Policy Updates: Sections 19, 21, and 29
Maine Department of Health & Human Services sent this bulletin at 10/27/2017 02:50 PM EDT
Correction to the Emergency Rule, Chapter III, Section 21, Allowances for Home and Community Benefits for Adults with Intellectual Disabilities or Autism Spectrum Disorder: Do Not Submit Adjusted Claims for T2016 Agency Group Home Per Diem Until the System has been Updated
The Department has identified an error in the emergency rule. Section 1300.3 specifies that there will be a $2.92 difference in the rate for T2016 between regular support hours up to 168 ($25.04) and hours in excess of 168 ($22.12). The emergency rule refers to an incorrect rate of $21.81, on pages 13 and 16. The correct rate and the rate used in the retro-rate calculation done by KEPRO is $22.12. The provisionally adopted rule will correct the erroneous rate.
We will notify you when the system has been updated and you can adjust affected claims. All other codes with rate increases are ready to be adjusted. Please contact Tammy Usher for questions about this policy at: Tammy.L.Usher@maine.gov or 207-624-6933. Please call KEPRO for questions about authorizations at: 1-866-521-0027.
Ch. III, Sections 21 and 29: Rate Increases
Rate increases were adopted through emergency rules for Ch. III - Section 21: Allowances for Home and Community Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder and for Section 29: Allowances for Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder. The emergency rules implement provisions of P.L. 2017, Ch. 284, the most recent budget bill passed by the Legislature.
The increased rates for Sections 21 and 29 are retroactive to July 1, 2017. Providers need to adjust their claims to account for the retroactive rate.
The Department continues to work on T2016 (Agency Home Support) and will send another notice when claims can be adjusted. All other codes are ready to be adjusted.
Rate Increase Adjustments
MaineCare recommends testing one claim or claim batch to see how long the process is going to take. This will allow providers to plan so that the process of claims reversal and repayment does not affect the agency’s revenue stream. MaineCare cannot guarantee that the reversal and repayment will be on the same Remittance Advice (RA), which is why we recommend a test claim or test batch.
Taking into consideration the complex process for updating Prior Authorizations (PA), MaineCare is working to update PAs with the correct rates. Please check PAs requests approved prior to September 29, 2017 before submitting claims to ensure the PA has been updated with the correct rate. Any PAs created on or after September 29, 2017 include the correct increased rates.
Rate Increase Adjustment Process
This process applies to claims for dates of service on or after July 1, 2017. No claims prior to July 1, 2017 can be adjusted to the higher rate.
In order to adjust claims with the higher reimbursement rate, please complete the following steps:
- Log into your Trading Partner Account on the Health PAS Online Portal.
- Under Form Entry, go to Claim Status.
- Click on the search icon. Here you may search for the affected claims by member, date span, or other identifying factors. Do not attempt to reverse and adjust a DENIED
- Click on the claim number hyperlink of the PAID claim you would like to adjust. This will bring up the claim image.
- Scroll to the bottom of the claim image and click on the option to reverse the claim.
- At this step, you have two options:
- Option One: Reverse the claim and use the details as a basis for your new claim (default option). The system will reverse the claim and generate a new claim with the same information.
- Option Two: Directly reverse the claim. This will take the money back. You need to submit a new claim with the higher charge amount (the new rate) once the reversal is on a Remittance Advice (RA).
- You can reverse this claim and use the details as a basis for your new claim. This is the default option. This option takes the money back, and starts the process for repaying at the higher rate. Go to your charges amount and adjust to reflect the higher amount (the new rate) you will be paid. Tab through the rest of the line. Adjudicate your claim by scrolling to the bottom and click Adjudicate. This will push the claim through the system edits.
- Click Save and wait for the dialog box indicating the claim was saved.
- Click Submit.
If you have questions, please contact Tammy Usher at: Tammy.L.Usher@maine.gov or 207-624-6933.
Section 29 Providers Interested in Adding Shared Living
Shared Living is a new service for Section 29, Support Services for Adults with Intellectual Disabilities or Autistic Spectrum Disorder. It is currently available for Section 29 members.
Chapter II, Section 29.02-25 defines Shared Living:
Shared Living (Foster Care-adult) is a model in which services are provided to a member by a person who meets all of the requirements of a Direct Support Professional with whom that member shares a home. The home may belong to the provider or the member, but the provider must enter into a contractual relationship with an Administrative Oversight Agency in order to provide services under this model. Only one member may receive services in any one Shared Living arrangement at the same time, unless a relationship existed prior to the service arrangement and the arrangement is approved by DHHS. In such case, no more than two members may be served in any one Shared Living arrangement concurrently. Please see 29.10-4 for additional qualifications.
Providers who are interested in enrolling should contact Lynne Raymond at: lynne.raymond@maine.gov or 207-493-4126.
If you are currently providing Shared Living services for Section 21 and you would like to provide this service for Section 29, you will not need to complete a new application with the Office of Aging and Disability Services (OADS) but you must still contact Lynne Raymond and receive written approval.
When enrolling in MIHMS, you must enroll with an identifiable title that includes SL 29 for each location (example: 12 Main St, SL 29). The system will assign a unique identifier for each location that is different from the Section 21 service location ID (example: 001 is the unique identifier assigned to Section 21 and 002 is the unique identifier assigned to Section 29).
If you need assistance with billing or have other questions, please contact Tammy Usher at: Tammy.L.Usher@maine.gov or 207-624-6933.
Attention Section 19, Home and Community Benefits for the Elderly and for Adults with Disabilities Waiver Services: Increased Reimbursement Rates and New Modifiers
MIHMS has been updated to reflect increased reimbursement rates and newly required modifiers for select Section 19 services. Please see the two tables below for a full list of new rates and modifier requirements. These rate changes are retroactive to July 1, 2017, and are now active in the system for dates of service on or after September 29, 2017. Providers must adjust their claims from July 1, 2017 – September 28, 2017 to receive the higher reimbursement. The new modifiers are required for dates of service on or after September 29, 2017.
See the linked document at the bottom of this message for all new rates and modifiers and modifier requirements.
Emergency rulemaking will follow. If you have questions, please contact Tammy Usher at: Tammy.L.Usher@maine.gov or 207-624-6933.