Current Projects
- Health Information Technology (HIT)
- HIPAA 5010
- NEW! Improving Health Outcomes for Children (IHOC)
- Value Based Purchasing
- PNMI Initiative
- Transportation Initiative
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Members
Providers
- Claims Billing and Rates
- General News
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- Policy-Related Announcements
- Provider Enrollment
See archives for older news items.
MaineCare Member News 
Claims, Billing, and Rates
Important HIPAA Versino 5010 Information - February 21, 2012
Elect to Receive a HIPAA Version 5010 835 File
Trading Partners will receive a HIPAA Version 4010 835 file, regardless of the type of transaction submitted (4010 vs. 5010), until both the acceptance of 5010 transactions has been announced and the trading partner elects to receive a 5010 835. By default, the 4010 835 version has been selected.
When MIHMS begins accepting HIPAA Version 5010 transactions, providers must elect to receive the 5010 835 by: - Logging into your Trading Partner account. - Clicking on “Provider Associations” button. - Clicking the “Edit” button. - Selecting the radio button for the 5010 version and click on the “Update” button.
An 835 can be generated in only one version (either 4010 or 5010) per payment and cannot be re-created in the other version. During the transition period, providers should be conscious and timely with their choice since the 835 cannot be regenerated in the other version. The 835 type is based on the selection made on the provider’s trading partner account at the time that the 835 is generated, which is normally on Friday. This selection is not dependent upon the format submission of claims. For example, if providers submit 5010 files, they have the option of receiving 4010 or 5010 835 files until the current March 31, 2012 deadline.
MaineCare anticipates accepting 5010 transactions by March 1, 2012. MIHMS will not accept HIPAA Version 5010 production transactions before that time. If a trading partner attempts to submit a 5010 transaction before the system is accepting them, an error message will be returned. For complete instructions and screen shots about electing to receive a 5010 835 file, please go to theHIPAA 5010 webpage.
Type 1 Attending Provider Required on Institutional Claims in HIPAA Version 5010
In HIPAA Version 5010, you are required to include the Attending Provider on all institutional claims other than non-scheduled transportation claims. All providers, including PNMI providers, must use a Type 1 NPI in this field to avoid rejection. The Attending Provider does not need to be enrolled in MaineCare.
Previously, listing the Attending Provider (the individual who has overall responsibility for the patient’s medical care and treatment reported in the claim) was only required for inpatient claims (ANSI Loop 2310A on the 837I or Field Number 76 on the UB-04).
Attn: Vision Providers, Regarding Refractions - May 14, 2012
The appropriate time to bill MaineCare for refractions is when a patient is eligible for both Medicare and Medicaid, and Medicare pays for the eye exam. Medicare’s definition of an eye exam does not include refractions. Therefore, MaineCare will pay for the refraction separately after Medicare. Although MaineCare’s definition of a comprehensive eye exam includes the refraction, it cannot be billed separately to MaineCare in the absence of Medicare.
If Medicare applies the total allowed for the eye exam to the patient’s Medicare deductible, you may bill MaineCare for the eye exam only. Since that payment is made according to MaineCare’s definition of a comprehensive eye exam which includes the refraction, the refraction cannot be billed separately. If Medicare applies only a portion of the eye exam to the deductible and pays the other portion, your bill to MaineCare can include a separate charge for the refraction.
5010 Certification Countdown - May 15, 2012
Congratulations to the 96% of MaineCare Trading Partners who have become HIPAA Version 5010-certified. For those who still need to complete certification testing, there are 30 business days left to do so. Start today!
MaineCare strongly encourages HIPAA Version 5010 certified trading partners to utilize the new transaction standard now. Some providers have submitted a small batch of 5010 claims as a trial to confirm that they are correctly configured to submit HIPAA Version 5010 claims. In order to receive a HIPAA Version 5010 835, HIPAA Version 5010-certified providers need to update their trading partner profile via the MIHMS Health PAS Online Portal. Please review the HIPAA Version 835 Tip Sheet found on the HIPAA 5010 webpage for more detailed instructions.
If your organization submits electronically in batches to MaineCare, you must complete certification testing by June 30, 2012. To certify, log in to the MIHMS Health PAS Online Portal. If you are unable to submit HIPAA Version 5010 transactions after June 30, 2012, you will be required to submit via Direct Data Entry (DDE) or through paper claims. On July 1, 2012, any HIPAA Version 4010 transactions submitted electronically in batches to MaineCare will be rejected.
Testing resources are available. Visit the HIPAA Version 5010 webpage for background information, testing instructions, and Frequently Asked Questions about testing HIPAA Version 5010 transactions with MaineCare.
Pharmacy
Attn: Pharmacies & Durable Medical Equipment Providers - May 16, 2012
Section 80, Pharmacy Services Update
Emergency rules went into effect on April 1, 2012 which discontinued reimbursement for nutritional products at retail pharmacies. With this change, MaineCare would continue to reimburse for nutritional supplements if purchased at medical supply dealers when deemed medically necessary with prior authorization.
Some MaineCare families have experienced difficulty with this change and have not been able to access these services, when needed. Effective Friday, May 18, 2012, we will add these products back into the formulary so members are able to get the medically necessary prescribed nutritionals at either a medical supply dealer or a retail pharmacy. This will allow MaineCare time to develop a clear plan on products that are covered by MaineCare and where members are able to receive the nutritional products.
Policy Related Announcements
Provider Enrollment
General News
Well Child Visit Reminder Form Letter is Now Available - May 15, 2012
MaineCare has developed a “model” reminder letter that primary care practices may use to remind families that a well-child visit is due. This well child visit form letter is available for use on the MaineCare website. Practices can customize this letter as needed and print it on their own letterhead.
MaineCare Services has discontinued sending reminder letters to families based on the child’s birth date and the Bright Futures periodicity schedule.
5010 Certification Countdown - May 15, 2012
Congratulations to the 96% of MaineCare Trading Partners who have become HIPAA Version 5010-certified. For those who still need to complete certification testing, there are 30 business days left to do so. Start today!
MaineCare strongly encourages HIPAA Version 5010 certified trading partners to utilize the new transaction standard now. Some providers have submitted a small batch of 5010 claims as a trial to confirm that they are correctly configured to submit HIPAA Version 5010 claims. In order to receive a HIPAA Version 5010 835, HIPAA Version 5010-certified providers need to update their trading partner profile via the MIHMS Health PAS Online Portal. Please review the HIPAA Version 835 Tip Sheet found on the HIPAA 5010 webpage for more detailed instructions.
If your organization submits electronically in batches to MaineCare, you must complete certification testing by June 30, 2012. To certify, log in to the MIHMS Health PAS Online Portal. If you are unable to submit HIPAA Version 5010 transactions after June 30, 2012, you will be required to submit via Direct Data Entry (DDE) or through paper claims. On July 1, 2012, any HIPAA Version 4010 transactions submitted electronically in batches to MaineCare will be rejected.
Testing resources are available. Visit the HIPAA Version 5010 webpage for background information, testing instructions, and Frequently Asked Questions about testing HIPAA Version 5010 transactions with MaineCare.
Residential Care Facilities Forum - May 16, 2012
To all Level IV (Case Mix), Residential Care Facilities:
On Thursday, June 7, 2012, from 1:00 PM to 2:00 PM, the Case Mix Team in collaboration with Licensing and Regulatory Services will hold the first quarterly “Minimum Data Set (MDS) 3.0 in Maine Residential Care Facilities” forum to discuss topics related to the MDS-RCA assessments.
This call is not intended for Nursing Facilities or Adult Family Care Homes.
This will be a web-based telephone conference call. We will be recording the call to capture the questions and discussion. There can be an unlimited number of people participating at each call-in location but we can host up to 90 call-ins only. For example, one facility can call using the designated phone number (one call-in) and have 20 or more people participating from that one location phone number.
Please submit questions or topics of discussion through the MDS email account, at by May 25, 2012. We can take questions during the call, but we offer no guarantee that these questions can be thoroughly researched to give the best possible response during the one-hour call. By requesting questions ahead of time, we are able to research your question.
To ensure we do not exceed the number of call-ins, we are asking facilities to pre-register by contacting Peter Lewis at 287-5882. We will send out the call-in number via email to those of you that register.
Moving forward, we will be offering a call-in forum on the first Thursday of every month, from 1:00 PM-2:00 PM, alternating between Nursing Facilities, Residential Care Facilities, and Adult Family Care Homes to discuss MDS issues. The next call-in will be scheduled for July 12, 2012 for Adult Family Care Homes.
