C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-55, subsec. 144-101-II-55.07

Current through 2024-51, December 18, 2024

Subsection 144-101-II-55.07 - REIMBURSEMENT

The MaineCare rates are posted on the Maine Health PAS Portal Provider Fee Schedule. Rates other than drug prices for new or changed codes (any CPT or HCPCS code) are determined based on the following lowest benchmark:

A. The fee for service rate is set at seventy percent (70%) of the 2009 CMS rate or seventy (70%) of the rate in the year CMS assigns a rate for that code. Where no other options are applicable, the Department researches other State Medicaid agencies that cover the relevant service/code. The Department then bases its rates on the average cost of the relevant services/codes from those other agencies.; or

B. The lowest amount allowed by Medicare Part B for Maine area "99" fee including the appropriate Medicare fee adjustments for place of service and modifiers; or

C. If CMS approves, the provider's usual and customary charge.

In accordance with Chapter I, Sec. 1 of the MaineCare Benefits Manual, it is the responsibility of the provider to seek payment from any other source that is available for payment of a rendered service prior to billing the Office of MaineCare.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-55, subsec. 144-101-II-55.07