MaineCare Updates - January 3, 2017

Correction to Presumptive Eligibility Denials, CR 63802

We are still working to correct the issue with claims with presumptive eligibility due to pregnancy denying in error. Please see the e-message from December 27, 2016 that was published in error:

Presumptive Eligibility Denials, CR 63802

An issue was identified where some claims denied for no coverage when the member received MaineCare coverage based on Presumptive Eligibility due to pregnancy. The system has been updated and these claims should no longer deny. No provider action is needed as claims that denied in error will be reprocessed.

We apologize for any inconvenience this may have caused.

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 New Pathways Prior Authorization Request Form Not Yet Available

The Pathways Prior Authorization Request form has not been updated on the Health PAS Online Portal as referenced below: 

An updated Pathways Prior Authorization Request Form is available by going to the Health PAS Online Portal and following this pathway: Provider Forms > Authorizations and Referrals > Pathways Prior Authorization Request Form. 

We will notify you when the new Pathways Prior Authorization Request Form is available on the portal. 

Positron Emission Tomography (PET) Scans No longer Require Prior Authorization (PA), CR 63496

Effective January 1, 2017, PA will no longer be required for PET Scans. 

In order to be covered by MaineCare, PET scans must be medically necessary and meet the requirements set forth in the MaineCare Benefits Manual, Section 101, Medical Imaging Services. This rule is available at:  http://www.maine.gov/sos/cec/rules/10/ch101.htm 

The following PET scan procedure codes no longer require PA: 

Modality	Body Part	CPT	Description
PET	Other	78812	PET tumor imaging, skull to mid-thigh
PET	Other	78813	PET tumor imaging, whole body
PET	Other	78814	PET tumor imaging with concurrent CT, limited
PET	Other	78815	PET tumor imaging with concurrent CT, skull to mid-thigh
PET	Other	78816	PET tumor imaging with concurrent CT, whole body
PET	Head	78608	PET brain, metabolic evaluation
PET	Head	78609	PET brain, perfusion evaluation
PET	Heart	78459	PET myocardial, metabolic evaluation
PET	Heart	78491	PET myocardial, perfusion, single study
PET	Heart	78492	PET myocardial, perfusion, multiple studies
PET	Other	78811	PET tumor imaging, limited

Please note: there are NO changes to the PA requirements for Computed Tomography (CT). For members age 21 -64, all non-emergency, out-patient CT scans will continue to require PA.

If you have questions, please contact Provider Services at: 1-866-690-5585.