August 23, 2021 MaineCare Updates

Maine Department of Health & Human Services sent this bulletin at 08/23/2021 03:41 PM EDT

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In this message: 

  • Addition of New COVID-19 Monoclonal Antibody Product and Administration Codes to MaineCare Benefits Manual (MBM), Chapters II and III, Sections 9, 31, 45, 90, and 103 Providers, CR 103435, 103801, & 103802 
  • Primary Care Plus Estimated Population-Based Payment Request Update  
  • Health Care Worker COVID-19 Vaccination FAQs 
  • Guidance on Section 96, Private Duty Nursing Services, Provided Outside the Home 
  • Primary Care Provider Incentive Payments (PCPIP) and Report Schedule  
  • National Drug Code (NDC) Reminder 
  • Required on Claims: National Provider Identifier with Service Location Indicator (NPI+3) 
  • Tobacco Cessation Program Improvements: Prior Authorization (PA) No Longer Needed for MaineCare Members   

Addition of New COVID-19 Monoclonal Antibody Product and Administration Codes to MaineCare Benefits Manual (MBM), Chapters II and III, Sections 9, 31, 45, 90, and 103 Providers, CR 103435, 103801, & 103802 

 

Attention providers of MBM, Chapter II and III, Sections: 

  • 9: Indian Health Services 
  • 31: Federally Qualified Health Center Services 
  • 45: Hospital Services 
  • 90: Physician Services 
  • 103: Rural Health Clinic Services  

The Office of MaineCare Services (OMS) has added coverage for the following COVID-19 monoclonal antibody infusion product and administration codes to your contracts: 

OMS Monoclonal Antibody Product Code Information

Code

Code Description

Labeler Name

Effective Date

End Date

Rate

Q0244

Injection, casirivimab and imdevimab, 1200 mg

Regeneron

06/03/21

N/A

$0 SL Modifier*

Q0247

Injection, sotrovimab, 500 mg

GlaskoSmithKline

05/26/21

N/A

$2,394.00

Q0249

Injection, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, 1 mg

Genentech

06/03/21

N/A

$6.57

*This monoclonal antibody COVID-19 product is provided by the federal government at no cost to providers. Must be billed with the SL modifier and has a $0 rate. 

 

OMS Monoclonal Antibody Administration Code Information

Code

Code Description

Labeler Name

Effective Date

End Date

Rates: Dates of Service to 5/5/21 (or code end date)

Rates: Dates of Service on or after 5/6/21

M0247

Intravenous infusion, sotrovimab, includes infusion and post administration monitoring

GlaskoSmithKline

05/26/21

N/A

N/A

$283.22*

* Reimbursement rate for providers of Section 9: Indian Health Services, Section 31: Federally Qualified Health Centers, and Section 103: Rural Health Centers is included in the encounter rate.

Attention providers of MBM, Chapter II and III, Sections:

  • 45: Hospital Services
  • 90: Physician Services 

OMS has added coverage for the following COVID-19 monoclonal antibody infusion administration codes to your contracts: 

OMS Monoclonal Antibody Administration Code Information

Code

Code Description

Labeler Name

Effective Date

End Date

Rates: Dates of Service to 5/5/21 (or code end date)

Rates: Dates of Service on or after 5/6/21

M0248

Intravenous infusion, sotrovimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the covid-19 public health emergency

GlaskoSmithKline

05/26/21

N/A

N/A

$472.53

M0249

Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, first dose

Genentech

06/24/21

N/A

N/A

$283.22

M0250

Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, second dose

Genentech

06/24/21

N/A

N/A

$283.22

The U.S. Food and Drug Administration (FDA) recently issued the following Emergency Use Authorizations (EUAs) for COVID-19 monoclonal antibody product and administration: 

 

COVID-19 Monoclonal Antibody Product and Administration EUA Fact Sheets for Healthcare Providers for these newly added codes: 

 

Providers may now resubmit any previously denied claims for these services.  

 

See the COVID-19 Coding and Billing Guidance (PDF) for a summary of COVID-19 codes and billing  information. 

 

Please contact your Provider Relations Specialist with questions. 

 

Primary Care Plus Estimated Population-Based Payment Request Update  

 

Some primary care providers have requested population-based payment estimates referenced in the May 28, 2021 e-message about  the proposed MaineCare Primary Care Plus (PCPlus) initiative, formerly known as Primary Care 2.0. We’ve received and processed over 120 requests from primary care locations and continue to process the remaining requests. If you have not yet received a response to your PCPlus payment estimate request, we intend to complete pending requests in the coming weeks.   

   

Please note that we are still accepting requests from primary care locations interested in learning more about their potential population-based payment under PCPlus. If you would like to submit a request, please complete the required information in the online form.  

  

For questions regarding PCPlus estimates you have received or requested, please e-mail: PCP-Network-Services.DHHS@maine.gov   

 

Health Care Worker COVID-19 Vaccination FAQs 

 

On August 12, 2021, the Mills Administration announced that health care workers in Maine must be fully vaccinated against COVID-19 by October 1. FAQs about this requirement are now available online.    

The State of Maine has long required the immunization of employees of designated health care facilities to reduce the risk of exposure to, and possible transmission of, vaccine-preventable diseases. Maine CDC amended the existing rule to include the COVID-19 vaccine to protect the health and lives of Maine people, safeguard Maine’s health care capacity, and limit the spread of the virus. The emergency rule issued on August 12, 2021, can be found here. 

 

Guidance on Section 96, Private Duty Nursing Services, Provided Outside the Home 

Under Chapter II, Section 96 of the MaineCare Benefits Manual, MaineCare can reimburse providers for private duty nursing (PDN) services “outside the Member's residence, when normal life activities take the Member outside his or her residence (school, preschool, daycare, medical appointments, etc.).”  See 96.01-3, Private Duty Nursing Services definition. 

Within the next few months, the Office of MaineCare Services plans to propose a rule change that will add specificity on the circumstances in which PDN services outside the home may be reimbursed. In the interim, the Department will approve requests for PDN services for “normal life activities” outside the Member’s residence, so long as the services requested outside the home meet other requirements of the rule regarding medical necessity and authorization of services and hours.  Specifically, services outside the home can include only authorized nursing services, must be medically necessary and consistent with the Authorized Plan of Care, and may not exceed what would have been allowed in a home setting in terms of hours and tasks. As is the general case for all MaineCare services, services are not available for travel outside the United States, and any non-emergency services provided out of state require prior approval from the Department. 

For approval of Section 96 PDN services outside the home for members under age 21, please contact your PDN provider agency. For approval of Section 96 PDN services outside the home for adults, please contact your service coordination agency. These agencies will seek prior approval from the Department to provide services outside of the member’s home.

Primary Care Provider Incentive Payments (PCPIP) and Report Schedule 

 

MaineCare has completed the PCPIP 63 reports for the reporting period of October 1, 2019 – September 30, 2020. The MaineCare e-messages from April 17, 2020 and July 30, 2021 noted that future PCPIP data may be adjusted due to COVID-19.  

  

MaineCare reviewed the data for the PCPIP 63 reports to determine the potential effects of COVID-19 on member attribution, quality measures, and payments. While performance was affected on some quality measures, the relative performance and resulting distribution of funds was not altered significantly from previous periods. As such, we will continue using the traditional scoring method and timeframe as it effectively mitigated the observed effects of COVID-19 on payment amounts.   

  

The reports are now available in the secure File Exchange area on the Health PAS Online Portal. Payments will be processed the week of August 23, 2021.  

 

As a reminder, the MaineCare e-messages from April 17, 2020 and July 30, 2021 noted that future PCPIP data may be adjusted due to COVID-19.    

  

Please email PCP Network Services with questions.  

 

National Drug Code (NDC) Reminder 

 

As a reminder, NDC numbers are required on all drugs submitted with a CPT/HCPC code. 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.  

 

Required on Claims: National Provider Identifier with Service Location Indicator (NPI+3)    

   

When providers submit MaineCare claims, the claims must include the correct National Provider Identifier with the 3-digit service location indicator (NPI+3) to indicate the service location where the service occurred. For reference, this requirement is listed in MaineCare Benefits Manual, Chapter I, Section 1.03-1 (I).   

   

For the UB claim form, the service location field is identified as FL2 and completed as follows:   

  • Service Location ID: 10 Digit NPI or API plus the 3-digit servicing location identifier of -001, -002, etc. (ex. 1234567890-003).   
  • Line 1 - Facility Name   
  • Line 2 - Address – Must be a physical address: not a PO Box   
  • Line 3 - City, State, and 9-digit Zip code   
  • Line 4 - Service Location ID   

   

For the 1500 claim form, the service location field is identified as Box 32b:  

  • Situational (Required if provider has more than one service location, unless the service location and billing provider address are the same).   
  • The service location ID is not needed if:   
  • The provider has enrolled with only one service location within MaineCare.   
  • The service location and the billing provider address are the same.   
  • Service Location ID: 10 Digit NPI or API plus the 3-digit servicing location identifier of  -001, -002, etc. (i.e. 1234567890-003).   

   

If you have any questions about submitting claims to MaineCare, please contact your Provider Relations Specialist (PDF) .   

 

Tobacco Cessation Program Improvements: Prior Authorization (PA) No Longer Needed for MaineCare Members  

 

The Maine QuitLink, formerly known as the Maine Tobacco HelpLine, now has even easier access andexpanded quit options. Participants, including MaineCare members, are now able to get free medications to help quit without needing a prior authorization.   

The Maine QuitLink offers a variety of free programs to meet the needs of those who smoke, vape, or use other tobacco products. Maine residents can choose from a variety of digital and phone-based programs to meet them where they are in their quitting process.  

 

Maine residents can:  

 

  • Choose from the robust integrated phone coaching program or from one of the standalone digital services.  

 

Why is this important?  

  

  • There are several medicines approved for quitting tobacco and are much safer than smoking or other tobacco use. These medicines are called Nicotine Replacement Therapy (NRT).  
  • These medicines contain nicotine but do not cause death and disease like tobacco does.  
  • Most of the dangers of tobacco are due to the hundreds of toxic chemicals, not the nicotine.  
  • NRT is much less addictive than tobacco while still helping decrease the urge to use.  
  • NRT reduces the uncomfortable feelings one experiences from nicotine withdrawal.  
  • Using NRT to quit smoking is usually temporary.  

 

Tobacco quitlines and medicines are effective resources to help those who use tobacco quit. When someone is ready to quit, they do not have to do it alone. The Maine QuitLink offers free, confidential supportive help over the phone or online.  

 

Quitlines are proven to increase a person’s chances of quitting successfully and staying tobacco-free.   

 

  • Tobacco users who receive support from the Maine QuitLink are two to three times more likely to successfully quit tobacco long-term than those who try quitting on their own.  
  • A quit coach will work with participants to develop a plan that is personalized for an individual’s needs.  

 

The Maine QuitLink is a trusted provider of services.  

 

  • The Maine QuitLink offers free, confidential support to all people, and does not discriminate on the basis of race, color, national origin, age, disability, gender identity or sexual orientation.   
  • This support includes qualified interpreters for people whose primary language is not English, and services to assist individuals who are deaf or hard of hearing.   
  • The work on behalf of the Maine QuitLink is administered by MaineHealth Center for Tobacco Independence (CTI). CTI has over 20 years of experience administering statewide tobacco treatment and prevention contracts on behalf of the Maine Center for Disease Control and Prevention (Maine CDC), Maine Department of Health and Human Services.