MaineCare General E-Message - August 5, 2016

Ambiguous Gender Specific Coding, TR 53014

The following information is being updated in MIHMS to ensure appropriate processing of claims when there is a discrepancy with the diagnosis codes, or CPT/HCPC codes, and a MaineCare member’s gender.

UB-04 - Use condition code 45 (Ambiguous Gender Category) to identify services that are gender specific (i.e., services that are considered female or male only).  This condition code should only be used on claims relating to transgender, ambiguous genitalia, or hermaphrodite issues.

CMS-1500 - KX modifier should be used to identify services that are gender specific (i.e., services that are considered female or male only).  This modifier should only be used on claims relating to transgender, ambiguous genitalia, or hermaphrodite issues.

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 APS HealthCare/KEPRO Process Updates

On July 5^th, the Office of MaineCare Services published an e-message in regarding discharging members from the APS CareConnection portal.  That message stated that backdating discharges will no longer be allowed.  This procedure has been updated to allow backdating up to 24 hours prior to the member’s call to APS member services.  The amended information is as follows:

Backdating Discharge Dates Change

Effective July 5, 2016, the member’s date of discharge from a provider can be backdated up to 24 hours prior to the member’s call to APS member services.

Previously, APS allowed the backdating of the discharge from a provider, when requested by the member.  Backdating of discharge dates will be allowed up to 24 hours prior to the date of contact of a member to APS member services.

Below is more detail about the date of discharge:

• The provider discharging the member should complete the discharge with APS Healthcare.
• If the discharge is not completed by the discharging provider, the date of discharge will be the date the member contacts APS Member Services to notify them of the discharge. This will help limit the potential for billing conflicts.
• The new provider should ensure that the previous provider has discharged the member before initiating services. You can call APS with the member during the intake appointment to ensure this step is complete.

Discharging a Member in the CareConnection Portal Reminder

As a reminder, you are required to complete the member discharge process within the APS CareConnection portal.

• The discharge process in CareConnection must be completed as soon as possible to avoid potential billing issues.  
• Discharging in CareConnection helps ensure that members will not be prevented from receiving services from another provider.
• Discharging the member correctly will ensure the most accurate medical records possible.

For questions, please call APS Healthcare at: 1-866-521-0027, option 1 or

Joshua Birdwell, Provider Relations Specialist at: (207) 624-6938.

Overlapping Authorizations Edits

Effective immediately, authorizations with overlapping dates will be edited by APS Healthcare staff. If a new authorization request is received, the previous requested will be end dated so there is no overlap of authorization dates. Any authorization that has been edited will include documentation of the change in the provider’s daily download notification.

For questions on this process change, please contact the APS provider relations team at 1-866-521-0027.