MaineCare Updates

Prior Authorization (PA) Letters Available on the Health PAS Online Portal

The MaineCare Health PAS Online Portal was upgraded in January 2017 and one of the improvements is the availability of PA letters under the secure section of the portal. These PA letters are to billing and referring providers and include denial, deferred, and approval letters. To access the letters, go to the Health PAS Online Portal and log into your Trading Partner Account. The letters will reside under the File Exchange > Reports > Other Reports. PA letters are identified by a “PA” at the beginning of the filename and the PA number is located near the end of the filename. 

Among other Reports located here, the most common PA letters are filenames starting with: 

• PA0002 for “Approved for Pay To”
• PA0006 for “Deferral for Referring”
• PA0008 for “Denial for Pay To”  
• PA0016 for “Automatic Approved for Pay To”
• PA0018 for “Approved for Referring” 

Portal users that have any of the R2 - R9 rights will have access to the Other Reports section. This section contains the PA letters along with other miscellaneous reports. If you have questions about accessing the letters, please contact Provider Services at: 1-866-690-5585.

---

QMB/Spenddown Claims Denied in Error, CR 56707 

An issue was identified where some crossover claims denied in error. The error occurred when the member had Medicare for primary insurance and QMB coverage with a spenddown as secondary insurance. The claim should have processed with QMB coverage, but instead denied in error. The issue has been corrected and claims that denied in error will be reprocessed. No provider action is needed. 

---

 Issue Corrected: Incorrect Copayments, TR 51231 

The issue where some copayment amounts were not being calculated correctly when there was more than one line on the claim has been corrected. Affected claims will be reprocessed. No provider action is needed. 

Please see the e-message from August 14, 2015 that originally described this issue: 

Incorrect Copayments, TR 51231 

An issue has been identified where some copayment amounts are not being calculated correctly when there is more than one line on the claim.  We are working to correct this issue and we will notify you once it is resolved.   

---

PT and OT Evaluations and Re-Evaluations, CR 65810  

An issue was discovered where Evaluation and Re-Evaluation Codes 97165, 97166, 97167, and 97168 denied incorrectly when submitted with a TM Modifier (Individualized Education Program or IEP). This has been corrected and claims will be reprocessed. 

---

CPT Evaluation Codes for Speech Therapy Denied in Error, CR 65772 

We have discovered an issue where hospitals billing CPT codes 92521, 92522, 92523 and 92524 denied in error. This issue has been resolved and impacted claims will be reprocessed. No provider action is needed. 

---

Place of Service (POS) Code Set 

The Office of MaineCare Services is reminding all providers who file professional claims (CMS 1500) that the appropriate two digit POS code needs to be utilized. These codes are used to specify the entity where service(s) were rendered. 

The Centers for Medicare & Medicaid Services publishes the most current Place of Service Code Set for providers to reference.  You may also utilize the CMS 1500 Billing Instructions guide on the Health PAS Online Portal for additional information. 

All POS codes are two digits and must be listed as such or the claim will deny. 

Please contact the appropriate Provider Relations Specialist by policy for any questions related to this notice.