4.05 NON-COVERED SERVICES AND LIMITATIONS (cont.) Personal care aide (PCA) services provided Chapter II, Section 96 of the MCBM, “Private Duty Nursing and Personal Care Services”; Pharmacy services for prescribed drugs provided under Chapter II, Section 80 of the MCBM, “Pharmacy Services”; Assistive Technology services provided under the following Sections of the MaineCare Benefits Manual: a. Chapter II, Section 18, “Home and Community Based Services for Adults with Brain Injury”; b. Chapter II, Section 19, “Home and Community Benefits for the Elderly and for Adults with Disabilities”; c. Chapter II, Section 20, “Home and Community-Based Services for Adults with Other Related Conditions”; d. Chapter II, Section 21, “Home and Community Benefits for Members with Intellectual Disabilities or Autistic Disorder”; d. Chapter II, Section 29, “Support Services for Adults with Intellectual Disabilities or Autistic Disorder”; and e. Chapter II, Section 32, “Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders”. Non–Emergency Medical Transportation services provided under Chapter II, Section 113 of the MBM, “Non-Emergency Transportation (NET) Services”; Ambulance services provided under Chapter II, Section 5 of the MBM, “Ambulance Services”; 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; Any service medically inappropriate for delivery through Telehealth Services. C. Reimbursement will not be provided for communications between Health Care Providers when the Member is not present at the Originating (Member) Site. D. Reimbursement will not be provided for communications solely between Health Care Providers and Members when such communications not otherwise be billable. E. The Originating Facility Fee may only be billed in the event that the Originating (Member) Site is in a Healthcare Provider’s facility. F. The Originating Site Fee may be paid only to a Health Care Provider. 4.06 POLICIES AND PROCEDURES
In the event an interpreter is required, the Home Health Agency may bill for interpreter services in accordance with another billable service and the requirements of Ch. I, Section 1 of the MBM. 4.07-4 Reimbursement Rates PROCEDURE CODE DESCRIPTION MAXIMUM ALLOWANCE Q3014 Telehealth Originating Site Facility Fee, per visit $15.86 S9110 Telemonitoring of Patient in their Home, per month $84.55 99446 Interprofessional Telephone/ internet assessment and management services provided by a consultative physician including a verbal and written report; 5-10 minutes of medical consultative discussion and review $24.14 99447 Interprofessional Telephone/ internet assessment and management services provided by a consultative physician including a verbal and written report; 11-20 minutes of medical consultative discussion and review $40.51 99448 Interprofessional Telephone/ internet assessment and management services provided by a consultative physician including a verbal and written report; 21-30 minutes of medical consultative discussion and review $61.05 REIMBURSEMENT (cont.) PROCEDURE CODE DESCRIPTION MAXIMUM ALLOWANCE 99449 Interprofessional Telephone/ internet assessment and management services provided by a consultative physician including a verbal and written report; 31 or more minutes of medical consultative discussion and review $82.60