Code of Maine Rules
10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL
Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL)
Chapter III - Allowances for Services
Section 144-101-III-21 - Allowances for Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder
GENERAL PROVISIONS
Subsection 144-101-III-21-1500 - AVERAGE BILLING METHOD
Current through 2024-38, September 18, 2024
When billing, the Home Support Agency per diem services providers may choose to bill for services provided using the weekly billing method or the monthly average billing method.
Weekly Billing Method - Providers bill at the end of each week based on the actual number of hours of direct support provided in comparison to the hours authorized. If the actual total weekly direct support hours provided for the facility falls within the range of allowable total weekly authorized support hours for the facility then the facility bills at the authorized per diem rate.
If the actual total weekly direct support hours provided for the facility is less than the range of allowable total weekly authorized support hours for the facility then the billable rate is determined by using the actual weekly total support hours provided for the facility. Providers may refer to the billable rate under the applicable table on http://www.maine.gov/dhhs/oads/disability/ds/MaineCare/index.shtml or use Appendix IIA or IIB to calculate the billable amount.
Monthly Average Billing Method - Providers may calculate a monthly average of weekly direct support services hours provided at the end of each month. If a provider chooses to use the monthly average billing method then all days in the month must be billed using this method. To use this method a provider must submit claims after the last day of the month.
To determine the actual total weekly direct support hours, the actual total hours of direct support provided in the month from 1st day of the month through the last day of the month are divided by number of weeks in the month.
A. If there are 31 days in the month, then the number of weeks in the month is 4.43.
B. If there are 30 days in the month, then the number of weeks in the month is 4.29.
C. If there are 29 days in the month, then the number of weeks in the month is 4.14.
D If there are 28 days in the month, then the number of weeks in the month is 4.00.
The result determines the average actual total weekly direct support hours provided by the facility for the entire month. If the average actual total weekly direct support hours provided by the facility falls within the range of allowable total weekly support hours that was authorized then the provider must bill at the authorized per diem rate.
If the average actual total weekly direct support hours provided by the facility is less than the range of allowable weekly support hours that was authorized then the billable rate will be determined by using the actual total support hours provided for the facility. Providers can determine the billable rate in the applicable table in Appendix IIB in Chapter III.
Partial Week- There are situational changes, often unpredictable, that occur resulting in a change in the authorized hours of support in a facility mid-week. Examples include death of a member, unanticipated move or the startup of a new program mid-week.
In these instances, if the Provider has chosen to bill on a monthly basis, services for the week in which the authorization change occurred must be billed on pro-rated basis to determine the actual total weekly support hours provided using the formula below:
If services are provided for 1 day, then the number of actual hours provided is .1428.
If services are provided for 2 days, then the number of actual hours provided is .2857.
If services are provided for 3 days, then the number of actual hours provided is .4285.
If services are provided for 4 days, then the number of actual hours provided is .5714.
If services are provided for 5 days, then the number of actual hours provided is .7142.
If services are provided for 6 days, then the number of actual hours provided is .8571.
Refer to the rate schedule to select the appropriate rate to bill based on the hours provided.
