MaineCare General E-Message - February 12, 2016

New Drug Testing Laboratory Codes, HCPCS Codes G0477 through G0483, CR54713 and CR55123

As you may be aware, the Centers for Medicare and Medicaid Services (CMS) had an issue with loading the new drug testing lab codes.  Since MaineCare has not received the CMS update pertaining to these codes, claims will not process correctly.  Claims are processed differently depending on the provider type.

The following information will help you determine how your claims will be processed:

• All Providers Submitting UB-04 and CMS1500 Claims:

Claims that were submitted before 01/22/16 as an 837I or 837P electronic transaction with codes G0477 through G0483 were rejected through the EDI Gateway. This means the claims did not make it into the MIHMS System.  These claims will require resubmission.

• Acute Care Hospitals:

Claims submitted with G0477 through G0483 and processed after 01/22/16 will be processed as zero pay.  The Remittance Advice (RA) will populate a Claims Adjustment Reason Code (CARC) 45 for the total charge amount.  We expect these codes to be on the CMS quarterly update and will be entered in MIHMS at that time.  Claims with these codes that paid at zero will be adjusted once the update from CMS is complete. 

• Critical Access and Out of State Hospitals:

Claims submitted with G0477 through G0483 and processed after 01/22/16 will be denied.  The RA will populate CARC 16 and Remittance Advice Remark Code (RARC) MA30.  We expect these codes to be in the system on 02/17/16 for Critical Access and Out of State Hospitals only.  Claims that denied in error prior to 02/17/16 will be adjusted.

• Providers Submitting CMS1500 Claims:

Claims submitted with G0477 through G0483 and processed after 01/22/16 will be denied.  The Remittance Advice will reflect CARC 204. These codes were entered in the system on 02/10/16, and should no longer deny.  Claims that denied in error prior to 02/10/16 will be adjusted.

Improve your Search for Prior Authorization (PA)

When searching for a PA on the Health PAS Online Portal, please include some specific search criteria. Including specific criteria will speed up your search and give you better results.

Some examples of specific search criteria are:

• Date range
• Member’s MaineCare ID
• Member’s first and last name
• Member’s Social Security Number
• Member’s date of birth

Not only will including specific search criteria improve you search speed and results, but it will also mitigate portal slowness and technical issues.

Please contact the EDI Helpdesk with questions at: 1-866-690-5585, option 3.

Reminder: Prior Authorization (PA) Requirement for Code J0585, Botox

PA is required for members who are 21 years of age or older on all claims with code J0585, Botox. 

Reminder: Managing Users in MyHealthPAS Trading Partner Accounts

As a Trading Partner, it is important to actively manage your user accounts in the Health PAS Online Portal.  Managing the security roles of users and deactivation of individuals is essential when access requirements have changed or when access is no longer needed. Deactivation of individuals no longer working for your organization is imperative as it will help prevent inappropriate access to Protected Health Information (PHI). 

Managing users can be done by going to the Health PAS Online Portal and logging into your trading partner account. Click on “Account Maintenance” and then select “Manage Users.”  Existing users may be edited, deactivated, or reactivated by clicking on the row of the user you would like to manage. The Administrator of the account and users with a security role of “‘R7-User Management” are allowed to use these features. 

Please contact the EDI Helpdesk with questions at: 1-866-690-5585, option 3.

Reminder for Institutional Claims Only: Use Valid Status Codes in the Health PAS Online Portal Patient Status Field

Please use valid status codes in the Patient Status Field. Applying the correct code will help ensure that you receive prompt and correct payment.

Issue Corrected: Incorrect Claim Adjustment Reason Codes (CARC) on the 835 Electronic Remittance Advice (RA), TR 49936

The issue where some denied claims were displaying two CARCSs on the 835 electronic RA has been corrected.

Please see the listserv from July 24, 2015 that originally described this issue:

Incorrect Claim Adjustment Reason Codes (CARC) on the 835 Electronic Remittance Advice (RA), TR 49936

An issue was identified where some denied claims are displaying two CARCs on the 835 electronic RA in error.  For example, the 835 may display part of the denied amount with a CARC that correctly corresponds to the denial reason and, on the same line, incorrectly report the remainder of the denied amount with a CARC 45, “Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.” When this occurs, CARC 45 should be disregarded.  You should post both dollar values using the correct CARC listed for the denied line.  We are working to correct this issue and will notify you once it is resolved.