportation to visit an inpatient adult
					 MaineCare member is not covered.
D.
					 Transportation for individuals ineligible for NET services. Brokers must verify
					 Member eligibility prior to authorizing transports.
E. Transportation to return a Member to Maine
					 from another state, unless the Member was in another state for the purpose of
					 obtaining MaineCare approved medical services.
F. Transportation for Members when those same
					 trips are available at no cost to the general public or when the general public
					 is being transported in the same vehicle at no cost. Brokers may waive this
					 requirement for Members for whom free transportation is medically
					 inappropriate.
G. Transportation
					 where no actual Member transport occurred, even if the NET services may have
					 been authorized by the Broker, such as a no-show or a cancellation.
H. Transportation for Members to see
					 providers not enrolled in MaineCare.
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-113 - Non-Emergency Transportation (NET) Services › Subsection 144-101-II-113.06 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
113.06-1
Broker Agreements
A. Broker(s)
					 are required to have a current executed MaineCare Provider Agreement with the
					 Department.
B. Broker(s) are
					 required to have a current executed Business Associate Agreement with the
					 Department.
C. Brokers are
					 required to have a current executed contract for NET services with the
					 Department.
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-113 - Non-Emergency Transportation (NET) Services › Subsection 144-101-II-113.07 - NET ADVISORY COMMITTEE

Current through 2024-29, July 17, 2024
The Broker will establish and convene a Regional NET
						Advisory Committee for the region(s) in which it operates. This NET Advisory
						Committee shall convene at least once every six (6) months to review and
						discuss the Broker's performance in the region(s). Topics may include
						coordination with local transportation companies, service expectations,
						coordination of services with any Federally Recognized Native Tribes in the
						region, or any other topic determined relevant by the Broker or the Department.
						The Committee shall serve in an advisory capacity only. The Broker will notify
						the Department of scheduled meetings and provide minutes and action items from
						the meetings to the Department. The Department may attend any scheduled
						meetings.
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-113 - Non-Emergency Transportation (NET) Services › Subsection 144-101-II-113.08 - PERFORMANCE STANDARDS

Current through 2024-29, July 17, 2024
The Broker will be required to meet all performance
						standards and reporting requirements as defined herein and in the contracts
						between the Brokers and the Department. The Broker must submit monthly Reports
						detailing performance in a format that is agreed upon by the
						Department.
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-113 - Non-Emergency Transportation (NET) Services › Subsection 144-101-II-113.09 - REPORTING REQUIREMENTS

Current through 2024-29, July 17, 2024
Brokers shall collect data on Member and Transporter
						characteristics, as specified by the Department, and on services furnished to
						Members through an encounter data system, as may be specified by the
						Department. The Broker shall submit encounter data to the State's Medicaid
						Management Information System (MMIS)-Maine Integrated Health Management
						Information System (MIHMS)-monthly, no later than the 15th of the month, for
						encounters related to service performed during the previous month. Encounter
						data shall be submitted in a HIPAA-compliant format (X12N and NCPDP format
						required by federally mandated timelines in effect at the time of
						submission).
The Broker shall submit "clean" American National
						Standards Institute (ANSI) ASC X 12N standard 837P claims encounter
						transactions as if submitting claims for payments, which document all NET
						services provided the previous month. The claims must comply with the current
						billing standards and must have at least the following information:
Documentation must include:
1. Date of service;
2. Transporter name;
3. Time driver/vehicle leaves base station to
					 begin transporting members;
4.
					 Point of Origin;
5. Drop-off
					 location (destination);
6 Return
					 time to base station;
7. Authorized
					 signature of Transporter (on file);
8. Mileage.
When appropriate to the service provided, Brokers shall
						report the current Healthcare Common Procedure Coding System (HCPCS) modifiers.
Examples:
Modifier
Description
D
Diagnostic or therapeutic site other than "P" or
								  "H" when these are used in origin codes
E
Residential, domiciliary, custodial facility
								  (other than 1819 facility)
G
Hospital-based ESRD facility
H
Hospital
I
Site of transfer (examples: airport or helicopter
								  pad) between modes of ambulance transport
J
Free standing ESRD facility
N
Skilled nursing facility (SNF)
P
Physician's office
R
Residence
S
Scene or accident or acute event
X
Intermediate stop at physician's office on way to
								  hospital (destination code only). Please note that Modifier X can only be used
								  as a destination code in the second position of a modifier.
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-113 - Non-Emergency Transportation (NET) Services › Subsection 144-101-II-113.10 - DENIAL OF SERVICES, COMPLAINT PROCEDURES, AND MEMBER APPEAL RIGHTS

Current through 2024-29, July 17, 2024
113.10-1.
Denial of Services
A. The Broker may deny a trip or immediately
					 discontinue a trip for any individual under the following circumstances:
1. The individual is found to be ineligible
					 for NET services on the basis of the information provided and available to the
					 Broker, including:
a. The individual is not
					 MaineCare eligible;
b. The
					 individual is not going to a covered MaineCare service; or
c. The individual is not medically eligible
					 for the coveredMaineCare service
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-113 - Non-Emergency Transportation (NET) Services › Subsection 144-101-II-113.11 - FRAUD AND ABUSE

Current through 2024-29, July 17, 2024
A. The Broker shall
					 have internal controls, policies and procedures in place designed to prevent,
					 detect, and report known or suspected instances of fraud and abuse. Such
					 policies and procedures must be in accordance with Federal regulations
					 described in 42 CFR Parts 455 and 456.
B. The Broker shall not allow the use of
					 Medicaid-funded transportation for any purpose other than as stated in this
					 policy, or in violation of any State or Federal law.
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-113 - Non-Emergency Transportation (NET) Services › Subsection 144-101-II-113.12 - CONFIDENTIALITY AND PRIVACY

Current through 2024-29, July 17, 2024
A. Pursuant to
					 state and federal laws, the Broker(s) shall maintain Member confidentiality and
					 shall only disclose such information as is necessary to determine a Member's
					 eligibility for NET services, to schedule transportation, and to provide
					 medical transportation. All Broker staff are required to sign a Confidentiality
					 Statement agreeing to maintain Member confidentiality.
B. Personal information about Members, their
					 treatment, or medical diagnoses shall not be relayed to the Transporters,
					 except for information necessary for meeting the Member's transportation needs.
					 Information which is important to meeting the Member's needs can be relayed to
					 Transporter, including: physical limitations, need for assistance, special
					 equipment used by Members, emotional or mental issues affecting the Member
					 during transport, and need for assistance entering or exiting a vehicle or
					 getting to or from the vehicle and home or medical office.
C. In the event that the Department
					 determines that disclosure of protected health information (PHI) of any or all
					 populations eligible for NET services under this rule require a signed
					 authorization to disclose such information, the Broker shall obtain such
					 authorization in writing from a Member, prior to disclosing any such PHI about
					 the Member. If a Member refuses to authorize disclosure of any information
					 which is required to verify Member and trip eligibility or otherwise is
					 required to authorize transportation services under this Section, the Member
					 may be denied transportation services.
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-150 - STD Screening Clinic Services (repealed)

Current through 2024-29, July 17, 2024
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-5 - AMBULANCE SERVICES › Subsection 144-101-III-5.00 - INTRODUCTION

Current through 2024-29, July 17, 2024
This section is a fee table. The table contains both
						fixed fees and fees based upon 100% of the current published Medicare rates
						depending upon the type of ambulance service provided and upon approval by the
						Centers for Medicare and Medicaid Services CMS. Providers should bill in
						accordance with the criteria cited below. Providers who bill in accordance with
						electronic information from the MaineCare Services website are still subject to
						the regulations pertaining to individual MaineCare benefits.
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-5 - AMBULANCE SERVICES › Subsection 144-101-III-5.01 - CODING

Current through 2024-29, July 17, 2024
Approximately once a year CMS issues to participating
						states a Healthcare Common Procedure Coding System (HCPCS) transaction list
						that includes additions to and deletions from the current schedule of
						codes.
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-5 - AMBULANCE SERVICES › Subsection 144-101-III-5.02 - DEFINITIONS

Current through 2024-29, July 17, 2024
Following are definitions for several terms which are
						used frequently throughout this publication:
5.02-1
HCPCS Codes:
Alpha-numeric codes, developed by the United States Department of Health and
					 Human Services. For the most part, HCPCS codes are used to describe health care
					 services rendered by providers other than physicians (ex: ambulance,
					 chiropractic, etc.). There are some HCPCS codes, however, which will be used by
					 physicians.
5.02-2
Modifiers:
A modifier is a two-character code added as a suffix to
					 the procedure code. A modifier provides the means whereby the reporting
					 provider can indicate that a service that has been performed has been altered
					 by some specific circumstances, but not changed in its definition or code.
					 Modifiers and their use are discussed in greater detail below.
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-5 - AMBULANCE SERVICES › Subsection 144-101-III-5.03 - MODIFIERS

Current through 2024-29, July 17, 2024
MaineCare will accept the two character modifiers listed
						on the following pages. Although CPT guidelines allow for the use of numeric
						modifiers up to five characters long (in addition to the procedure code),
						MaineCare only accepts and processes two character modifiers.
As with the procedure codes, there are two types of
						modifiers: CPT modifiers, which are numerical; and HCPCS modifiers, which are
						alphabetical. Modifiers can be used interchangeably with all codes; that is CPT
						modifiers can be used with HCPCS codes, etc. Some modifiers are meant to affect
						the fee payable for a particular service. These are called pricing
						modifiers.
Other modifiers do not affect the pricing of a
						particular code, but they do describe more accurately the service being
						provided. These are called descriptive modifiers.
There are several modifiers that define services not
						covered by MaineCare. These modifiers have not been included in the following
						list. Modifier(s) listed in this section must be selected to describe the
						appropriate service.
Single letter modifiers must be combined to indicate the
						origin and destination of the trip. For example, base transport from the
						member's home to the hospital would be coded A0428RH, while base transport from
						the hospital to the member's home would be coded A0428HR.
5.03-1
Descriptive Modifiers
Modifier
Definition
D
Diagnostic or therapeutic site other than "P" or
								  "H" when these are used as origin codes.
E
Residential, domiciliary, custodial facility.
G
Hospital-based dialysis facility (hospital or
								  hospital-related).
H
Hospital.
I
Site of transfer (e.g., airport or helicopter pad)
								  between modes of ambulance transport.
J
Non hospital-based dialysis facility.
N
Nursing facility.
P
Physician's office (includes HMO non-hospital
								  facility, clinic, etc.)
R
Residence.
S
Scene of accident or acute event.
X
(Destination code only) intermediate stop at
								  physician's office enroute to the hospital (includes HMO non-hospital facility;
								  clinic, etc.)
QL
Patient pronounced dead after ambulance called.
5.03-2
Pricing Modifiers
Modifier
Definition
H9
Court-ordered. [This modifier is to be
								used to designate when reimbursement should be paid at the Emergency
								Involuntary Admission to a Psychiatric Facility (Blue Paper) ambulance run and
								mileage rates].
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-5 - AMBULANCE SERVICES › Subsection 144-101-III-5.04 - ELEMENTS OF HCPCS CODING

Current through 2024-29, July 17, 2024
HCPCS codes for services are arranged in tabular form.
						Specific information regarding each code is given under the following
						headings:
1.
Procedure
					 Code
The actual HCPCS procedure code will be listed in this
					 column.
2.
HCPCS
					 Description
The narrative description of the procedure will appear here
					 along with any age restrictions.
3.
Maximum Allowance
This column will show the maximum reimbursement
					 MaineCare will allow for a particular procedure. Please remember that MaineCare
					 pays the lowest of the usual and customary charge, the Medicare maximum rate,
					 or the MaineCare maximum allowance.
4.
Prior Authorization
Some
					 procedures require prior authorization in order for MaineCare to allow payment.
					 If prior authorization is required, it will be indicated by the message "Yes"
					 in this column.
5.
Modifier
					 Required
Add two-letter modifier as a suffix to codes
					 (origin/destination). Codes that require modifier will be indicated by the
					 message "yes" in this column.
Not all procedures are reimbursable in every setting. If
						you have a question as to whether or not a particular service can be rendered
						in a particular setting, please consult Chapter II, Section 5 of the
MaineCare Benefits Manual
or contact your Provider Relations
						Specialist.
General
The procedure codes and descriptions
						for Ambulance Services as listed below are to be used in completing the CMS
						1500 Claim Form.
Please Note
: Where Departmental review
						indicates charges and payments in excess of the Medicare Part B allowed amount
						at the time of service delivery, the Department will seek restitution for any
						payments that exceed the Medicare allowance.
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-5 - AMBULANCE SERVICES › Subsection 144-101-III-5.05 - MEDICARE PERCENTAGE RATES

Current through 2024-29, July 17, 2024
Effective March 1, 2015 and upon approval by CMS,
						MaineCare Ambulance Services codes with Medicare equivalents are reimbursed at
						65% of the current published Medicare rates.
*Effective January 1, 2020, MaineCare Ambulance Services
						codes with Medicare equivalents are reimbursed at 100% of the current published
						Medicare rates.
* The Department shall submit to CMS and
						anticipates approval for a State Plan Amendment related to these
						provisions.
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-5 - AMBULANCE SERVICES › Subsection 144-101-III-5.07 - NOTES

Current through 2024-29, July 17, 2024
A. This code is to be used for air ambulance
					 layover charges, for air ambulance landing fees, and for any other air or
					 ground ambulance service which is not otherwise classified. Claims for such
					 services shall be evaluated individually as the claim is processed and only
					 actual cost will be reimbursed.
The air ambulance layover charge is limited to $65.00
						per hour, plus reasonable expenses incurred by employees covered under Chapter
						II, Section 5 of the MaineCare Benefits Manual either when the return flight is
						delayed due to poor weather conditions or while waiting for the member when it
						has been determined that the charges while waiting would be less than making
						two separate trips.
Reimbursement for air ambulance landing fees is limited
						to $48.00.
Ambulance services not otherwise classified shall cover
						all medically necessary services not identified in any of the codes.
B. The fixed-wing per transport
					 rate shall cover all costs associated with financing the fixed wing aircraft
					 and providing equipment, supplies, routine personnel and all necessary medical
					 services administered to the member. The fixed wing per transport rate shall
					 also cover all administrative costs associated with providing the air ambulance
					 services and arranging for the land ambulance services as specified in Chapter
					 II, Section 5 of the MaineCare Benefits Manual.
C. Air Helicopter Base Rate may be billed in
					 conjunction with Rotary Wing Air Mileage. This reimbursement shall cover all
					 costs associated with providing equipment, supplies, personnel, and all
					 necessary medical services provided to the member which are not already
					 reimbursed through the air helicopter service reimbursement. The air helicopter
					 base rate shall also cover all administrative costs associated with providing
					 the air helicopter services and arranging for the land ambulance services as
					 specified Chapter II, Section 5 of the MaineCare Benefits Manual.
D. Use modifier H9 to designate Basic Life
					 Support Non-Emergency Transports (Procedure Code A0428) and ground mileage
					 (Procedure Code A0425) performed under the auspices of an Emergency Involuntary
					 Admission to a Psychiatric Facility (Blue Paper) commitment
					 proceeding.
E. Reimbursement for
					 neonatal transport services under MaineCare are developed using the currently
					 published Medicare rate for procedure code A0434-Specialty Care Transport
					 (SCT).
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-7 - Free-standing Dialysis Services

Current through 2024-29, July 17, 2024
CODE
HCPCS ***
CODE
DESCRIPTION
MAXIMUM
ALLOWANCE
0821
90999
HEMODIALYSIS/COMPOSITE
BY REPORT
0825
90993, 90989
SUPPORT SERVICES (HEMODIALYSIS
BY REPORT
0831
90999
PERITONEAL DIALYSIS/COMPOSITE
BY REPORT
0835
90993, 90989
SUPPORT SERVICES (IP)
BY REPORT
0841
90999
CAPD/COMPOSITE
BY REPORT
0845
90993, 90989
SUPPORT SERVICES/CAPD
BY REPORT
0849
90945
OTHER CAPD DIALYSIS
BY REPORT
0851
90999
CONTINUOUS CYCLING PERITONEAL DIALYSIS (CCPD)
BY REPORT
0855
90993, 90989
SUPPORT SERVICES (CCPD)
BY REPORT
0634 *
EPO- INJECTION, EPOETIN ALFA, under 10,000 UNITS
BY REPORT
0635 *
EPO- INJECTION, EPOETIN ALFA, above 10,000 UNITS
0636**
ARANESP- INJECTION, DARBEPOETIN ALFA, 1 MCG
BY REPORT
* Providers must also put HCPCS Q4081 on claim form.
* * Providers must also put HCPCS JO882 on claim
					 form.
*** These HCPCS codes will become effective upon
					 implementation of MIHMS.
(APA Office Note: This occurred on
					 September°1, 2010.)
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-12 - Allowances for Consumer-Directed Attendant Services

Current through 2024-29, July 17, 2024
The Department is seeking and anticipates receiving
					 CMS approval for this Section.
There are four separate proposed rate changes pending
					 before CMS: one submitted in September 2015, one submitted in July 2016, one
					 submitted in August 2017, and one submitted in July 2018; thus there are four
					 retroactive effective dates applicable for these rates.
Pending CMS approval, the following rates will be
					 effective.
PROCEDURE CODE
DESCRIPTION
UNITS
AMOUNT
Effective 10/1/15
AMOUNT
Effective 7/29/16 to 2/21/17
AMOUNT
Effective 2/22/17 to 6/30/17 and 7/1/18 to
								7/31/18
AMOUNT
Effective 7/1/17 - 6/30/18
AMOUNT
Effective 8/1/18 to 6/30/19
AMOUNT
Effective 7/1/19
S5125 U2
Attendant Care Services
15 minutes
$2.93
$3.33
$3.33
$3.66
$4.07
$3.73
S5125 U2 UN
Attendant Care Services 2 person
15 minutes
N/A
N/A
$1.83
$2.01
$2.24
$2.05
S5125 U2 UP
Attendant Care Services 3 person
15 minutes
N/A
N/A
$1.33
$1.47
$1.63
$1.49
H2014
Skills Training Service
15 minutes
$14.03
$14.03
$14.03
$14.03
$14.03
$14.03
G9001
Care Coordination Service - Initial Visit
15 minutes
$17.00
$17.00
$17.00
$17.00
$17.00
$17.00
G9002
Care Coordination Service - Ongoing
15 minutes
$17.00
$17.00
$17.00
$17.00
$17.00
$17.00