Billing Guidance and Implementation Timing for the Updated Payment Methodology for Section 31, Federally Qualified Health Centers (FQHCs), Including Changes When Providing Services Now Outside the Encounter Rate

May 01, 2023

The Office of MaineCare Services (OMS) previously announced that we will submit a State Plan Amendment to add an Alternative Payment Methodology (APM) option for FQHCs, effective March 1, 2023. This APM is based on costs and visits from fiscal years 2018 and 2019 for all State Plan covered services, with the exceptions identified in the lists below, consistent with federal requirements. 

The Department will be updating its claims processing system, retroactive to March 1, 2023, to align with this change. We expect this change to be in place mid-May and will send another message when we have made the updates. 

So that the Department and providers can more easily adjust claims after implementing the system changes, we encourage FQHCs to start billing claims now according to the following guidelines. 

For claims not yet billed for dates of service starting March 1, 2023

We ask FQHCs to bill the following services as separate claim lines, for fee-for-service reimbursement according to rates identified under the appropriate sections of the MaineCare Benefits Manual (MBM):  

• Injectable drugs for treatment of Opioid Use Disorder (OUD) (under Section 90) 

• Services for and associated with Dental Crowns and Dentures (under Section 25) 

Until we update the system, the Department will continue to pay these claims at the encounter rate, instead of the fee-for-service rate, for the services above when they are included on the claim. We still ask FQHCs to bill on the separate claim lines, however, as this will make claims adjustments easier once the changes are in the claims system. We will share further information regarding reprocessing these claims when we announce the implementation of the system changes. 

Each FQHC should also continue to bill the following services on separate claim lines, to receive fee-for-service reimbursement, consistent with current billing practices: 

• Interpreter Services 

• Court Testimony 

• Intrauterine devices (IUDs) and long-acting contraceptives (LARC) 

• Administrative fee for Immunizations (flu and pneumonia only)  

• Education Diabetes/Asthma (group only) 

• Smoking/Tobacco Cessation & Preventative Counseling (group only) 

For claims already billed for dates of service starting March 1, 2023

Please do not adjust your claims at this time. We will share further information regarding reprocessing these claims when we announce the implementation of the system changes.  

Reminder: All services must be delivered and billed according to the requirements outlined in relevant sections of the MBM unless otherwise noted in Section 31. E.g., all dental services must meet requirements outlined in Section 25, Dental Services. 

Please contact Shannon Beggs, Provider Relation Specialist, with any questions.