February 18, 2022 MaineCare Updates

In this message:

• MaineCare Adds Coverage for Pfizer COVID-19 Ready-To-Use Vaccine Codes and Pediatric Third Dose Code, CR 107547 & CR 107724 
• Primary Care Provider Incentive Payment (PCPIP) and Report Schedule 
• Reminder for Providers Billing on UB-04 and 837I Claims, CR 107682

---

MaineCare Adds Coverage for Pfizer COVID-19 Ready-To-Use Vaccine Codes and Pediatric Third Dose Code, CR 107547 & CR 107724  

Effective January 3, 2022, the Office of MaineCare Services (OMS) has completed a system update to add the Pfizer COVID-19 ready-to-use vaccine codes. Please review the following table for more information.

COVID-19 Pfizer Ready-To-Use COVID-19 Vaccine Codes
Code	Description	Effective Date	MaineCare Rate
91305	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, trissucrose formulation, for intramuscular use	01/03/2022	$0 with the SL Modifier
0051A*	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, tris-sucrose formulation; first dose	01/03/2022	$36.98
0052A*	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, tris-sucrose formulation; second dose	01/03/2022	$36.98
0053A*	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, tris-sucrose formulation; third dose	01/03/2022	$36.98
0054A*	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, tris-sucrose formulation; booster dose	01/03/2022	$36.98
*These COVID-19 vaccine administration codes have been added for roster billing.

 Effective January 3, 2022, OMS has also completed a system update to add the Pfizer COVID-19 pediatric third dose vaccine code. Please review the following table for more information.

COVID-19 Pfizer Pediatric Third Dose COVID-19 Vaccine Code
Code	Description	Effective Date	MaineCare Rate
0073A*	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; third dose	01/03/2022	$36.98
*This code is for the administration of the third dose of the Pfizer pediatric COVID-19 vaccine product identified by CPT code 91307 and has been added for roster billing.

 

Please contact your Provider Relations Specialist with questions.

 

---

Primary Care Provider Incentive Payment (PCPIP) and Report Schedule 

 

MaineCare has completed the PCPIP 64 reports for the reporting period of April 1, 2020 – March 31, 2021. 

• The reports are now available in the secure File Exchange area on the Health PAS Online Portal.
• We will process payments the week of February 21, 2022.
• This will be the final PCPIP due to the upcoming transition to Primary Care Plus (PCPlus). 

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 64 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 between eligible providers and resulting distribution of funds did not change significantly from previous periods. As such, we will continue to use the traditional scoring method and timeframe as it effectively mitigated the observed effects of COVID-19 on payment amounts. 

 

For questions, please email PCP Network Services. 

---

Reminder for Providers Billing on UB-04 and 837I Claims, CR 107682 

Effective June 30, 2022, UB-04 and 837I claims submitted without an attending provider will be denied.

Providers who bill on UB-04 or 837I claims must include an Attending Physician Name, including secondary identifiers, when submitting claims in MIHMS. Form Locator 76 is a required field and will be used to validate that your attending physician is enrolled with MaineCare. The attending provider is the individual who has overall responsibility for the patient’s medical care and treatment. There are only a few services that do not require a National Provider Identifier (NPI) in the Attending Provider field.

Services that do not require an NPI in the Attending Provider field:

1. Emergency ambulance trips

• Emergency transportation services when they are the only services on the claim. Service codes identified: A0021, A0225, A0420, A0424, A0425, A0427, A0429, A0430, A0431, A0432, A0433, A0434, A0435, A0436, A0998, and A0999 (to also include A0428 when billed with modifier QL)
• Revenue code 0540

2. Singular or roster billing of Influenza or Pneumococcal Vaccinations and their administrations when these are billed as the only services on the claims. Administration codes are:

• Influenza G0008
• Pneumococcal G0009
• If all UB-04/837I billers are using the above admin codes, Revenue Code 0771

3. Vaccines

• Influenza 90655, 90656, 90657, 90658, 90660, 90673, 90685, 90686, 90688
• Pneumococcal 90670
• Revenue Code 0636

Type 1 vs. Type 2 NPI

Providers are required use a Type 1 NPI unless a self-referred screening mammography is the only service billed on the claim. As a reminder, Private Non-Medical Institutions (PNMI) are required to use a Type I NPI once you have completed the full enrollment revalidation process. See the e-message from April 12, 2021 for more detail.

When screening mammography services are self-referred, and as a result an attending physician NPI is not available, use the facility Type 2 NPI in the attending physician identifier field on the claim. For the self-referred mammography screenings, Type 2 NPIs are allowed.

• 77057, Screening mammography, bilateral (2-view film study of each breast)
• G0202, Screening mammography, producing direct digital image, bilateral, all views
• 77063, Screening digital breast tomosynthesis, bilateral (List separately in addition to the code for primary procedure)
• 77052, CAD screening mammography

In addition to including the attending physician’s NPI, you must also include a secondary identifier qualifier, as listed below.

UB-04: Secondary Identifier Qualifiers

• 0B - State License Number
• 1G - Provider UPIN Number
• G2 - Provider Commercial Number

837I: Secondary Identifier Qualifier

This is based on the provider’s NPI or Atypical Provider Identifier (API) number(s). If the provider enrolled with an NPI, then use “EI” and the NPI number as in the example below.

NPI Example:

NM1*71*1*LastName*FirstName****XX*9999999999~

REF*EI*111111111~

If the provider enrolled with an API then use “1D” and the Employer Identification Number (EIN) number as in the example below.

API Example:

NM1*71*1*LastName*FirstName****24*111111111~

REF*1D*A#########~

Health PAS Online Portal

When entering claims in the portal, you will enter the NPI only in the attending provider field. Do not enter the provider’s name, as the portal will not translate that information to MIHMS at this time.

Please call Provider Services with questions at: 1-866-690-5585.