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:
MaineCare will confirm providers are billing AAC by conducting sample audits where we compare provider documentation of their AAC prices to the claim amounts being reconciled. Reminder: Ongoing 340B Requirements 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:
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:
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.
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:
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