Covered Services include core services, and other
ambulatory services.
103.04-1 Core
Services are billable at the PPS rate. Core Services include:
A. services provided by physicians, physician
assistants, advanced practice registered nurses, clinical psychologists,
licensed clinical social workers, and licensed clinical professional
counselors;
B. services and
supplies furnished as incident to services of conditionally, temporarily, fully
licensed, otherwise legally recognized or approved practitioners who are
designated in Section 103.06-1 of this Manual; and
C. basic laboratory services essential for
the immediate diagnosis and treatment of illness or injury, including, but not
limited to:
1. chemical examination of urine
by stick or tablet method or both (including urine ketones);
2. hemoglobin test or hematocrit;
4. examination of stool specimens for occult
blood;
6. primary culturing for
transmittal to a certified laboratory.
Note: To qualify for reimbursement, laboratory services
must be in compliance with the rules implementing the Clinical
Laboratory Improvement Amendments of 1988 (CLIA "88") and any related
amendments.
D.
emergency medical care treating life-threatening injuries and acute illnesses,
including drugs and biologicals such as:
E. visiting nurse services (as described in
103.04-4).
103.04-2
Other Ambulatory Services include:
A. Podiatric services for the diagnosis and
treatment of problems concerning the human foot. These are limited by the
conditions in Chapter II, Section
95, "Podiatry Services", of the
MaineCare Benefits Manual.
B.
Prevention, Health Promotion and
Optional Treatment Services ((PHPOT) formerly EPSDT) provided to
eligible children in accordance with Chapter II, Section
94, of the
MaineCare
Benefits Manual.
C. Asthma
programs are reimbursable if they are based on the Open Airways or Breathe
Easier curricula. Any other asthma management service which is approved by the
National Heart, Lung and Blood Institute/American Lung Association or the
Asthma and Allergy Foundation of America, is also reimbursable.
Each asthma program must have:
2. primary instructor (a licensed health
professional or a health educator with baccalaureate degree);
3. pre-assessment and post-assessment for
each participant which shall be kept as part of the member's record;
4. an advisory committee which may be part of
an overall patient education advisory committee; and
5. a physician referral for all participants.
Note: Providers should bill the actual cost of the
asthma program upon completion of the service, using the procedure code listed
in Chapter III, Section 103.
D. Ambulatory Diabetes Education and
Follow-Up (ADEF) Services, or similar services approved by the Centers for
Medicare and Medicaid Services (CMS) approved national accreditation
organization, will be reimbursed when a provider enrolled with the Maine
Diabetes and Prevention Control Program furnishes this service to a MaineCare
member whose physician has prescribed this program for the management of the
member's diabetes. The service includes:
1. a
pre-assessment interview to determine the member's knowledge, skills and
attitudes about diabetes management and to develop an individualized education
plan and behavior change goals;
2.
group class instruction covering the comprehensive curriculum outlined by the
Maine Diabetes and Prevention Control Program and based on the individualized
education plan;
3. a meal planning
interview to determine the member's knowledge, skills and attitudes about meal
planning and to develop an individualized meal plan and behavior change
goals;
4. A post-assessment
interview to assess and document what the member has learned during the
service, and to develop a plan for follow-up sessions to address the component
areas not learned in the class series, and finalize behavioral goals;
and
5. follow-up contacts to
reassess and reinforce self-care skills, evaluate learning retention and
progress toward achieving the member's behavior change goals. At a minimum,
three-month, six-month, and one-year follow-up visits from the date of the last
class are required to complete the member's participation in the service.
When the MaineCare member is under age 21, this service
will also be reimbursed when provided to the person/people who provide the
member's daily care.
E. Effective August 1, 2014, Tobaccocessation
treatment services will be reimbursed, for eligible Members, provided by
physicians or other providers who can provide tobacco cessation treatment
services under their licenses or permits. There are no annual or lifetime
limits ontobacco cessation treatment services. Counseling services may be
provided in the form of individual or group counseling. Both forms of
counseling may be provided by licensed practitioners within the scope of
licensure as defined under State law and who are eligible to provide other
coverable services in Section 103.
Tobacco cessation treatment services includes the
provision of all pharmacotherapy approved by the Food and Drug Administration
(FDA) for tobacco dependence treatment. MaineCare members are not required to
participate in tobacco cessation counseling to receive tobacco cessation
products Tobacco cessation products are "covered services" reimbursable
pursuant to Ch. II, Section 80.05 of the MaineCare Benefits
Manual. The services for tobacco cessation treatment are copay exempt.
Tobacco cessation treatment services may be billed alone, or in combination
with other RHC services. Documentation of the tobacco cessation treatment
services must be contained in the medical record.
F. Contraception (injectable, implantable
capsules, intrauterine devices) and the administration of influenza and
pneumococcal vaccines.
103.04-3
Off-site delivery of
services furnished by clinic staff are reimbursed when Rural Health
Clinic Services are provided away from the clinic and when it is documented in
the member's chart that it is the most appropriate setting for the provision of
services. Examples of off-site service locations include: a nursing facility,
an emergency room, or a member's home.
103.04-4
Visiting nurse services
will be reimbursed when:
A. a registered
nurse or licensed practical nurse provides the services to a member who is
homebound;
B. the services are
provided in accordance with a written Plan of Treatment;
C. the member's record documents that the
member would not otherwise receive these services;
D. the services are provided in an area that
the Secretary of the U.S. Department of Health and Human Services has
determined has a shortage of home health agencies; and
E. the Rural Health Clinic that provides in-home
services by a registered licensed practical nurse is licensed by the State of
Maine as a home health service provider.
103.04-5
Interpreter Services -
Refer to Chapter I of the MaineCare Benefits Manual for
information about reimbursement for interpreter services.
