November 19, 2021 MaineCare Updates

In this message:

• MaineCare Adds Coverage for COVID-19 Pediatric and Booster Vaccine Product and Administration Codes, CR 105646 and 105668
• Updated COVID-19 Billing Codes Document
• Drug Rate Updates, CR 105335
• PCCM, PCPIP, and Primary Care Health Home Programs Ending
• Primary Care Plus (PCPlus) Provider Application Period in Now Open
• Electronic Data Interchange (EDI) Receiver ID or Sender ID Changes, CR 103741
• Provider Trainings 

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MaineCare Adds Coverage for COVID-19 Pediatric and Booster Vaccine Product and Administration Codes, CR 105646 and 105668  

Attention MaineCare providers of the following MaineCare Benefits Manual (MBM), Chapter II and III sections of services: 

• Section 3: Ambulatory Care Clinic Services 
• Section 5: Ambulance Services 
• Section 7: Free-standing Dialysis Services 
• Section 9: Indian Health Services 
• Section 14: Advanced Practice Registered Nursing Services 
• Section 31: Federally Qualified Health Center Services 
• Section 40: Home Health Services 
• Section 45: Hospital Services 
• Section 80: Pharmacy Services (Please see additional guidance below.) 
• Section 90: Physician Services 
• Section 103: Rural Health Clinic Services  

The Office of MaineCare Services (OMS) has updated our system to add the following COVID-19 Pediatric and Booster vaccine codes:  

COVID-19 Pediatric and Booster Vaccine Codes
CPT & HCPC Codes	Code Description	Vaccine Type	MaineCare Effective Date	Rate
91306	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 50 mcg/0.25 mL dosage, for intramuscular use	Moderna Low-dose Booster Product	10/20/21	$0 with SL Modifier*
0064A	Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 50 mcg/0.25 mL dosage, booster dose	Moderna Low-dose Booster Administration	10/20/21	$37.29**
0004A	Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted: booster dose	Pfizer Booster Dose Administration	9/22/21	$37.29**
0034A	Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5x1010 viral particles/0.5 mL dosage; booster dose	Janssen (J&J) Booster Administration	10/20/21	$37.29**
91307	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use	Pfizer Pediatric Product	10/29/21	$0 with SL Modifier*
0071A	Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation: first dose	Pfizer Pediatric Administration of First Dose	10/29/21	$37.29**
0072A	Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation: second dose	Pfizer Pediatric Administration of Second Dose	10/29/21	$37.29**
*This COVID-19 vaccine product is provided by the federal government at no cost to providers. Must be billed with the SL modifier and has a $0 rate.  **MaineCare UCR Fee Schedule Rate. Section 45: Hospital Services claims shall be APC priced in accordance with CMS status.

COVID-19 Vaccine Code Updates for MBM, Chapter II, Section 80: Pharmacy Services Providers Additional Guidance   

OMS has updated its MEPOPS system to include all available COVID-19 vaccine National Drug Codes (NDCs), including the pediatric and booster vaccines.   

Pharmacies may submit claims for administration of a booster dose of the COVID-19 vaccine. 

The Submission Clarification Code (420-DK) field should be used to differentiate which dose is being administered to allow proper reimbursement.  

• Submission Clarification Code = 10 should be used for the booster dose for population with waning immunity.  
• Submission Clarification Code = 7 should be used for the additional dose for immunocompromised patients. 

For pharmacy questions, please contact the Change Healthcare Pharmacy Help Desk at 1-888-420-9711. MaineCare providers can also send inquiries via email to PBA_helpdesk@changehealthcare.com.   

For other questions, please contact your Provider Relations Specialist.   

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Updated COVID-19 Billing Codes Document 

The COVID-19 Billing Codes document has been updated and can be found on our COVID-19 webpage as well as in the Supplemental Billing Folder on the Health PAS Online Portal. 

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Drug Rate Updates, CR 105335

Effective October 1, 2021, drug code rates have been updated in MIHMS and are now available for viewing on the Health PAS Online Portal for MaineCare Benefits Manual (MBM) Chapter II, Sections:

• 25: Dental Services
• 30: Family Planning Agency Services
• 45: Hospital Services
• 55: Laboratory Services
• 60: Medical Supplies and Durable Equipment
• 75: Vision Services
• 90: Physician Services
• 95: Podiatric Services
• 101: Medical Imaging Services

The updated rates can be found on the Codes and Rates webpage.

Claims billed at the previous rates for dates of service between October 1, 2021 and October 27, 2021 will be reprocessed, and no provider action is needed.

Please contact your Provider Relations Specialist with questions.

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PCCM, PCPIP, and Primary Care Health Home Programs Ending 

 

The Primary Care Case Management (PCCM) program, Primary Care Incentive Payment (PCPIP), and primary care Health Home (HH) program are anticipated to end on the following dates: 

• PCCM - final month ends March 20, 2022, with payment in March 2022
• PCPIP - final report and payment in January 2022
• Primary care HH - final month ends March 20, 2022, with payment in April 2022

 

Future communications will provide additional details related to the ending of these programs as the above dates approach.  

 

For information about the transition to Primary Care Plus (PCPlus), anticipated to begin in April 2022, please go to our Primary Care webpage. 

 

For questions, contact the Delivery System Reform Unit at PCP-Network-Services.DHHS@maine.gov.   

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Primary Care Plus (PCPlus) Provider Application Period is Now Open 

  

PCPlus is a new MaineCare initiative to support primary care practices in delivering high-quality primary care and is anticipated to begin in April 2022. The PCPlus application period is now open for primary care providers to apply for the PCPlus program.   

 

To ensure a timely transition to PCPlus, please take note of the following:    

• If you are a provider that has not completed the pre-application and would like to apply to the PCPlus program, you must complete and submit the PCPlus application no later than January 7, 2021. Organizations with more than one location must complete a separate application for each location. 

• If you are a provider that has submitted a pre-application for PCPlus, MaineCare will notify you to confirm receipt of your pre-application and remind you if any supporting documents still need to be submitted, starting the week of November 29, 2021. You do not need to complete the application again, though you may need to submit further information.    

If you would like to review the questions prior to completing the application, see the PDF version available on the Primary Care webpage. 

 

It is important to note that some deliverables that are part of the application, such as the Community Health Worker environmental scan and the Joint Care Management and Population Health Strategy, are now due on July 31, 2022, after the program start date.

 

We expect the proposed rule for PCPlus to be available by the end of the month on our Proposed and Recently Adopted Rules webpage. MaineCare will reach out to applicants for a final confirmation about joining PCPlus upon rule adoption.

 

For additional information about the PCPlus program, visit the Primary Care webpage, where you can also find Frequently Asked Questions, or email us at PCP-Network-Services.DHHS@maine.gov.  

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Electronic Data Interchange (EDI) Receiver ID or Sender ID Changes, CR 103741  

Effective January 8, 2022, the Receiver ID format for EDI inbound files and the Sender ID format for EDI outbound files will change as follows:

• Current formats: ME_MMIS_4MOLINA or ME_MMIS_4_DXCMS
• New format: ME_MES_4_MMS_IG 

Outbound files 

Effective January 8, 2022, Gainwell will begin sending ALL outbound files with the new Sender ID: ME_MES_4_MMS_IG. The sender ID Header loop changes are in segments ISA06 and GS02.  

Inbound files  

MIHMS will accept and process EDI inbound files received after January 8, 2022 that have both the current and new formats, as listed above. For inbound files, the receiver ID is in the Header loop, segments ISA08 and GS03. MIHMS will transmit ALL outbound acknowledgment and response files (TA1, 999, 824, BRR, 271, 277, 835) with the new Sender ID (ME_MES_4_MMS_IG) in the file name and body.

We will notify providers when MIHMS will no longer accept the old formats.  

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

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Provider Trainings

The Office of MaineCare Services is hosting virtual provider trainings about multiple sections of MaineCare policy. Each session will include information regarding provider enrollment and MaineCare policy. The trainings will be held via Zoom and registration is required for each session. Please be advised, the registration link will be emailed directly to you on the morning of the scheduled training. Please be sure to key in your correct email address when registering.

You can register online, and the Zoom link will be provided after registration.

Training Schedule

All trainings are scheduled from 9:00 – 11:00 am unless noted otherwise below.

• Section 102, Rehabilitative Services: November 30, 2021
• Section 15 Chiropractic Services: December 2, 2021 FROM 9:00 to 10:00
• Section 75, Vision Services: December 2, 2021 FROM 10:00 to 11:00
• Section 9, Indian Health Services: December 7, 2021
• Section 19 & 96, Home/Comm Based Benefits for the Elderly and/or Adults w/ Disabilities and Private Duty Nursing and Personal Care Services: December 9, 2021
• Section 30, Family Planning Agency Services: December 14, 2021