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 I - Specific Policies By Service › Sec2 144-101-I-1 - GENERAL ADMINISTRATIVE POLICIES AND PROCEDURES › Subsection 144-101-I-1.09 - COPAYMENT

Current through 2024-29, July 17, 2024
A copayment will be charged to each MaineCare member
						each time certain MaineCare services are provided if stipulated in the Chapter
						and Section of this Manual covering those services. If a section does not
						specify that copays be charged, no MaineCare copayment is collected from
						MaineCare members for services provided under that section. If a copayment is
						required, the exact amount of the copayment shall be as specified in the MBM
						that covers the specific service provided.
1.09-1
Copayment Amount
This section supplements the copayment information
						included in all sections of Chapter II of the MBM, except in those sections
						where additional provisions are specifically noted.
A. The member shall be responsible for
					 copayments up to the limit per month specified in the section of Chapter II
					 covering the particular service, whether the copayment has been paid or not.
					 The limit may vary, depending upon the service type. After the monthly 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.
B. 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 money available to
					 pay the copayment. A member's inability to pay a copayment does not relieve
					 him/her of liability for a copayment.
C. Providers are responsible for documenting
					 the amount of copayments charged to each member regardless of whether the
					 member has made payment.
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 I - Specific Policies By Service › Sec2 144-101-I-1 - GENERAL ADMINISTRATIVE POLICIES AND PROCEDURES › Subsection 144-101-I-1.10 - SUBMISSION OF CLAIMS

Current through 2024-29, July 17, 2024
1.10-1
Claims
A. Charges to the
					 Department for services provided under MaineCare are to be submitted only on
					 original claims approved by MaineCare Services, or in the electronic format
					 approved by MaineCare Services. The MaineCare Services web site contains
					 information pertaining to billing instructions. MaineCare providers must
					 include their NPI on all MaineCare claims.
B. Claims based on orders or referral from
					 Non-Billing, Ordering, Prescribing and Referring Providers (NOPR) will be
					 denied if the NOPR is not enrolled with MaineCare, and if the claim does not
					 submit the NPI of the MaineCare NOPR.
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 I - Specific Policies By Service › Sec2 144-101-I-1 - GENERAL ADMINISTRATIVE POLICIES AND PROCEDURES › Subsection 144-101-I-1.11 - PAYMENT PROCESS

Current through 2024-29, July 17, 2024
1.11-1
Payments
The Office of the State Treasurer issues all payments. A
						Remittance Advice (RA) is generated with each payment showing the payment or
						denial of specific claims. Payment will be made by Electronic Fund Transfer
						(EFT), unless the provider is unable to accept payment in this manner. In those
						cases the Office of the State Treasurer shall provide an alternative method of
						payment.
1.11-2
National Correct Coding Initiative Edits
A. MaineCare will perform National Correct
					 Coding Initiative (NCCI) Edits on all outpatient UB-04 and 1500 claims forms.
					 There are two (2) types of NCCI edits:
1.
					 Procedure-to-Procedure (PTP) Edits define pairs of HCPCS and CPT codes that
					 should not be reported together.
2.
					 Medically Unlikely Edits (MUEs) define the maximum units of service for each
					 HCPCS and CPT code that a provider would generally report for a single patient
					 on a single date of 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 I - Specific Policies By Service › Sec2 144-101-I-1 - GENERAL ADMINISTRATIVE POLICIES AND PROCEDURES › Subsection 144-101-I-1.13 - INQUIRY PROCESS

Current through 2024-29, July 17, 2024
There are two (2) options available to providers to
						check member eligibility, co-pay information, claim status, third party payment
						insurance, and eligibility for MaineCare managed care benefits. These options
						are a web based system and an Interactive Voice Response System. These options
						are available twenty-four (24) hours a day, seven (7) days a week and allow
						unlimited inquiries. Providers will be required to furnish the MaineCare
						provider ID number, the member's name, date of birth, and the member's ID
						number or Social Security Number before any information can be given. Providers
						should attempt to resolve questions via the web based system or the Interactive
						Voice Response System, or other means made available by the Department, prior
						to calling the Provider Services Unit.
When a provider is in need of an immediate resolution to
						a policy and/or procedural question, the Provider Relations Unit may be
						contacted by telephone, or by submitting an e-mail inquiry.
Written inquiries regarding the payment or nonpayment of
						claims should be mailed or faxed to:
Provider Services
MaineCare Services
11 State House Station
Augusta, Maine 04333-0011
Priority will be given to written inquiries that contain
						copies of claims, Remittance Advices and any other pertinent documents, because
						these documents expedite issue resolution.
1.13-1
Unpaid Claims
When a provider does not receive information regarding
						the payment of a specific claim from the Department, he or she may use the
						web-based system or call the Interactive Voice Response System, or use other
						means made available by the Department, regarding the status of the claim
						before rebilling. The web based system and Voice Response System will let the
						providerknow if the claim has been paid or denied and on what date. If there is
						no information on file, it means the claim was not received and should be
						resubmitted.
1.13-2
Re-evaluation of Charges
If a provider questions the payment he or she has
						received for a service, a written inquiry must be made within one hundred and
						twenty (120) calendar days from the date of the Remittance Advice. The provider
						must comply with the most current procedures made available 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 I - Specific Policies By Service › Sec2 144-101-I-1 - GENERAL ADMINISTRATIVE POLICIES AND PROCEDURES › Subsection 144-101-I-1.14 - PRIOR AUTHORIZATION

Current through 2024-29, July 17, 2024
Prior authorization (PA) is required for certain
						services. The PA requirement is spelled out in each section of other Chapters
						of this Manual whenever it applies to a covered service. In addition,
						management of high cost member services and/or supplies may require PA by the
						Department or its Authorized Entity.
1.14-1
In-State Services
A. The dated and signed request for PA must
					 be made by the member's provider in writing and sent to the MaineCare Prior
					 Authorization Unit, or as appropriate, to the Department's Authorized Entity or
					 any other office as required by the Department and provided in other sections
					 of this Manual.
For PA, contact information and where to send completed
						PA forms, visit the MaineCare Services website at:
https://mainecare.maine.gov
.
A request for prior authorization must be signed by the
						provider and must include:
1. Member's
					 name and MaineCare identification number;
2. Diagnosis for which the request is being
					 made;
3. The procedure(s) requested
					 and its/their corresponding code(s);
4 Date(s) of the scheduled procedure, if
					 known;
5. The billing provider ID
					 number of the physician and/or physicians practice or other authorized provider
					 that will render the requested service(s), if known;
6. All clinical records to support the
					 requested service (describing diagnostic studies and treatment completed to
					 date along with results, and clinical records upon which the request has been
					 made); and
7. Additional
					 information as determined by the Department or its Authorized Entity.
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 I - Specific Policies By Service › Sec2 144-101-I-1 - GENERAL ADMINISTRATIVE POLICIES AND PROCEDURES › Subsection 144-101-I-1.15 - PROVISION OF NECESSARY TRANSPORTATION TO MEDICAL SERVICES

Current through 2024-29, July 17, 2024
MaineCare meets the federal requirement to provide
						necessary transportation (
						42 C.F.R. §
												431.53 ) to MaineCare members who have no
						other means of transportation to MaineCare covered services. See MBM, Ch. II,
						Sec. 113 (Non-Emergency Transportation (NET) Service), and Sec. 5 (Ambulance
						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 I - Specific Policies By Service › Sec2 144-101-I-1 - GENERAL ADMINISTRATIVE POLICIES AND PROCEDURES › Subsection 144-101-I-1.16 - AUDITS

Current through 2024-29, July 17, 2024
The Division of Audit, Program Integrity Unit, or duly
						Authorized Entities appointed by the Department have the authority to monitor
						payments to any MaineCare provider by an audit or post-payment
						review.
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 I - Specific Policies By Service › Sec2 144-101-I-1 - GENERAL ADMINISTRATIVE POLICIES AND PROCEDURES › Subsection 144-101-I-1.17 - UTILIZATION REVIEW

Current through 2024-29, July 17, 2024
The Department or its Authorized Entity is responsible
						for carrying out a series of safeguarding measures. These measures safeguard
						against excessive payments, unnecessary or inappropriate utilization of care
						and services, and assess the quality of services available under MaineCare. The
						Department may use consultants and peer reviewers with expertise appropriate to
						the medical care or services to be reviewed.
Delegation of any utilization review activities
						pertaining to length of stay in acute care hospitals will be carried out in
						accordance with the hospital's utilization review program/plan.
The Department has the authority to request medical
						records and other records as necessary to support utilization review,
						utilization management, concurrent review, or other service review activities.
						Providers must respond to the requests in a timely manner and at no charge to
						the Department.
1.17-1
Behavioral Health Managed Care
The Department uses a behavioral health managed care
						system for all members receiving selected behavioral health services that are
						covered by MaineCare to ensure access to appropriate care and improve member
						outcomes.
The Department's Administrative Services Organization
						(Authorized Entity) is used for eligibility verification, utilization
						management, and for examination of clinical appropriateness for selected
						services as identified in the behavioral health services sections of the MBM.
						The Authorized Entity performs the following duties: facilitates referrals to
						appropriate service providers; prior authorizes selected services; expedites
						delivery of services to members in need of treatment; tracks the service status
						of members enrolled in the system; and gathers data that will inform the
						Department of resource development needs. The Department's goal is to promote
						early intervention of services provided to avoid unnecessary reliance on
						emergency and inpatient services. All providers must submit notification of
						their intent to initiate behavioral health services identified in the MBM prior
						to the start of services for all members. The Department's Authorized Entity
						must have prior notification of services for utilization review purposes to
						assess the medical necessity, efficiency, appropriateness of services and
						treatment plans on a prospective, concurrent or retrospective basis.
Please refer to the appropriate Sections of the MBM for
						additional requirements and information on behavioral health managed
						care.
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 I - Specific Policies By Service › Sec2 144-101-I-1 - GENERAL ADMINISTRATIVE POLICIES AND PROCEDURES › Subsection 144-101-I-1.18 - PROGRAM INTEGRITY

Current through 2024-29, July 17, 2024
The Program Integrity Unit, Division of Audit, or the
						Department's Authorized Entity, or any combination of the three (3) entities,
						is responsible for surveillance and referral activities that may include, but
						are not limited to:
A. A continuous
					 sampling review of the utilization of care and services for which payment is
					 claimed;
B. An on-going sample
					 evaluation of the necessity, quality, quantity and timeliness of the services
					 provided to members;
C. An
					 extrapolation from a random sampling of claims submitted by a provider and paid
					 by MaineCare;
D. A post-payment
					 review that may consist of member utilization profiles, provider services
					 profiles, claims, all pertinent professional and financial records, and
					 information received from other sources;
E. The implementation of the Restriction
					 Plans (described in Chapter IV of this Manual);
F. Referral to appropriate licensing boards
					 or registries as necessary;
G.
					 Referral to the Maine Attorney General's Office, Healthcare Crimes Unit, for
					 those cases where fraudulent activity is suspected; and
H. A determination whether to suspend
					 payments to a provider based upon a credible allegation of fraud.
The Department and its professional advisors regard the
						maintenance of adequate clinical and other required financial and
						product-related records as essential for the delivery of quality care. In
						addition, providers should be aware that comprehensive records, including but
						not limited to: treatment/service plans, progress notes, product and/or service
						order forms, invoices, and documentation of delivery of services and/or
						products provided are key documents for post-payment reviews. In the absence of
						proper and comprehensive records, no payment will be made and/or payments
						previously made may be recouped.
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 I - Specific Policies By Service › Sec2 144-101-I-1 - GENERAL ADMINISTRATIVE POLICIES AND PROCEDURES › Subsection 144-101-I-1.19 - TERMINATION FROM PARTICIPATION IN MAINECARE

Current through 2024-29, July 17, 2024
1.19-1
Termination of Participation by
					 Provider or Department
A.
Non-Emergency Termination
The Department may terminate a provider's participation,
						or the provider may terminate participation in MaineCare, without cause. The
						terminating party must send written notification of the termination at least
						thirty (30) days prior to the effective date of termination. Providers must
						send this notification to the Director of Compliance, MaineCare Services,
						Department of Health and Human Services, 11 State House Station, Augusta, Maine
						04333-0011.
Primary care providers must also abide by the termination
						regulations set forth in the Primary Care Case Management Policy.
B.
Emergency
					 Termination
The Department may terminate MaineCare participation of
						a provider immediately by giving written notice to the provider if the
						Department reasonably believes that conditions exist that place the health and
						safety of members in immediate jeopardy. The provider will be given the
						opportunity for an informal review after the effective date of the emergency
						termination. A request for an informal review must be made within seven (7)
						days of the date of the receipt of the termination notice, or an informal
						review shall be deemed waived. Any administrative hearing or informal review
						will be scheduled after the effective termination date and the transfer of
						members.
C.
Procedures Following Notice of Termination
1. Except as otherwise directed by the
					 Department, after notice of termination by either the provider or the
					 Department or after notice of emergency termination, the provider shall furnish
					 the Department with access to all information pertaining to each individual
					 member presently being cared for by the provider in such detail as deemed
					 necessary by the Department.
2. The
					 Department shall reimburse providers for covered services rendered during the
					 period following a notice of termination up to the effective date of
					 termination. The Department may decide to extend the effective date of a
					 termination for providers of residential services, if necessary, to achieve the
					 safe relocation of members. A provider remains obligated to follow the
					 provisions of its MaineCare Provider Agreement and all applicable sections of
					 the MBM in order to continue to receive reimbursement for 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 I - Specific Policies By Service › Sec2 144-101-I-1 - GENERAL ADMINISTRATIVE POLICIES AND PROCEDURES › Subsection 144-101-I-1.21 - REINSTATEMENT FROM TERMINATION OR EXCLUSION

Current through 2024-29, July 17, 2024
A.
Reinstatement Procedures from Termination or Exclusion
1. For reinstatement to occur, a request for
					 reinstatement must be addressed to the Manager of Program Integrity in writing.
					 Considerations for reinstatement include:
a.
					 Any sanctions, including outstanding monetary sanctions;
b. Whether all fines and debts (including
					 overpayments) due and owed to any federal, state or local government that
					 relate to MaineCare, Medicare or any state health care program have been paid
					 or whether satisfactory arrangements have been made to fulfill these
					 obligations;
c. The conduct of the
					 individual or entity prior to the date of the notice of the exclusion,
					 including conduct not known to the agency at the time of the exclusion; and
d.  The conduct of the individual
					 or entity after the date of the notice of exclusion.
Any request for reinstatement will be reviewed in
						relation to any decisions or actions made by the United States Department of
						Health and Human Services, to past actions in MaineCare, and to other relevant
						factors such as professional sanctions.
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 I - Specific Policies By Service › Sec2 144-101-I-1 - GENERAL ADMINISTRATIVE POLICIES AND PROCEDURES › Subsection 144-101-I-1.24 - MEMBER APPEALS

Current through 2024-29, July 17, 2024
1.24-1
Right
					 to Administrative Hearing
In accordance with
						42 C.F.R. §
													431.220 the Department must grant an
						opportunity for a hearing to:
A. Any
					 member who requests it because his or her claim for services is denied or not
					 acted upon with reasonable promptness; and B. Any member who requests it
					 because he or she believes the agency has erroneously terminated, reduced, or
					 suspended MaineCare medical eligibility or covered 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 I - Specific Policies By Service › Sec2 144-101-I-1 - GENERAL ADMINISTRATIVE POLICIES AND PROCEDURES › Subsection 144-101-I-1.25 - MAINECARE ADVISORY COMMITTEE

Current through 2024-29, July 17, 2024
1.25-1
Definitions
The MaineCare Advisory Committee (MAC) is a committee
						required by Federal Statute (Section 1902(a) (22) of the
Social
						Security Act
) to advise the MaineCare agency about health and medical
						care services. Policy for the Committee is set forth in Section 431.12, Title
						42, (Chapter IV) of the
Code of Federal Regulations
.
1.25-2
Purposes
The MAC shall advise MaineCare Services and the Office
						for Family Independence of the Department of Health and Human Services on
						MaineCare services. The MaineCare Advisory Committee shall be given adequate
						opportunity for meaningful participation in policy development and program
						administration, including furthering the participation of beneficiary members
						in the MaineCare program. The advice of the Committee is not binding upon the
						Department.
1.25-3
Members of the Committee
The Director of MaineCare Services shall appoint members
						of the Committee. There shall be no fewer than fifteen (15) and no more than
						thirty (30) members on the Committee. The Committee shall include as
						members:
A. Board-certified physicians
					 and other representatives of the health professions who are familiar with the
					 medical needs of low-income population groups and with the resources available
					 and required for their care.
B.
					 Members of consumers' and consumer advocacy groups, including at least two (2)
					 Medicaid beneficiaries, and consumer organizations, such as labor unions,
					 cooperatives, consumer-sponsored prepaid group practice plans, and others.
C. The Director of the Office for
					 Family Independence and/or the State's public health department.
Each member shall be appointed to a three (3) year term
						and may be re-appointed for additional three (3) year terms after serving a
						full term. Appointments shall be made on a continuous and rotating
						basis.
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 I - Specific Policies By Service › Sec2 144-101-I-1 - GENERAL ADMINISTRATIVE POLICIES AND PROCEDURES › Appendix 144-101-I-1-1 - CODE OF ETHICS FOR INTERPRETERS*

Current through 2024-29, July 17, 2024
The following principles of ethical behavior are affirmed
						to protect and guide interpreters and transliterators, both for non-English
						speaking, and for hearing and deaf members. Underlying these principles is the
						desire to ensure for all the right to communicate.
This Code of Ethics applies to all interpreters and
						transliterators providing services to MaineCare members and reimbursed by
						MaineCare.
[] Interpreters/transliterators shall keep all
						assignment-related information strictly confidential.
[] Interpreters/transliterators shall render the message
						faithfully, always conveying the content and spirit of the speaker using
						language most readily understood by the person(s) whom they serve.
[] Interpreters/transliterators shall not counsel, advise
						or interject personal opinions.
[] Interpreters/transliterators shall accept assignments
						using discretion with regard to skill, setting, and the members
						involved.
[] Interpreters/transliterators shall request
						compensation for services in a professional and judicious manner.
[] Interpreters/transliterators shall function in a
						manner appropriate to the situation.
[] Interpreters/transliterators shall strive to further
						knowledge and skills through participation in workshops, professional meetings,
						interaction with professional colleagues, and reading of current literature in
						the field.
[] Interpreters/transliterators shall strive to maintain
						high professional standards in compliance with the Code of Ethics.
I have read, understand and agree to abide by the
						Code of Ethics as stated above.
____________________________________________
Printed name Written Signature
____________________________________________
Date
* Adapted from the Code of Ethics of the Registry of
						Interpreters for the Deaf (RID).
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 I - Specific Policies By Service › Sec2 144-101-I-2 - State Medicaid Health Information Technology (HIT) Program › Subsection 144-101-I-2.01 - INTRODUCTION AND STATUTORY AUTHORITY

Current through 2024-29, July 17, 2024
This Rule establishes policies for the Medicaid Health
						Information Technology (HIT) electronic health record (EHR) initiatives. It
						includes requirements for Medicaid professionals and hospitals to receive
						incentive payments under the MaineCare Meaningful Use Program (Program) and/or
						to be deemed as having fully implemented an EHR.
The Program is overseen by the Director, State Health
						Information Technology Initiatives Program, within the Office of MaineCare
						Services (OMS).
The authority for implementing HIT initiatives derives
						from Section 4201 of the
American Reinvestment and Recovery Act of
						2009
and Sections 1903(a)(3)(F) and 1903(t) of the
Social
						Security Act
(
						42 U.S.C.
						§1396(b) ) and
						 22 M.R.S.A.
						§§42 and
						3173.
						States must submit a State Medicaid Health Plan (SMHP) and an Implementation
						Advanced Planning Document (IAPD) or Update (IAPDU) and receive Center for
						Medicare and Medicaid Services (CMS) approval of the SMHP and the IAPD or
						IAPD-U prior to implementing the incentive payment Program. Maine's SMHP,
						IAPD-U, and OMS rules supplement federal law and rules, as amended, in areas
						where federal law and rules delegate authority to states. Maine's approved
						SMHP, IAPD, and IAPD-U can be found at
http://www.maine.gov/dhhs/oms/HIT/ehr_incent.htm#ehr_benes
.
To be eligible for an incentive payment and/or to be
						deemed as having fully implemented an EHR, a professional or hospital must:
A. Be of a certain type of
					 professional or hospital and meet Medicaid or needy individual patient
					 thresholds established for that type of professional or hospital as shown in
					 Sections 2.04 and 2.05; and
B.
					 Adopt, implement or upgrade certified electronic health records before being
					 approved for the first payment under the incentive program, or meet Meaningful
					 Use provisions before being approved for subsequent payments; and
C. Meet all the requirements of this Rule and
					 Maine's SMHP and IAPDU.
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 I - Specific Policies By Service › Sec2 144-101-I-2 - State Medicaid Health Information Technology (HIT) Program › Subsection 144-101-I-2.03 - REQUIREMENTS FOR EHR INCENTIVE PAYMENT PROGRAM

Current through 2024-29, July 17, 2024
A provider may apply as an Eligible Professional or an
						Eligible Hospital, but not both. See
						42 C.F.R.
						§495.310(c).
The incentive payment program process and requirements
						for EPs are those described in
						42 C.F.R. §§
												495.310(a) through (e),
						495.314
						and
						495.312(b).
The incentive payment program process and requirements
						for EHs are those described in
						42 C.F.R. §§
												495.310(e) through (j),
						495.314
						and
						495.312(b).
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 I - Specific Policies By Service › Sec2 144-101-I-2 - State Medicaid Health Information Technology (HIT) Program › Subsection 144-101-I-2.05 - ELIGIBLE HOSPITAL

Current through 2024-29, July 17, 2024
A. To be an
					 Eligible Hospital, an Acute Care Hospital, Critical Access Hospital or Cancer
					 Hospital must have at least a 10% Medicaid patient volume. An Eligible Hospital
					 shall calculate its patient volume in accord with
					 42 C.F.R.
					 §495.306(c)(2).
					 Children's Hospitals are exempt from meeting a Medicaid patient volume
					 threshold.
B.
Application
					 process for EHs
1. A hospital must
					 register with CMS through the CMS National Level Repository (NLR)
					 system.
2. After a hospital
					 registers, CMS sends an electronic notification to OMS of the
					 registration.
3. Using the contact
					 information from the NLR registration, OMS will contact the hospital to begin
					 the application process.
4. A
					 hospital must establish that it is an Eligible Hospital and must meet the
					 following requirements:
a. Consistent with
					 42 C.F.R.
					 §495.314, attest that it has adopted,
					 implemented or upgraded electronic health records to be eligible for the first
					 payment year,
or
has met meaningful use requirements to be
					 eligible for subsequent payment years;
b. Attest that it uses an EHR that is
					 included on the list of certified EHRs maintained by CMS;
c. Attest that it has not received an
					 incentive payment for that year from another state;
d. Meet all other requirements under
					 42 C.F.R.
					 §495.314;
e. Satisfactorily complete the application
					 process; and
f. Meet the meaningful
					 use reporting requirement set forth by
					 42 C.F.R
					 §495.312(b).
5. After confirming that the
					 hospital meets the above requirements, MaineCare will calculate the total
					 incentive payment for the EH in accord with 42 C.F.R.§§ 495. 310(e),
					 (f) and (g). See for example, Hospital Calculation at:
http://www.maine.gov/dhhs/oms/HIT
.
					 If data from the hospital is non-existent, the Department shall deem an amount
					 in accordance with
					 42 C.F.R.
					 §495.310(i).
6. OMS will notify CMS that a payment is
					 being issued, and will issue a payment to the EH according to the requirements
					 of
					 42 C.F.R.
					 §495.312(e)(2).
7. If the Department determines that a
					 hospital has not met the requirements of Section 2.05, it will notify the
					 hospital in writing within two (2) business days of making that
					 determination.
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 I - Specific Policies By Service › Sec2 144-101-I-2 - State Medicaid Health Information Technology (HIT) Program › Subsection 144-101-I-2.06 - FEDERAL FINANCIAL PARTICIPATION

Current through 2024-29, July 17, 2024
A policy established in this rule shall be null and void
						if CMS denies federal financial participation for this policy or disapproves
						the policy.
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 I - Specific Policies By Service › Sec2 144-101-I-4 - Telehealth Services › Subsection 144-101-I-4.02 - MEMBER ELIGIBILITY

Current through 2024-29, July 17, 2024
4.02-1
Telehealth Services
If a Member is eligible for the underlying Covered
						Service to be delivered, and if delivery of the Covered Service via Telehealth
						Services is medically appropriate, as determined by the Health Care Provider,
						the Member is eligible for Telehealth Services.
4.02-2
Telemonitoring Services
In order to be eligible for Telemonitoring Services, a
						Member must:
A. Be eligible for Home
					 Health Services under Chapter II, Section
					 40, Home Health Services;
B. Have a current diagnosis of a health
					 condition requiring monitoring of clinical data at a minimum of five times per
					 week, for at least one week;
C.
					 Have documentation in the patient's medical record that the patient is at risk
					 of hospitalization or admission to an emergency room;
OR
Have continuously received Telemonitoring Services during
						the past calendar year and have a continuing need for such services, as
						documented by an annual note from a Health Care Provider;
D. Have Telemonitoring Services included in
					 the Member's Plan of Care. A notation from a Health Care Provider, dated prior
					 to the beginning of service delivery, must be included in the Member's Plan of
					 Care. MaineCare shall not reimburse for Telemonitoring Services if they began
					 prior to the date recorded in the Provider's note.
E. Reside in a setting suitable to support
					 telemonitoring equipment; and
F.
					 Have the physical and cognitive capacity to effectively utilize the
					 telemonitoring equipment or have a caregiver willing and able to assist with
					 the equipment.
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 I - Specific Policies By Service › Sec2 144-101-I-4 - Telehealth Services › Subsection 144-101-I-4.03 - PROVIDER REQUIREMENTS

Current through 2024-29, July 17, 2024
4.03-1
Telehealth Services
In order to be eligible for reimbursement for Telehealth
						Services, a Health Care Provider must
A. Act within the scope of their
					 license;
B. Be enrolled as a
					 MaineCare provider;
C. Be otherwise
					 eligible to deliver the underlying Covered Service according to the
					 requirements of the applicable Section of the MBM; and
D. Be appropriately licensed, accredited,
					 certified, and/or registered in the State where the Member is located during
					 the provision of the Telehealth 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 I - Specific Policies By Service › Sec2 144-101-I-4 - Telehealth Services › Subsection 144-101-I-4.04 - COVERED SERVICES

Current through 2024-29, July 17, 2024
4.04-1
Telehealth Services
Any medically necessary MaineCare Covered Service may be
						delivered via Telehealth Services, provided the following requirements are
						met:
1. The Member is otherwise
					 eligible for the Covered Service, as described in the appropriate Section of
					 the MBM; and
2. The Covered Service
					 delivered by Telehealth Services is of comparable quality to what it would be
					 were it delivered in person.
Prior authorization is required for Telehealth Services
						only if prior authorization is required for the underlying Covered Service. In
						these cases, the prior authorization is the usual prior authorization for the
						underlying Covered Service, rather than a prior authorization for the mode of
						delivery. Unless otherwise required by law, a face-to-face encounter is not
						required prior to delivering Telehealth 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 I - Specific Policies By Service › Sec2 144-101-I-4 - Telehealth Services › Subsection 144-101-I-4.05 - NON-COVERED SERVICES AND LIMITATIONS

Current through 2024-29, July 17, 2024
A. Except as
					 set forth herein, services not otherwise covered by MaineCare are not covered
					 when delivered via Telehealth Services.
B. Services covered under other MaineCare
					 Sections but specifically excluded from Telehealth coverage include, but are
					 not limited to the following:
1. Services that
					 require direct physical contact with a Member by a Health Care Provider and
					 that cannot be delegated to another Health Care Provider at the site where the
					 Member is located are not covered;
2. Any service medically inappropriate for
					 delivery through Telehealth Services - e.g. services that include providing
					 medical procedures or administration of medications that must be conducted in
					 person.
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 I - Specific Policies By Service › Sec2 144-101-I-4 - Telehealth Services › Subsection 144-101-I-4.06 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
4.06-1
Telehealth Equipment and Technology
A. Health Care Providers must ensure that the
					 telecommunication technology and equipment used at the Receiving (Provider)
					 Site and the Originating (Member) Site is sufficient to allow the Health Care
					 Provider to appropriately provide the Member with services billed to
					 MaineCare.
B.
Security
1. Health Care Providers must comply with all
					 federal, state, and local regulations that apply to its business including, but
					 not limited to, the
Electronic Communications Privacy Act of
					 1986
. Any services that use networked services must comply with HIPAA
					 requirements.
2. A Telehealth
					 Service shall be performed on a secure telecommunications line or utilize a
					 method of encryption adequate to protect the confidentiality and integrity of
					 the Telehealth Service information in accordance with State and Federal laws,
					 rules, and regulations.
3. Both the
					 Originating (Member) Site and the Receiving (Provider) Site shall use
					 authentication and identification to ensure the confidentiality of a Telehealth
					 Service.
4. A Health Care Provider
					 shall implement confidentiality protocols that include, but are not limited to:
a. Identifying personnel who have access to a
					 telehealth transmission;
b. Usage
					 of unique passwords or identifiers for each employee or person with access to a
					 telehealth transmission; and
c.
					 Preventing unauthorized access to a telehealth transmission.
5. A Health Care Provider's
					 protocols and guidelines shall be available for inspection by the Department
					 upon request.
C. Except
					 as set forth herein, services may not be delivered through electronic
					 mail.
D. The Department will not
					 separately reimburse Health Care Providers for any charge related to the
					 purchase, installation, or maintenance of telehealth equipment or technology,
					 nor any transmission fees. Health Care Providers shall not bill Members for
					 such costs or fees.
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 I - Specific Policies By Service › Sec2 144-101-I-4 - Telehealth Services › Subsection 144-101-I-4.07 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
4.07-1
General Conditions
A. Services are to be billed in accordance
					 with applicable Sections of the MBM. Providers must submit claims in accordance
					 with Department billing instructions.
B. Telehealth Services are subject to all
					 conditions and restrictions described in Chapter I, Section
					 1, of the MBM.
C. Telehealth Services are subject to
					 co-payment requirements for the underlying Covered Service, if applicable, as
					 established in Chapter I, Section
					 1, of the MBM. However, there shall
					 be no separate co-payment for telehealth 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 I - Specific Policies By Service › Sec2 144-101-I-5 - COVID-19 Public Health Emergency Services › Subsection 144-101-I-5.02 - CO-PAYMENTS

Current through 2024-29, July 17, 2024
The Department waives co-payments for the following
						MaineCare services for all MaineCare members:
A.
Pharmacy
: All co-payments
					 charged by pharmacies under Section 80, Pharmacy Services.
B.
Clinical Visits
: MaineCare
					 currently requires some members to pay a co-payment for clinical visits based
					 on the member's eligibility coverage group. All co-payments for clinical visits
					 for MaineCare members, regardless of eligibility coverage group, are waived.
					 This includes, but is not limited to, Hospital Services (Sec. 45 ), Federally
					 Qualified Health Center Services (Sec. 31 )*, Rural Health Clinic Services
					 (Sec. 103 ), Physician Services (Sec. 90 )*.
C.
Medical Imaging Services
: All
					 co-payments charged under Section 101, Medical Imaging Services.
D.
Laboratory Services
: All
					 co-payments charged under Section 55, Laboratory Services.
E.
Behavioral Health Services
:
					 All co-payments charged under Section 65, Behavioral Health Services.
F.
Medical Supplies and Durable Medical
					 Equipment
: All co-payments charged under Section 60, Medical Supplies
					 and Durable Medical Equipment.
G.
Home Health Services
: All co-payments charged under Section 40,
					 Home Health Services.
H.
Consumer Directed Attendant Services
: All co-payments charged
					 under Section 12, Allowances for Consumer Directed Attendant
					 Services.*
I.
Private Duty
					 Nursing and Personal Care Services
: All co-payments charged under
					 Section 96, Private Duty Nursing and Personal Care Services.
J.
Benefit for People Living with
					 HIV/AIDS
: All co-payments charged under Chapter X, Section 1.
					 *
K. Should COVID-19 specific
					 treatments and/or vaccines become available during the duration of this public
					 health emergency rule, co-payments will be waived.
*The Department shall seek and anticipates
						receiving approval of these changes from CMS retroactive to March 18, 2020.
						Pending approval, these changes are effective upon adoption.
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 I - Specific Policies By Service › Sec2 144-101-I-5 - COVID-19 Public Health Emergency Services › Subsection 144-101-I-5.03 - WAIVER OF PREMIUMS

Current through 2024-29, July 17, 2024
The Department waives all enrollment fees, premiums, and
						similar charges for all beneficiaries.
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 I - Specific Policies By Service › Sec2 144-101-I-5 - COVID-19 Public Health Emergency Services › Subsection 144-101-I-5.04 - PHARMACY SERVICES

Current through 2024-29, July 17, 2024
The Department alters certain provisions of the MBM,
						Section 80, Pharmacy Services, as follows:
A.
Initial Prior Authorization
					 requirements for asthma and immune-related prescriptions
: Restrictions
					 on asthma related medications like Albuterol are removed to allow all forms of
					 Albuterol without Prior Authorization. Restrictions on Immune-related
					 medications, like Neupogen, are removed for approval with completion of Prior
					 Authorization form, if necessary, for the treatment of COVID-19.
B.
COVID-19 Treatments or
					 Vaccines
: Should COVID-19 specific treatments or vaccines become
					 available during the duration of this emergency rule, Prior Authorization will
					 be waived.
C.
Prescription
					 Refills
: Early refills of prescription medications are allowed in the
					 same days' supply and quantity as the original prescription; the requirements
					 set forth in Ch. II, Sec. 80.07-7 are waived.
D.
Buprenorphine and Buprenorphine
					 Combination Products for Substance Use Disorder (SUD)
: The physical
					 assessment requirements for Buprenorphine and Buprenorphine Combination
					 Products for SUD set forth in Ch. II, Sec. 80.07-13 are waived.
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 I - Specific Policies By Service › Sec2 144-101-I-5 - COVID-19 Public Health Emergency Services › Subsection 144-101-I-5.05 - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT

Current through 2024-29, July 17, 2024
A.
COVID-19-Related Supplies and
					 Durable Medical Equipment
: Prior Authorization approvals currently in
					 effect for Section 60, Durable Medical Equipment (DME), will be extended for
					 individuals with COVID-19 (who should be in quarantine), individuals with
					 pending COVID-19 tests in self-isolation, and individuals in the high-risk
					 category for developing severe complications from COVID-19, and early refills
					 will be temporarily allowed as follows on the following DME items:
1. Glucose supplies;
2. Hearing aid batteries; and 3. The
					 following Continuous positive airway pressure (CPAP) and bi-level positive
					 airway pressure (Bi-PAP) supplies:
a.
					 Oral/nasal mask - one (1) per three (3) months;
b. Oral cushion- two (2) per one (1)
					 month;
c. Nasal pillow - two (2)
					 per one (1) month;
d. Full face
					 mask - one (1) per three (3) months;
e. Facemask interface - one (1) per one (1)
					 month;
f. Nasal interface - two (2)
					 per one (1) month;
g. Tubing - one
					 (1) per one (1) month;
h. Tubing
					 (with heating element) - one (1) per three (3) months;
i. Filter (disposable) - two (2) per one (1)
					 month;
j. Oral interface - one (1)
					 per three (3) months; and
k. Water
					 chamber - one (1) per one (1) month.