MaineCare Updates - January 3, 2017
Maine Department of Health & Human Services sent this bulletin at 01/03/2017 01:40 PM ESTHaving trouble viewing this email? View it as a Web page.
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.
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.