Child Health Incentive Payments Update – Additional Information and Payment Details 

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Child Health Incentive Payments Update – Additional Information and Payment Details 

In response to the ongoing COVID-19 pandemic and its impact on children’s access to preventive primary care and dental services, on August 21, 2020 we announced that we would be offering special Per Member Per Month (PMPM) incentive payments to primary care and dental providers who deliver the following services to children covered by MaineCare between September through December 2020: 

  • Primary Care Preventive Services: A provider practice will receive an incentive payment for each child on MaineCare who receives both a primary care wellness visit that is appropriate to the child’s age and a vaccination (this includes a flu vaccine) from the same practice during this time period (September-December 2020).  
  • Dental Services: A practice will be eligible to receive an incentive payment for each child on MaineCare who receives one or more dental services (including oral health screenings and application of fluoride varnish) from the practice during the month.  

The codes associated with these payments are outlined below. Providers need to include both the CPT and ICD-10-CM codes to indicate a well visit. Well visits and dental services billed without the codes listed below will not qualify for the child health incentive payments.  

In alignment with the MaineCare Benefits Manual (MBM), Federally Qualified Health Centers (FQHCs, see MBM Section 31) and Rural Health Clinics (RHCs, see MBM Section 103) must report all services provided, including all procedures, with the standard CPT, HCPCS, or CDT codes, in addition to their encounter code (T1015).   

Preventive Medicine Services: New Patients 

CPT/HCPCS Codes 

ICD-10-CM Codes 

99381, Infant (younger than 1 year) 

Z00.110, Health supervision for newborn under 8 days old or 

Z00.111, Health supervision for newborn 8 to 28 days old or 

Z00.121, Routine child health exam with abnormal findings or 

Z00.129, Routine child health exam without abnormal findings 

99382, Early childhood (age 1-4 years) 

99383, Late childhood (age 5-11 years) 

99384, Adolescent (age 12-17 years) 

Z00.121, Routine child health examination with abnormal findings 

Z00.129, Routine child health examination without abnormal findings 

99385, 18 years or older 

Z00.00, General adult medical exam without abnormal findings 

Z00.01, General adult medical exam, with abnormal findings 

G0438, Annual wellness visit, initial visit  

Z00.00, Z00.01, Z00.110, Z00.111, Z00.121, or Z00.129 

Preventive Medicine Services: Established Patients 

CPT/HCPCS Codes 

ICD-10-CM Codes 

99391, Infant (younger than 1 year) 

Z00.110, Health supervision for newborn under 8 days old or 

Z00.111, Health supervision for newborn 8 to 28 days old or 

Z00.121, Routine child health exam with abnormal findings or 

Z00.129, Routine child health exam without abnormal findings 

99392, Early childhood (age 1-4 years) 

99393, Late childhood (age 5-11 years) 

99394, Adolescent (age 12-17 years) 

Z00.121 

Z00.129 

99395, 18 years or older 

Z00.00, General adult medical exam without abnormal findings 

Z00.01, General adult medical exam with abnormal findings 

G0439, Annual wellness visit, subsequent visit  

Z00.00, Z00.01, Z00.110, Z00.111, Z00.121, or Z00.129 

Vaccination Administration 

  • 90460 (includes physician counseling), first shot 
  • 90461, second shot  
  • 90467 (no physician counseling), intranasal 
  • 90471, first shot 
  • 90472, second shot 
  • 90473, intranasal 
  • G0008, Administration of influenza virus vaccine       
  • G0009, Administration of pneumococcal vaccine 
  • G0010, Administration of hepatitis B vaccine 

Dental Services 

  • Any CDT code (procedure codes beginning with D*) 
  • 99188, fluoride varnish  

Please see below to learn more about when to expect these payments and how to identify them on the Remittance Advices (RAs). Please share this information with the staff responsible for posting your facilities’ payments and RAs.     

As a reminder, the PMPM payment amounts are: 

  • $31.14 for preventive primary care (wellness visit and vaccine) 
  • $37.09 for dental care 

These payments will occur in October, November, December, and January. You will receive these special payments automatically on the basis of the claims you regularly submit for the services. MaineCare will analyze your claims to determine how many members were served during the month, and issue you a payment based on the number of members served multiplied by the corresponding PMPM rate for the service. It is important that you submit claims in a timely manner to ensure you receive your PMPM payments according to the schedule outlined below. Any claims submitted after the October, November, December, and January claim submission windows will be accounted for in a final February payment. Claims submitted after the February submission deadline will not be eligible for the PMPM payment.     

Payment Schedule and Details  

 

Dates of Service 

Claims Submission Deadline 

Date PMPM Payment Issued  

October Payment 

9/1/20-9/30/20 

Submit by 10/6/2020 

10/28/20 

November Payment 

9/1/20-10/31/20 

Submit by 11/10/20 

11/25/20 

December Payment 

9/1/20-11/30/20 

Submit by 12/8/20 

12/30/20 

January Payment 

9/1/20-12/31/20 

Submit by 1/5/21 

1/27/21 

February Payment 

9/1/20-12/31/20 

Submit by 2/9/21 

2/24/21 

These payments will be made as part of MaineCare’s normal cycle payments, so providers will receive their payments according to their regular payment schedules. The special PMPM payments can be identified on the printed RA summary page as “other.” For providers who use the electronic RA (835), these payments can be identified in the PLB section of the 835 and will contain an invoice ID prefix of CHWELL for wellness visit PMPM payments, and CHDENT for dental services.      

The RAs and 835s will not provide detailed claim information for these PMPM payments; this will be sent separately in February to assist with claim reconciliation. At that time, the following information will be provided: member ID, service month, first service date that activated the payment within that month, service location, procedure codes, and any relevant modifiers, payment amount, and payment month.    

Please contact your Provider Relations Specialist with questions.