July 8, 2021 MaineCare Updates

In this message:

• MaineCare 340B Billing Guidance
• Room and Board Services Denials, CR 91586
• Maine Center for Disease Control & Prevention (CDC) Maine Press Release: New Program to Prevent Overdose Deaths
• Upcoming Provider Training Sessions
• Maintain Financial, Provider, and Professional Records Reminder: Keep Records for Five Years

---

MaineCare 340B Billing Guidance

Please read below regarding billing requirements regarding the submission of 340B claims to MaineCare.

All 340B providers:

When submitting 340B claims, please bill your usual and customary charge for the drug and populate it in the charge field of the claim. As we previously communicated, all providers who supply 340B drugs to MaineCare members are required to identify these drugs by appending modifier JG to the CPT/HCPC code. These modifiers were added to MIHMS with dates of service on or after January 1, 2019. Providers should check their records to ensure that JG modifiers are appended. Providers must adjust 340B drug claims that were paid without submitting these modifiers within 120 days from the date of this message.

National Drug Code (NDC) numbers are required on all drugs submitted with a CPT/HCPC code, even if they are not purchased under the 340B program. This includes claims that are billed to Medicare and third-party insurance when the member has dual eligibility. Medicare does not edit on the NDC number but passes the information to MaineCare for rebate purposes. Please refer to our previous communication for more details on submission of NDC numbers.

MaineCare collects rebates from manufacturers on drugs that are not purchased under the 340B program. Federal Law (42 USC 256b(a)(5)(A)(i)) prohibits duplicate discounts. Under this statute, 340B covered entities are responsible to ensure they bill claims appropriately to prevent duplicate discounts collected by this rebate process. Appending modifiers JG or TB properly excludes 340B drugs from the rebate process. Claims are routinely audited by Office of Inspector General, the State, and manufacturers. Any 340B covered entity that fails to comply with 340B requirements may be liable to manufacturers for refunds of the discounts obtained.

340B Hospitals only:

Hospitals that bill Medicare as the primary payor for a 340B drug for which Medicare does not require a JG modifier will need to submit that claim to Medicare with a TB modifier. When MaineCare receives the crossover claim, the TB modifier will identify the service as a 340B drug. This is only for crossover claims where Medicare is billed as primary payor.

The following reminders are for hospitals when submitting 340B drug claims:

• Billing MaineCare as primary - must append JG modifier to all drug claim lines to identify drugs purchased under the 340B program.
• Billing MaineCare secondary to commercial insurance - must append JG modifier to all drug claim lines to identify drugs purchased under the 340B program.
• Billing MaineCare secondary to Medicare - must append JG or TB modifier (see above) to all drug claim lines to identify drugs purchased under the 340B program.   

The hospital must adjust any claims submitted to Medicare without TB modifiers after January 1, 2021 to include the modifiers within 120 days from the date of this message. MaineCare will ensure drug rebates are not collected on claims related to the TB modifier that were submitted prior to January 1, 2021. Moving forward, if you adjust a claim submitted prior to January 1, 2021 for any purpose, you must include the appropriate modifiers to prevent duplicate discounts.

Please contact Shannon Beggs, Provider Relations Specialist, with questions.

---

Room and Board Services Denials, CR 91586 

We have corrected an issue that caused some claims submitted with room and board services to deny in error. The affected claims included a type of bill with a frequency of 1 or 2.  

The Remittance Advice or 835 showed the following CARC and RARC combination for the denied claims:   

• 16 - Claims/service lacks information or has submission/billing error(s).
• N345 - Date range not valid with units submitted. 

Affected claims will be reprocessed. No provider action is needed. 

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

---

Maine Center for Disease Control & Prevention (CDC) Maine Press Release: New Program to Prevent Overdose Deaths 

Below is an excerpt of the Maine CDC’s June 25, 2021 press release.

DHHS and Partnership to End Addiction Launch Free Text Alert Program To Prevent Overdose Deaths

AUGUSTA— The Maine Department of Health and Human Services (DHHS) and Partnership to End Addiction, today launched a free texting service that alerts Maine residents to any sudden increase in overdoses in their counties and connects them with resources that can save lives, support those struggling with substance use, and promote recovery.

Today, residents – including parents, caregivers, medical professionals, first responders, community groups and those struggling with substance use -- in all Maine counties can sign up for the Partnership’s SPIKE Auto Text Program. Individuals can sign up by texting SPIKE to 1 (855) 963-5669 (855-9-OD-KNOW) and following the prompts.

The program will link them to resources through Maine’s OPTIONS initiative, which is placing mobile response teams in each Maine county to engage communities with high rates of drug overdoses to promote harm reduction strategies, connect people directly to recovery services and treatment, and distribute naloxone, the lifesaving overdose medication. The text messaging system can help to prevent overdose deaths by directing individuals to the Know Your OPTIONS website, where they can learn how to get a naloxone kit or contact the OPTIONS liaison in their county.

Those who sign up will receive free notifications on their mobile device if three or more fatal or non-fatal overdoses occur in their county within a 24-hour period.

For more detail, see the full June 25, 2021 press release.

---

Upcoming Provider Training Sessions 

The Office of MaineCare Services, in coordination with Kepro, is hosting virtual provider trainings about multiple sections of MaineCare policy. Each session will include information regarding provider enrollment, MaineCare policy, and submitting authorization requests. The trainings will be held via Zoom and registration is required for each session. You can register online, and the Zoom link will be provided after registration.

Training Schedule

• Section 13, Targeted Case Management: July 22 (Children) and July 29 (Adult)
• Section 17, Community Support Services: July 13 and July 20
• Section 28, Community-Based: August 10 and August 12
• School-Based Services, Sections 28 and 65: August 17 and August 19
• Section 46, SHH and Acadia only: September 14
• Section 65, Behavioral Health Services: August 24 and August 26
• Section 92, Behavioral Health Homes: August 3 and August 5
• Section 93, Opioid Health Homes: September 16
• Section 97, Appendix D and Treatment Foster Care: August 31 and September 2
• Section 97, Adult PNMI only: September 9

For questions about the registration process, please contact Tia Bolduc. For general training questions, please contact Kepro provider relations.

---

Maintain Financial, Provider, and Professional Records Reminder: Keep Records for Five Years 

All providers are required to maintain and retain contemporaneous financial, provider, and professional records sufficient to fully and accurately document the nature, scope, and details of the healthcare and/or related services or products provided to each individual MaineCare member. These records are to be kept for a period of not less than five (5) years in order to meet statutory requirements. At all reasonable times during the prescribed retention period, authorized persons from the Department of Health and Human Services or the federal government shall be given access to such records. Failure to comply with any request to examine or receive copies of such records shall be grounds for immediate suspension from participation in the MaineCare program. Please refer to the MaineCare Benefits Manual, Chapter 1.03-8 (M) for more details about record keeping requirements.

Please contact your Provider Relations Specialist with questions.