January 1, 2021 Change in MaineCare 340B Payment Methodology 

    December 8, 2020  

Effective January 1, 2021, as part of the Covered Outpatient Drug Final Rule (81 FR 5170), the Office of MaineCare Services (OMS) is changing its payment methodology and instituting a new claims reconciliation process for drugs acquired through the 340B drug pricing program.   

With this methodology change, MaineCare will reimburse 340B providers for physician-administered drugs purchased through the federal 340B program at the 340B actual acquisition cost (AAC) instead of at the usual and customary charge amount. This change will also apply to payment for physician-administered specialty drugs.   

Process for 340B Claims Submission to MaineCare 

Per current practice, MaineCare providers submitting claims through 340B should bill their usual and customary charge for the drug and populate it in the charge field of the claim. Providers must append a JG modifier to these claims.   

Providers who bill Medicare as the primary payor for a 340B drug that does not require a JG modifier when billing Medicare will need to submit that claim to Medicare with a TB modifier. When MaineCare receives the crossover claim, the TB modifier will identify the service as a 340B drug. This is only for crossover claims where Medicare is billed as primary payor.  

New 340B Claims Reconciliation Process 

340B providers will be responsible for cooperating with the claims reconciliation process that will be implemented upon the end of the first quarter of calendar year 2021. This process as follows will enable MaineCare to reconcile the difference between the AAC and the usual and customary charge amount we pay for the 340B claims at the time of service:  

1. On a quarterly basis beginning on April 1, 2021, MaineCare will send each 340B provider a Quarterly 340B Utilization File in Excel that contains all drug claims that have been submitted to MaineCare in the past quarter.  
2. Providers will need to identify each claim in the file that is eligible for 340B pricing.   
3. For each 340B eligible claim in the file, providers will need to indicate the AAC for each  drug for that quarter. If providers identify any 340B claims in the file that do not include the required JG or TB modifiers, they will need to reverse these claims and resubmit them with these modifiers included.  
4. Providers must return the file to Gainwell (formerly DXC) within 45 days of receipt.  
5. Once Gainwell has received the file, they will calculate the amount that the provider needs to refund to MaineCare; this will be the difference between AAC and what MaineCare initially paid the provider.  
6. The Department plans to reconcile payment amounts through a claims offset process. This will prevent the need for providers to manually submit payment. The Department will be in touch with further details about this process.  

As a reminder, OMS does not allow contract/retail pharmacies to enroll in the 340B Medicaid drug program, either directly or under subcontract with a 340B entity.     

All 340B providers who submit claims to MaineCare must determine whether they will use 340B drugs for their MaineCare patients (carve-in to the program) or whether they will purchase drugs for these patients through other mechanisms (carve-out of the program).   

In alignment with existing MaineCare policy, 340B providers are responsible for completing the following steps:   

• Enrolling with the Health Resources and Services Administration’s (HRSA) Office of Pharmacy Affairs.  
• Checking the HRSA Medicaid Exclusion File (MEF) to ensure that it accurately represents their proper Medicaid Exclusion status. The MEF lists 340B providers who have carved in their Medicaid populations.   
• Completing the OMS 340B Provider Agreement Form, which must be kept on file and up-to-date. As part of this form, providers must assign an individual contact to establish communications between the OMS Program Integrity reconciliation team and the provider. Additionally, they must provide a full list of their service locations that will dispense 340B drugs.  
• Uploading the signed 340B Provider Agreement Form to the MIHMS Health PAS Online Portal when updating enrollments using a maintenance case.    

OMS will verify 340B provider status on the HRSA website prior to reimbursing a 340B provider and on at least a quarterly basis thereafter. This helps ensure that MaineCare does not seek federal rebate on 340B discounted drugs.  

Providers can contact provider relations specialist, Tia Bolduc at [email protected] with any questions.   

Electronic Visit Verification (EVV): Weekly Billers of Personal Care Services (PCS) Reminder

In preparation for EVV editing, providers should ensure billing software is configured to have individual dates for services on separate lines when claims are submitted so that they match up with the EVV verified records.

If you currently use billing software or a billing agency, please verify that your systems will allow individual dates of service on separate lines of the claim when they are uploaded as a batch into the Health PAS Online Portal.

Providers who “span” bill should only do so when the services are consecutive. For example, you should only bill from December 1, 2020 – December 7, 2020 when services are provided on each day of the week. If members are receiving services on non-consecutive dates such as Monday, Wednesday, and Friday, you should not span bill; otherwise, your claims will warn, then deny starting January 1, 2021, for no verified EVV record found on Saturday, Sunday, Tuesday, or Thursday. You should submit a separate claim line for each date of service when the dates of service are not consecutive.

The National Uniform Claim Committee (NUCC) has developed a 1500 Reference Instruction Manual detailing how to complete the claim form to help standardize nationally the way the form is being completed. Please see the Health Insurance Claim Form Reference Instruction Manual, which states:  

TITLE: Date(s) of Service [lines 1–6]

INSTRUCTIONS: Enter date(s) of service, both the “From” and “To” dates. If there is only one date of service, enter that date under “From.” Leave “To” blank or re-enter “From” date. If grouping services, the place of service, procedure code, charges, and individual provider for each line must be identical for that service line. Grouping is allowed only for services on consecutive days. The number of days must correspond to the number of units in 24G.

*ITEM NUMBER 24G

DESCRIPTION: “Days or Units” is the number of days corresponding to the dates entered in 24A or units as defined in CPT or HCPCS coding manual(s).

For more information, see MaineCare’s EVV webpage.

Please email the EVV email box with questions.

Electronic Visit Verification (EVV) Trainings and Forums

As a reminder, EVV requirement deadlines are January 1, 2021 for Personal Care Services (PCS) and January 1, 2023 for Home Health providers delivering services under Section 40.

With these EVV deadlines quickly approaching, we continue to offer weekly provider and aggregator trainings and forums. All trainings and forums are online via Microsoft Teams.

NOTE:  The Absorb training system has been updated to allow providers to register for trainings and/or forums more than once.

Training Topics

Training topics include, but are not be limited to:

• Accessing the Sandata EVV portal via the Health PAS Online Portal
• Performing EVV administrative functions such as creating and editing information for employees who will use the system
• Navigating through the Sandata EVV system
• Entering and editing visit records
• Recording visit data using other devices
• Accessing and reviewing reports 
• Avoiding EVV visit exceptions

Training Schedule

You can register for these courses through the Absorb training platform.

EVV Forums

The purpose of the forums is to answer technical questions regarding the State EVV system and Alternate EVV System Integration process.

If you are interested in implementing an Alternate EVV System, please invite your vendor partners to join the aggregator forums as well.

Forum Schedule

You can register for the forums through the Absorb training platform.

Forum Questions

Please prepare questions in advance. Once the forum has started, questions can be submitted for review through the Teams chat feature at any time. Instructions on how to submit questions will be reviewed during the beginning of the forum. If you wish to submit questions, please be sure to use your computer to access the Teams chat.

IMPORTANT: During the forum, please submit questions in the following format.

• NPI
• Contact Name
• Contact Phone Number/Email Address
• Question

This information will help State and DXC staff to follow up with answers to your questions. The team will work to answer as many questions as possible during the call, but, due to time constraints, some questions may need to be addressed after the forum. If we cannot answer your question during the call, we will record your contact information and question(s), and follow-up afterward.

Absorb First Time Users

If you have not registered with the Absorb training platform, see the First Time User Guide for assistance. To access the guide, go to the Health PAS Online Portal and log into your TPA (Trading Partner Account). Next, click on the section called "Trading Partner User Training," and you will see the link to the First Time User Guide.

Questions?

See the EVV webpage for more information, including Frequently Asked Questions (FAQ).

Please contact Provider Services with questions:

• Email MaineCare's EVV email box
• Call Provider Services at 1-866-690-5585, option 3