MaineCare General Topic- September 2, 2016
Maine Department of Health & Human Services sent this bulletin at 09/02/2016 02:08 PM EDT
Some Claims Denied In Error for CARC 237, CR 60082
An issue was identified and corrected where some crossover claims denied in error for “Invalid Medicare Action Code”. This was specific to CARC 237 (Legislated/Regulatory Penalty). Claims that denied in error will be reprocessed. No provider action is needed.
Reminder: Prior Authorization (PA) Cover Sheets and Required Form Fields
Requests for PA of medical services and durable medical equipment can be submitted to MaineCare by Direct Data Entry (DDE) into the Health PAS Online Portal or by fax. Failure to correctly complete a PA request by either method may result in a rejection of the PA request.
DDE on the Health PAS Online Portal
- Input fields with a red asterisk (*) are required for online PA requests.
- To ensure we are able to contact you regarding a decision for your authorization request, include contact information such as name and phone number of the person entering the authorization in the “Notes” The “Notes” field is pictured below.
- Add attachments to the online PA request. Supporting documentation must be attached to the online PA request. Types of required attachments are:
- Letter of Medical Necessity
- McKesson InterQual Criteria Sheets
The Health PAS Online: Prior Authorization User Guide is available at: https://mainecare.maine.gov/MyHealth%20PAS%20User%20Guides/Forms/Publication%20View.aspx
If the supporting documents are not attached to the online PA request or faxed in with the “Prior Authorization Supporting Documents or Updates Cover Sheet,” the PA request may be rejected and closed for being incomplete.
Faxing a PA Request
You must complete a cover sheet with your faxed PA request. The required cover sheets for faxed PA requests are located on the Health PAS Online Portal. Two fax sheets are available and should be used as appropriate:
- Initial Authorization Request Form
- Prior Authorization Supporting Documents or Updates Cover Sheet
If you submit a PA request via fax, it is mandatory to complete all required data form fields on the cover sheet. Refer to the “Initial Authorization Request Form, Section 3: Instructions” for designated “Required” and “Situational” form fields. Failure to complete all required form fields may result in a rejection of the PA request and its return to the submitting provider. Also, whenever additional information is submitted in support of an active PA, the “Prior Authorization Supporting Documents or Updates Cover Sheet” is required.
The Prior Authorization Manual is available at: https://mainecare.maine.gov/Provider%20Handbooks/Forms/Publication.aspx
If you have questions regarding the PA request process, please contact Provider Services at 1-866-690-5585.
New MaineCare Website for State Plan Methodology Notices
MaineCare will now publish State Plan Methodology Notices at: http://www.maine.gov/dhhs/oms/rules/stateplan/. This website allows the public to review upcoming changes to MaineCare methods for setting payment rates and submit feedback, including input related to access to care, directly to the Department via the “Submit Comments” function. MaineCare will no longer publish methodology notices in print newspapers around the state. Please contact Olivia Alford with any questions.