MaineCare General E-Message - March 4, 2016
Maine Department of Health & Human Services sent this bulletin at 03/04/2016 03:09 PM EST
Vision Services Compliance: Glasses for MaineCare Members Reminder
This is a reminder that ophthalmologists and optometrists billing under MaineCare Benefits Manual (MBM), Ch. II Section 75 Vision Services are required to provide eyeglasses to members if that provider has provided an eye exam. If you have provided an eye exam to a MaineCare member, you may not refer to another provider for eyeglasses.
Please see the MaineCare Benefits Manual, Ch. II – Section 75: Vision Services, 75.03 Covered Services:
Exam Referral Restrictions
An ophthalmologist or optometrist who has provided an eye exam for a MaineCare member may not refer that member to another vision service provider for the sole purpose of obtaining eyeglasses through the Vision Care Volume Purchase Contractor.
Dispensing
The dispensing process, once initiated, must include: initial fitting, selection, adjustment, and processing of the prescription order prior to manufacture; inspection and verification of the completed order; bending and adjusting of eyeglasses and lenses at the time of dispensing; and additional adjusting as required for best visual use and continued comfort.
MaineCare providers may not impose an extra charge for adjusting and fitting of eyeglasses made after the initial dispensing process regardless of who has dispensed the eyeglasses.
Additionally, the MaineCare Benefits Manual, Chapter I - Section 1.03-3: Requirements of Provider Participation:
Provide Services and supplies to members in the same quality and mode of delivery as they are provided to the general public.
Providers who bill MaineCare for services under Section 75 and who provide glasses to non-MaineCare patients must also make eyeglasses available to MaineCare members.
MaineCare Coverage of Liletta and Mirena Intrauterine Devices (IUDs), CR 53870
Effective January 1, 2016, CMS discontinued the use of HCPCS code J7302, Levonorgestrel-releasing intrauterine contraceptive system, 52 mg and began using the following codes:
- J7297, Levonorgestrel-releasing intrauterine contraceptive system, 52 mg, 3 year duration (Liletta)
- J7298, Levonorgestrel-releasing intrauterine contraceptive system, 52 mg, 5 year duration (Mirena)
Provider contracts that contained HCPCS Code J7302, Levonorgestrel-releasing intrauterine contraceptive system, 52 mg have been updated, effective January 1, 2016, to include both of the replacement codes. This includes the addition of coverage for Liletta. For those providers that had J7302 in their contracts, coverage for Liletta will have a retroactive effective date of July 1, 2015.
Issue Corrected Message: New Drug Testing Laboratory Codes, HCPCS Codes G0477 through G0483, CR 54713 and CR 55123
Effective January 1, 2016, the new Drug Testing Laboratory Codes HCPCS Codes G0477 through G0483 have been added to MIHMS.
Please see the e-message from February 12, 2016 that originally described this issue:
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.
Code and Rate Additions, Deletions, and Corrections
The “Code and Rate Additions, Deletions, and Corrections” spreadsheets have recently been updated. The spreadsheets are used to notify you of code and rate changes. You can view these spreadsheets on the Claims, Billing, and Enrollment webpage. We will send a listserv update when new information is added.
Provider Relations Policy Assignment Update
MaineCare's Provider Relations Specialists, by policy section of the MaineCare Benefits Manual, has been updated. Please review the Provider Relations Specialists Assignments to see who you should contact for assistance with MaineCare policy questions and training. For assistance with claims status, member eligibility, or general inquiries, please contact the Provider Services Call Center at 1-866-690-5585.