Maine

Last updated 05/20/2024

Consent Requirements

A patient may provide verbal, electronic or written consent for telehealth and telemonitoring services under this section.

SOURCE: ME Statute Sec. 22:855.3173-H, Sub. Sec. 6, (Accessed May 2024).

The department may not require a licensed facility to obtain written informed consent from a person receiving mental health services or substance use disorder treatment from the licensed facility during a public health emergency. A licensed facility shall obtain consent from a person receiving mental health services or substance use disorder treatment during a public health emergency; such consent may be obtained through verbal, electronic or written means.

SOURCE: ME Statute Title 22, Subtitle 1, Ch. 1, Subchapter 2, Sec. 51, (Accessed May 2024).

Before providing a Telehealth Service to a Member, a Health Care Provider shall ensure and document that the following information is provided to the Member or authorized representative in a format and manner that the Member is able to understand:

• Description of the telehealth services and what to expect;
• An explanation that use of Telehealth Services is voluntary. The Member shall have the option to refuse the Telehealth Services at any time without affecting the right to future care or treatment and without risking the loss or withdrawal of a MaineCare benefit to which the Member is entitled;
• An explanation that MaineCare will pay for the Member’s transportation to MaineCare Covered Services pursuant to Section 113, Non-Emergency Transportation Services, of the MBM;
• An explanation that the Member shall have access to all information resulting from the Telehealth Service as provided by law;
• The information contained in subparts C, D, and E of this subsection.;

Health Care Providers shall comply with federal and Maine state laws and regulations regarding individual health care data confidentiality when disseminating, storing, or retaining an identifiable Member image or other information from a Telehealth Service;

At the onset of the Telehealth Service, the Health Care Provider shall inform the Member of the persons present at the Receiving (Provider) Site, and the Member shall have the right to exclude any person from either site during the service; and

The Member shall have the right to object to the audio and/or visual recording of a Telehealth Consultation.

Prior to the provision of any Telehealth Services, the Health Care Provider shall obtain the Member’s written, electronic, or verbal informed consent to receive services via Telehealth Services, to Store-and-Forward Telehealth Services, Remote Consultation, Virtual Check-In, or Telephone Evaluation and Management. copy of the informed consent shall be retained in the Member’s medical record and provided to the Member or the Member’s legally-authorized representative upon request.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4. (Nov. 6, 2023).  Adopted 10-144 C.M.R. Chapter 101, Chapter I, Section 4, Telehealth Services. (Nov. 6, 2023).  (Accessed May 2024).

The member’s record must document the member’s consent and commitment to the Assistive Technology plan elements including all assistive communication, environmental control and safety components.

SOURCE: MaineCare Benefits Manual, Home and Community Benefits for the Elderly and for Adults with Disabilities, 10-144 Ch. II, Sec. 19.04, p. 13 (May 2, 2021). (Accessed May 2024).

Prior to the provision of telemonitoring services, the Health Care Provider shall document that it has provided the member with choice and educational information (set forth in Chapter I, Section 4, 4.06-2, Telehealth) obtained the member’s written informed consent to the receipt of telemonitoring services. The Health Care Provider shall retain a copy of the signed informed consent in the member’s medical record and provide a copy to the member or the member’s legally authorized representative upon request.

SOURCE:  Mainecare Benefits Manual. Ch. 11. Home Health Services. Sec. 40.08. p. 24. (Aug 11, 2019). (Accessed May 2024).

Last updated 05/20/2024

Definitions

Telehealth Services: The use of information technology by a Health Care Provider to deliver clinical services at a distance for the purpose of diagnosis, disease monitoring, or treatment. Telehealth Services may be either Telephonic or Interactive and includes synchronous encounters, asynchronous encounters, store-and-forward transfers, and telemonitoring.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4., p. 2 (11/6/23). (Accessed May. 2024).

“Telehealth,” as it pertains to the delivery of MaineCare services, means the use of information technology and includes synchronous encounters, asynchronous encounters, store and forward transfers and telemonitoring.

SOURCE: ME Statute Sec. 22:855.3173-H(D). (Accessed May 2024).

Teledentistry, as it pertains to the delivery of oral health care services, means the use of interactive, real-time visual, audio or other electronic media for the purposes of education, assessment, examination, diagnosis, treatment planning, consultation and directing the delivery of treatment by individuals licensed under 32 MRS Chapter 143 (Dental Professions) and includes synchronous encounters, asynchronous encounters, remote patient monitoring, and mobile oral health care in accordance with practice guidelines specified in rules adopted by the Board.

SOURCE: ME Benefits Manual, Dental Services and Reimbursement Methodology, 10-144, Ch. II, Sec. 25, pg. 1, (Sept. 28, 2022), (Accessed May 2024).

Last updated 05/20/2024

Email, Phone & Fax

Telephonic Services: The use of audio-only telephone communication by a Health Care Provider to deliver clinical services at a distance for the purpose of diagnosis, disease monitoring, or treatment.

Receiving (provider) Site: When billing for Telehealth Services, Health Care Providers at the Receiving (Provider) Site must bill for the underlying Covered Service using the same claims they would if it were delivered face-to-face and must add the GT modifier for Interactive Telehealth Services and the 93 modifier for Telephonic Services.

Remote Consultation Between a Treating Provider and Specialist

A Specialist provides interprofessional telecommunications assessment and management services to a Treating Provider. The interaction includes discussion (via telephone or internet) of a written report by the Specialist to assess the Member’s Electronic Health Record and/or diagnoses/treatment. Duration of this service must be a minimum of five minutes and no greater than thirty minutes. The Treating Provider must document that they have informed the Member as to results and conclusions following the Remote Consultation. The Treating Provider must document in the Member’s medical record the Member’s written, electronic, or verbal consent for each Remote Consultation. Billing for interprofessional services is limited to those practitioners who can independently bill MaineCare for evaluation and management services. Remote Consultation may be utilized as often as medically necessary, per the terms of these rules.

Virtual Check-In

Virtual Check-in is a brief communication where an established patient checks in with a Health Care Provider using a telephone or other telecommunications device for 5-10 minutes to determine the status of a chronic clinical condition(s) and to determine whether an office visit is needed. Modalities permitted for Virtual Check-Ins include Telephonic Services or Interactive Services to deliver clinical services at a distance for the purpose of diagnosis, disease monitoring, or treatment.

Communications exclusively by email, text, or voicemail are not reimbursable.

The Health Care Provider must document a Virtual Check-In in the Member’s record, including the length of the Virtual Check-In, an overview and outcome of the conversation, and the modality of the interaction.

If the Virtual Check-In takes place within seven (7) days after an in-person visit or triggers an in-person office visit within 24 hours (or the soonest available appointment), the Virtual Check-In is not billable under this Section.

Telephone Evaluation and Management Services

The Department will reimburse providers for Telephone Evaluation and Management Services provided to members.

Telephone Evaluation and Management Services are not to be billed if clinical decision-making dictates a need to see the member for an office visit within 24 hours or at the next available appointment. In those circumstances, the telephone service shall be considered a part of the subsequent office visit. If the telephone call follows an office visit performed and reported within the past seven (7) days for the same diagnosis, then the telephone services are considered part of the previous office visit and are not separately billable.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4. (Nov. 6, 2023).  Adopted 10-144 C.M.R. Chapter 101, Chapter I, Section 4, Telehealth Services. (Nov. 6, 2023).  (Accessed May 2024).

Interprofessional Codes for Medication Management Providers

Medication management providers and other treating providers of Section 65 of the MaineCare Benefits Manual (MBM) may deliver and bill MaineCare for interprofessional consultations in alignment with MBM Chapter 1, Section 4.04-2(B). As described in CMS state health official letter #23-001, interprofessional consultations are assessments and management services in which a patient’s treating provider requests the opinion and/or treatment advice of a consultant with specific specialty expertise to assist the treating provider in the diagnosis and/or management of the patient’s condition without the need for the patient’s face-to-face contact with the consultant.

The consulting provider and the provider requesting the consultation must be able to independently bill for evaluation and management services. Examples of these provider types include physicians, nurse practitioners, clinical nurse specialists, physician assistants, and licensed clinical social workers. A registered nurse, for example, is not an eligible provider type.

The following examples illustrate when medication management providers may deliver and bill for interprofessional consultations:

• A medication management provider provides consultation to a primary care provider (PCP) on cross-tapering a patient from one antidepressant to another due to concerning side-effects.
• A medication management provider provides consultation to a PCP regarding antipsychotic medications because the PCP has a symptomatic patient who has been off of medications, and the PCP has never prescribed antipsychotic medication before.
• The PCP has been treating a behavioral health patient who was previously stabilized and who is now reporting increased symptoms with active substance use. The PCP is not sure of what to do about medications in the context of active substance use and consults a medication management provider.

Providers must bill for interprofessional consultations using common procedural terminology (CPT) codes 99446-99449, 99451, and 99452. However, CPT code 99452 is different. Interprofessional consultation code 99452 applies when the patient’s PCP or other qualified health professional interacts with a consultant via telephone, the Internet, or an electronic health record to provide the consultant with the patient’s clinical data so that the consultant can form an opinion regarding further management of the patient’s condition. For example, a PCP would bill CPT code 99452 if they send a patient to a medication management provider and the PCP provided background information.

SOURCE: State of Maine Department of Health and Human Services, Bulletin:  Interprofessional Codes for Medication Management Providers, Nov. 13, 2023, (Accessed May 2024).

When there is a direct effect to Indian Health Services the second tier of consultation will be utilized. The second tier consultation consists of the following:

• Face-to-face meetings
• Direct email communications
• Written notification via the Interested Parties List
• Listserv updates
• Any other correspondence that pertains to general changes
• Telephone communications

SOURCE: MaineCare Benefits Manual, Indian Health Services, 10-144 Ch. II, Sec. 9, p. 5 (March 21, 2012). (Accessed May 2024).

Under Targeted Case Management, monitoring and follow-up activities may involve either face-to-face or telephone contact.

SOURCE:  MaineCare Benefits Manual, Targeted Case Management Services, 10-144 Ch. 101, Sec. 13.02, p. 6 (Mar. 20, 2014). (Accessed May 2024).

Crisis Resolution Services

Covered services include direct telephone contacts with both the member and the member’s Parent or Guardian or adult’s member’s guardian when at least one face-to-face contact is made with the member within seven (7) days prior to the first contact related to the crisis resolution service. The substance of the telephone contact(s) must be such that the member is the focus of the service, and the need for communication with the Parent or Guardian without the member present must be documented in the member’s record.

Telephonic collateral contacts covered for Multi-Systemic Therapy and telephone outreach and team meetings for functional family therapy.

SOURCE:  MaineCare Benefits Manual, Behavioral Health Services, 10-44 Ch. II, Sec. 65, p. 4, 12 (Nov. 2022). (Accessed May 2024).

When a telephonic consult occurs, the physician, or nurse practitioner must examine the member in person within the following time constraints:

• Within one (1) hour of when the registered nurse requests an examination;
• Within one (1) hour of when information relayed is suggestive of causes leading to physical harm to the member;
• Within one (1) hour if an examination has not yet occurred during the member’s stay; or
• Within six (6) hours in all other circumstances.

SOURCE:  MaineCare Benefits Manual, Psychiatric Residential Treatment Facility Services, 10-44 Ch. II, Sec. 107, p. 32 (Oct. 3, 2018). (Accessed May 2024).

MaineMOM Services and Reimbursement

The MaineMOM provider shall ensure twenty-four (24) hour availability of information for triage and referral to treatment for medical emergencies.  This requirement may be fulfilled through an after-hours telephone number.

The following do not constitute adequate coverage:

• A twenty-four (24) hour telephone number answered only by an answering machine without the ability to arrange for interaction with the MaineMOM provider or their covering provider

SOURCE:  MaineCare Benefits Manual, MaineMOM Services and Reimbursement, 10-44 Ch. II, Sec. 89, p. 21 (Dec. 6, 2023). (Accessed May 2024).

Last updated 05/20/2024

Live Video

POLICY

If a Member is eligible for the underlying Covered Service to be delivered, and if delivery of the Covered Service via Telehealth Services is medically appropriate, as determined by the Health Care Provider, the Member is eligible for Telehealth Services.

Except as set forth herein, reimbursement will not be provided for communications between Health Care Providers when the Member is not participating.

Except as set forth herein, reimbursement will not be provided for communications solely between Health Care Providers and Members when such communications would not otherwise be billable.

Reimbursement

Services are to be billed in accordance with applicable Sections of the MBM. Providers must submit claims in accordance with Department billing instructions.

Telehealth Services are subject to all conditions and restrictions described in Chapter I, Section 1, of the MBM.

Telehealth Services are subject to co-payment requirements for the underlying Covered Service, if applicable, as established in Chapter I, Section 1, of the MBM. However, there shall be no separate co-payment for telehealth services.

Specific reimbursement rates for other telehealth services can be found in the appropriate Sections of the MBM or the MaineCare Provider fee schedules on the MaineCare Health PAS Portal.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4., (Nov. 6, 2023). (Accessed May 2024).

“Synchronous encounters” means a real-time interaction conducted with interactive audio or video connection between a patient and the patient’s provider or between health professionals regarding the patient.

SOURCE: ME Statute Sec. 22:855.3173-H, Sub. Sec. 1 (Accessed May 2024).

ELIGIBLE SERVICES/SPECIALTIES

Any medically necessary MaineCare Covered Service may be delivered via Telehealth Services, provided the following requirements are met:

• The Member is otherwise eligible for the Covered Service, as described in the appropriate Section of the MBM; and
• The Covered Service delivered by Telehealth Services is of comparable quality to what it would be were it delivered in person.

Prior authorization is required for Telehealth Services only if prior authorization is required for the underlying Covered Service. In these cases, the prior authorization is the usual prior authorization for the underlying Covered Service, rather than a prior authorization for the mode of delivery. Unless otherwise required by law, a face-to-face encounter is not required prior to delivering Telehealth Services.

Non-Covered Services and Limitations

Except as set forth herein, services not otherwise covered by MaineCare are not covered when delivered via Telehealth Services.

Services covered under other MaineCare Sections but specifically excluded from Telehealth coverage include, but are not limited to the following:

• Services that require direct physical contact with a Member by a Health Care Provider and that cannot be delegated to another Health Care Provider at the site where the Member is located are not covered;
• Any service medically inappropriate for delivery through Telehealth Services – e.g. services that include providing medical procedures or administration of medications that must be conducted in person.

Except as set forth herein, reimbursement will not be provided for communications between Health Care Providers when the Member is not participating.

Except as set forth herein, reimbursement will not be provided for communications solely between Health Care Providers and Members when such communications would not otherwise be billable.

The Originating Site Fee may be paid only to a Health Care Provider.

Virtual Check-In

Virtual Check-in is a brief communication where an established patient checks in with a Health Care Provider using a telephone or other telecommunications device for 5-10 minutes to determine the status of a chronic clinical condition(s) and to determine whether an office visit is needed. Modalities permitted for Virtual Check-Ins include Telephonic Services or Interactive Services to deliver clinical services at a distance for the purpose of diagnosis, disease monitoring, or treatment.

Communications exclusively by email, text, or voicemail are not reimbursable.

The Health Care Provider must document a Virtual Check-In in the Member’s record, including the length of the Virtual Check-In, an overview and outcome of the conversation, and the modality of the interaction.

If the Virtual Check-In takes place within seven (7) days after an in-person visit or triggers an in-person office visit within 24 hours (or the soonest available appointment), the Virtual Check-In is not billable under this Section.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4., (Nov. 6, 2023). (Accessed May 2024).

Rules adopted by the department:

• May not include any requirement that a patient have a certain number of emergency room visits or hospitalizations related to the patient’s diagnosis in the criteria for a patient’s eligibility for telemonitoring services;
• Except as provided in paragraph E, must include qualifying criteria for a patient’s eligibility for telemonitoring services that include documentation in a patient’s medical record that the patient is at risk of hospitalization or admission to an emergency room;
• Must provide that group therapy for behavioral health or addiction services covered by the MaineCare program may be delivered through telehealth;
• Must include requirements for providers providing telehealth and telemonitoring services; and
• Must allow at least some portion of case management services covered by the MaineCare program to be delivered through telehealth, without requiring qualifying criteria regarding a patient’s risk of hospitalization or admission to an emergency room.

SOURCE:  ME Revised Statute Sec. 3173,-H, (Accessed May 2024)

A multitude of services are listed as being allowed either face-to-face or through telehealth in the behavioral health services manual.

SOURCE:  MaineCare Benefits Manual, Behavioral Health Services, 10-44 Ch. II, Sec. 65, (Nov. 9, 2022). (Accessed May 2024).

Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations

Telemedicine may be utilized as clinically appropriate, according to the standards described in Chapter I, Section 4 of the MaineCare Benefits Manual.

SOURCE: MaineCare Benefits Manual, Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations, 28.08, Ch. 101, Ch. II, Sec. 28, p. 12, (9/23/19), (Accessed May 2024).

Durable Medical Equipment

A face-to-face encounter is a mandatory encounter (including encounters through telehealth (as described in Chapter I, Section 4) and other than encounters incidental to services involved) between the member and a  Qualified Provider that takes place within the six (6) months prior to the date of a written order for DME. The written order may be, but does not have to be, prescribed by the provider who performed the face-to-face encounter.

SOURCE: MaineCare Benefits Manual, Durable Medical Equipment, 60.06, Ch. 101, Ch. II, Sec. 60, p. 4, (10/31/23), (Accessed May 2024).

Children’s Residential Care Facilities (CRCFs)

The nurse may provide in-person, telehealth, and/or telephonic support outside of normal business hours as needed. The nurse must be either a psychiatric mental health nurse practitioner (APRN-PMH-NP), or a registered nurse (RN) with experience in the treatment of children with serious behavioral health conditions or requisite training to treat children with serious behavioral health conditions.

SOURCE: MaineCare Benefits Manual, Private Non-Medical Institution, 97.07, Ch. 101, Ch. II, Sec. 97, (11/1/21), (Accessed May 2024).

Teledentistry

Providers may deliver diagnostic services via telehealth in accordance with Chapter I, Section 4, of the MaineCare Benefits Manual (MBM) and current Board rules and guidance. When delivering services via telehealth, providers shall bill for the underlying service and include, for tracking purposes only, the appropriate teledentistry CDT code that indicates a synchronous real-time encounter or an asynchronous encounter in which information is stored and forwarded to the dentist for subsequent review.

SOURCE: ME Benefits Manual, Dental Services and Reimbursement Methodology, 10-144, Ch. II, Sec. 25, pg. 1, (Sept. 28, 2022), (Accessed May 2024).

Primary Care Plus (PCP)

In PCP Tier II Services, providers must offer telehealth as an alternative to traditional office visits in accordance with MBM, Ch. I, Sec. 4, Telehealth Services, and/or for non-office visit supports and outreach to increase access to the care team and clinicians in a way that best meets the needs of Members.

SOURCE: MaineCare Benefits Manual, Primary Care Plus, 10-144, Ch. VI,  Sec. 3.03, pg. 6, June 21, 2022, (Accessed May 2024).

Home Health Services

Face to Face Encounter means an encounter between the member and the certifying physician, or a nurse practitioner or clinical nurse specialist who is working in collaboration with the physician, or a certified nurse midwife as authorized by State law or physician assistant under the supervision of the physician. The encounter may be through telehealth, consistent with Section 1834(m) of the Social Security Act and 42 CFR 424.22. The face-to-face encounter must be related to the primary reason the patient requires Home Health Services.

SOURCE: Main Care Benefits Home Health Services, 10-144, Chapter II, Section 40 (Aug. 11, 2019), p. 1.  (Accessed May 2024). 

Community Care Teams

A comprehensive biopsychosocial assessment, conducted face-to-face or via telehealth.  See manual for necessary components.

SOURCE: Maine Care Benefits Manual Home Health Services – Community Care Teams, 10-144, Chapter II, Section 91 (June 21, 2022), p. 15, (Accessed May 2024).

Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder

AT-Assessment:  Evaluation of the assistive technology needs of a member, including a functional evaluation of the impact of the provision of appropriate assistive technology and appropriate services to the member in the customary environment of the member.

Evaluation of the assistive technology needs of a Member may be delivered via telehealth when the provider ensures that the assessment via telehealth meets the requirements of the scope of the service.

SOURCE: Maine Care Benefits Manual Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder, 10-144, Chapter II, Section 29 (Jan. 24, 2024), p. 15, Adopted Rule: 10-144 C.M.R. Chapter 101, MaineCare Benefits Manual, Chapter II, Section 29, Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder (Jan. 12, 2024).  (Accessed May 2024).

Diabetes Prevention Program

Providers shall bill 0403T for each in-person session and bill 0403T with the GT modifier for sessions delivered through telehealth, e.g. online and distance learning sessions, as defined in the DPRP Standards.

SOURCE: Maine Care Benefits Manual National Diabetes Prevention Program Services, 10-144, Chapter II, Section 71 (Nov. 8, 2023), p. 5,  Adopted Rule: 10-144 C.M.R. Chapter 101, Chapter II, Section 71, National Diabetes Prevention Program Services (Nov. 8, 2023). (Accessed May 2024).

MaineMOM Services and Reimbursement

The MaineMOM provider shall offer telehealth as an alternative to traditional office visits in accordance with the MBM, Chapter I, Section 4, and/or for non-office visit supports and outreach to increase access to the care team and clinicians in a way that best meets the needs of members.

SOURCE:  MaineCare Benefits Manual, MaineMOM Services and Reimbursement, 10-44 Ch. II, Sec. 89, p. 22 (Dec. 6, 2023). (Accessed May 2024).

Newly Adopted Rule:

MaineCare will reimburse providers for one health assessment visit per member for each age shown on the Bright Futures Periodicity Schedule. The Department covers one additional health assessment visit per member within a year following an initial assessment via telehealth for each age shown on the Bright Futures Periodicity Schedule.

SOURCE:  MaineCare Benefits Manual, Early and Periodic Screening, Diagnosis and Treatment Services, 10-44 Ch. II, Sec. 94, p. 10 (Apr. 22, 2024) Adopted Rule: 10-144 C.M.R., Chapter 101, MaineCare Benefits Manual, Chapter II Section 94, Early and Periodic Screening, Diagnosis and Treatment Services (EPSDT) (Apr. 22, 2024).  (Accessed May 2024).

Note: MaineCare issued a notice indicating they plan to submit a waiver renewal for the MaineCare Benefits Manual, Section 18, Home and Community Based Services for Members with Brain Injury which will include updates to assistive technology services by allowing qualified providers to conduct Assistive Technology Assessments via telehealth when the provider ensures that the assessment via telehealth meets the requirements of the scope of the service.  The manual does not yet indicate this change.

SOURCE:  MaineCare Benefits Manual, Notice of Agency Waiver Renewal: Section 18, Home and Community Based Services for Members with Brain Injury, Mar. 22, 2024, (Accessed May 2024).

ELIGIBLE PROVIDERS

A health care provider is an individual or entity licensed or certified to provide medical, behavioral health, and related services to MaineCare Members. Health Care Providers must be enrolled as MaineCare Providers to receive reimbursement for services.

In order to be eligible for reimbursement for Telehealth Services, a Health Care Provider must

• Act within the scope of their license;
• Be enrolled as a MaineCare provider;
• Be otherwise eligible to deliver the underlying Covered Service according to the requirements of the applicable Section of the MBM; and
• Be appropriately licensed, accredited, certified, and/or registered in the State where the Member is located during the provision of the Telehealth Service.

Reimbursement – Receiving (Provider) Site

• Except as described below, only the Health Care Provider at the Receiving (Provider) Site may receive payment for Telehealth Services.
• When billing for Telehealth Services, Health Care Providers at the Receiving (Provider) Site must bill for the underlying Covered Service using the same claims they would if it were delivered face-to-face and must add the GT modifier for Interactive Telehealth Services and the 93 modifier for Telephonic Services.
• When billing for Telephone Evaluation and Management Services, Health Care Providers at the Receiving (Provider) Site must use the appropriate E&M code. The GT and 93 modifier should not be used.
• No separate transmission fees will be paid for Telehealth Services. The only services that may be billed by the Health Care Provider at the Receiving (Provider) Site are the fees for the underlying Covered Service delivered with the GT or 93 modifier.

The Health Care Providers at the Receiving and Originating Sites may be part of the same organization. A Health Care Provider at the Originating (Member) Site may bill MaineCare and receive payment for Telehealth Services if the service is provided by a Treating Provider who is under a contractual arrangement with the Originating (Member) Site.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4.03., (Nov. 6, 2023). (Accessed May 2024). 

Telehealth Services may be included in a Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC), or Indian Health Center (IHC) scope of practice, as approved by the State. If approved, these facilities may serve as the provider site and bill under the encounter rate. When an FQHC or RHC serves as the Originating (Member) Site, the Originating Facility Fee is paid separately from the center or clinic all-inclusive rate.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4., p. 12. (Nov. 6, 2023). (Accessed May 2024).

Interprofessional Codes for Medication Management Providers

Medication management providers and other treating providers of Section 65 of the MaineCare Benefits Manual (MBM) may deliver and bill MaineCare for interprofessional consultations in alignment with MBM Chapter 1, Section 4.04-2(B). As described in CMS state health official letter #23-001, interprofessional consultations are assessments and management services in which a patient’s treating provider requests the opinion and/or treatment advice of a consultant with specific specialty expertise to assist the treating provider in the diagnosis and/or management of the patient’s condition without the need for the patient’s face-to-face contact with the consultant.

The consulting provider and the provider requesting the consultation must be able to independently bill for evaluation and management services. Examples of these provider types include physicians, nurse practitioners, clinical nurse specialists, physician assistants, and licensed clinical social workers. A registered nurse, for example, is not an eligible provider type.

The following examples illustrate when medication management providers may deliver and bill for interprofessional consultations:

• A medication management provider provides consultation to a primary care provider (PCP) on cross-tapering a patient from one antidepressant to another due to concerning side-effects.
• A medication management provider provides consultation to a PCP regarding antipsychotic medications because the PCP has a symptomatic patient who has been off of medications, and the PCP has never prescribed antipsychotic medication before.
• The PCP has been treating a behavioral health patient who was previously stabilized and who is now reporting increased symptoms with active substance use. The PCP is not sure of what to do about medications in the context of active substance use and consults a medication management provider.

Providers must bill for interprofessional consultations using common procedural terminology (CPT) codes 99446-99449, 99451, and 99452. However, CPT code 99452 is different. Interprofessional consultation code 99452 applies when the patient’s PCP or other qualified health professional interacts with a consultant via telephone, the Internet, or an electronic health record to provide the consultant with the patient’s clinical data so that the consultant can form an opinion regarding further management of the patient’s condition. For example, a PCP would bill CPT code 99452 if they send a patient to a medication management provider and the PCP provided background information.

SOURCE: State of Maine Department of Health and Human Services, Bulletin:  Interprofessional Codes for Medication Management Providers, Nov. 13, 2023, (Accessed May 2024).

Electronic Visit Verification (EVV) Place of Service Providers

Telehealth Personal Care Services (PCS) claims are excluded from Electronic Visit Verification (EVV) record requirements. When billing telehealth claims on the CMS 1500 Claim Form, you must use the POS code 02 or 10 and include the GT modifier, as this indicates you are providing services via telehealth and not in-person.

See the table below for affected codes. UB04 claim lines submitted with telemedicine revenue code 078x are exempt from EVV editing.

SOURCE: ME Department of Health and Human Services, Office of MaineCare Services, Electronic Visit Verification (EVV) Place of Service Reminders, Sept. 26. 2022. (Accessed May 2024).

ELIGIBLE SITES

Originating (Member) Site:  The site at which the Member is located at the time of Telehealth Service delivery. The site must be physically located in the United States.

When an FQHC or RHC serves as the Originating (Member) Site, the Originating Facility Fee is paid separately from the center or clinic all-inclusive rate.

The Health Care Providers at the Receiving and Originating Sites may be part of the same organization. A Health Care Provider at the Originating (Member) Site may bill MaineCare and receive payment for Telehealth Services if the service is provided by a Treating Provider who is under a contractual arrangement with the Originating (Member) Site.

Reimbursement – Originating (Member Site)

• If the Health Care Provider at the Originating (Member) Site supports the Member’s access to Telehealth Services the Health Care Provider at the Originating (Member) Site may bill MaineCare for an Originating Facility Fee using code Q3014 for the service of supporting access to the Telehealth Service. Supporting access to telehealth services means providing a room and/or telecommunications equipment and/or helping a Member use audio or video conferencing software or equipment to enable the Member to utilize telehealth.
• The Health Care Provider at the Originating (Member) Site may not bill for assisting the Health Care Provider at the Receiving (Provider) Site with an examination.
• No separate transmission fees will be paid for Telehealth Services.
• The Health Care Provider at the Originating (Member) Site may bill for any clinical services provided on-site on the same day that a Telehealth Service claim is made, except as specifically excluded elsewhere in this Section.
• Telehealth Services may be included in a Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC), or Indian Health Center (IHC) scope of practice, as approved by the State. If approved, these facilities may serve as the provider site and bill under the encounter rate. When an FQHC or RHC serves as the Originating (Member) Site, the Originating Facility Fee is paid separately from the center or clinic all-inclusive rate.
• In the event an interpreter is required, the Health Care Provider at either the Originating (Member) Site or the Receiving (Provider) site must provide and may bill for interpreter services in accordance with the provisions of Chapter I, Section 1, of the MBM. Members may not bill or be reimbursed by the Department for interpreter services utilized during a telehealth encounter.
• If the technical component of an X-ray, ultrasound, or electrocardiogram is performed at the Originating (Member) Site during a Telehealth Service, the technical component and the Originating Facility Fee are billed by the Health Care Provider at the Originating (Member) Site. The professional component of the procedure and the appropriate visit code are billed by the Receiving (Provider) Site.  The professional component of the procedure and the appropriate visit code are billed by the Receiving (Provider) Site.

The Health Care Providers at the Receiving and Originating Sites may be part of the same organization. A Health Care Provider at the Originating (Member) Site may bill MaineCare and receive payment for Telehealth Services if the service is provided by a Treating Provider who is under a contractual arrangement with the Originating (Member) Site.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4. (Nov. 6, 2023).  Adopted 10-144 C.M.R. Chapter 101, Chapter I, Section 4, Telehealth Services. (Nov. 6, 2023).  (Accessed May 2024).

Electronic Visit Verification (EVV) Place of Service Reminders

Personal Care Services (PCS) claims are included or excluded from EVV record requirements based on the POS code and EVV service codes that are submitted on the CMS 1500 claim form.

Claims for services delivered in the following locations are not subject to EVV and do not require a verified EVV visit record:

• POS 02: Telehealth provided other than in a patient’s home
  • Use this POS for Home Support-Remote Support: Monitor Only and Interactive services (including MaineCare policy Sections 18, 19, 20, 21, and 29).
  • Please refer to our additional telehealth billing guidance for PCS.
• POS 10: Telehealth provided in patient’s home

SOURCE: ME Department of Health and Human Services, Office of MaineCare Services, Electronic Visit Verification (EVV) Place of Service Reminders, Sept. 26. 2022. (Accessed May 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Originating Facility Fee: Fee paid to the Health Care Provider at the Originating (Member) Site for the service of coordinating Telehealth Services.

If the Health Care Provider at the Originating (Member) Site supports the Member’s access to Telehealth Services the Health Care Provider at the Originating (Member) Site may bill MaineCare for an Originating Facility Fee using code Q3014 for the service of supporting access to the Telehealth Service. Supporting access to telehealth services means providing a room and/or telecommunications equipment and/or helping a Member use audio or video conferencing software or equipment to enable the Member to utilize telehealth.

The Health Care Provider at the Originating (Member) Site may not bill for assisting the Health Care Provider at the Receiving (Provider) Site with an examination.

No separate transmission fees will be paid for Telehealth Services.

When an FQHC or RHC serves as the Originating (Member) Site, the Originating Facility Fee is paid separately from the center or clinic all-inclusive rate.

If the technical component of an X-ray, ultrasound, or electrocardiogram is performed at the Originating (Member) Site during a Telehealth Service, the technical component and the Originating Facility Fee are billed by the Health Care Provider at the Originating (Member) Site.

The professional component of the procedure and the appropriate visit code are billed by the Receiving (Provider) Site.

The Department will not separately reimburse Health Care Providers for any charge  related to the purchase, installation, or maintenance of telehealth equipment or technology, nor any transmission fees. Health Care Providers shall not bill Members for such costs or fees.

The rate for Telehealth Originating Facility Fee, per visit, code Q3014, is listed on the MaineCare Provider fee schedule, which is posted on the Department’s website in accordance with 22 MRSA Section 3173-J(7) at https://mainecare.maine.gov/Provider%20Fee%20Schedules/Forms/Publication.aspx.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4. (Nov. 6, 2023).  Adopted 10-144 C.M.R. Chapter 101, Chapter I, Section 4, Telehealth Services. (Nov. 6, 2023).  (Accessed May 2024).

Last updated 05/20/2024

Miscellaneous

See manual for information regarding telehealth equipment, technology, security, documentation and member choice and education requirements.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4. (Nov. 6, 2023).  Adopted 10-144 C.M.R. Chapter 101, Chapter I, Section 4, Telehealth Services. (Nov. 6, 2023).  (Accessed May 2024).

Beginning January 1, 2018 and annually thereafter, the department shall report to the joint standing committee of the Legislature having jurisdiction over health and human services matters on the use of telehealth in the MaineCare program, including the number of providers providing telehealth and telemonitoring services, the number of patients served by telehealth and telemonitoring services and a summary of grants applied for and received related to telehealth and telemonitoring.

The Department is required to conduct educational outreach to providers and MaineCare members on telehealth and telemonitoring services.

SOURCE: ME Statute Sec. 3173-H. (Accessed May 2024).

Telepharmacy is a method of delivering prescriptions dispensed by a pharmacist to a remote site. Pharmacies using telepharmacy must follow all applicable State and Federal regulations, including use of staff qualified to deliver prescriptions through telepharmacy.

Providers may dispense prescriptions via telepharmacy when obtaining approval from the Department. Providers must assure that member counseling is available at the remote site from the dispensing provider or the provider delivering the prescription, and that only qualified staff, as defined by the Maine State Board of Pharmacy, deliver prescriptions. The Department may terminate this approval at any time by written notice.

SOURCE: MaineCare Benefits Manual, Pharmacy Services, 10-144 Ch. II, Sec. 80 p. 5 & 30. (Sept. 1, 2017), (Accessed May 2024).

ME established the ME Telehealth and Telemonitoring advisory group to evaluate difficulties related to telehealth and telemonitoring services and make recommendations to the department to improve it statewide.

SOURCE: ME Statute Sec. 3173-I. (Accessed May 2024).

Last updated 05/20/2024

Out of State Providers

Health Care Provider: Individual or entity licensed or certified to provide medical, behavioral health, and related services to MaineCare Members. Health Care Providers must be enrolled as MaineCare Providers to receive reimbursement for services.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4. (Nov. 6, 2023).  Adopted 10-144 C.M.R. Chapter 101, Chapter I, Section 4, Telehealth Services. (Nov. 6, 2023).  (Accessed May 2024).

Last updated 05/20/2024

Overview

Maine Medicaid (MaineCare) reimburses for live video telehealth under certain conditions, and remote patient monitoring for patients with certain risk factors.  They also reimburse for store-and-forward, including virtual transfer of health information and remote consultation between a treating provider and specialist.  Telephone evaluation and management services are also reimbursed in certain circumstances, as well as the virtual check-in and interprofessional codes for medication management providers.

Last updated 05/20/2024

Remote Patient Monitoring

POLICY

Telemonitoring Services are the use of information technology to remotely monitor a member’s health status through the use of clinical data while the member remains in the residential setting. Telemonitoring may or may not take place in real time.

SOURCE: MaineCare Benefits Manual. Ch. II. Home Health Services. Sec. 40.01, p. 5 (Aug. 11, 2019). (AccessedMay 2024).

“Telemonitoring,” as it pertains to the delivery of MaineCare services, means the use of information technology to remotely monitor a patient’s health status via electronic means, allowing the provider to track the patient’s health data over time. Telemonitoring may be synchronous or asynchronous.

SOURCE: ME Statute Sec. 22:855.3173-H(E), (Accessed May 2024).

Telemonitoring Services: The use of information technology to remotely monitor a Member’s health status via electronic means, allowing the provider to track the enrollee’s health data over time. Telemonitoring may be synchronous or asynchronous.

Telemonitoring Services are intended to collect a Member’s health related data, such as pulse and blood pressure readings, that assist Health Care Providers in monitoring and assessing the Member’s medical conditions. The following activities qualify as Telemonitoring Services:

• Evaluation of the Member to determine if Telemonitoring Services are medically necessary for the Member. Prior to conducting an evaluation, the Home Health Agency must assure that a Health Care Provider’s order
  or note demonstrating the necessity of Telemonitoring Services, is included in the Member’s Plan of Care.
• Evaluation of the Member to assure that the Member is cognitively and physically capable of operating the Telemonitoring equipment or assurance that the Member has a caregiver willing and able to assist with the equipment;
• Evaluation of the Member’s residence to determine suitability for Telemonitoring Services. If the residence appears unable to support Telemonitoring Services, the Home Health Agency may not implement Telemonitoring Services in the Member’s residence unless necessary adaptations are made. Adaptations are not reimbursable by MaineCare;
• Education and training of the Member and/or caregiver on the use, maintenance and safety of the Telemonitoring equipment, the cost of which is included in the monthly flat rate paid by MaineCare to the Home Health Agency;
• Remote monitoring and tracking of the Member’s health data by a registered nurse, nurse practitioner, physician’s assistant, or physician, and response with appropriate clinical interventions. The Home Health Agency and Health Care Provider utilizing the data shall maintain a written protocol that indicates the manner in which data shall be shared in the event of emergencies or other medical complications;
• At least monthly Interactive Telehealth Services or Telephonic Services with the Member;
• Maintenance of equipment, the cost of which is included in the monthly flat rate paid by MaineCare to the Home Health Agency; and
• Removal/disconnection of equipment from the Member’s home when Telemonitoring Services are no longer necessary or authorized.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4. (Nov. 6, 2023).  Adopted 10-144 C.M.R. Chapter 101, Chapter I, Section 4, Telehealth Services. (Nov. 6, 2023).  (Accessed May 2024).

Home and Community Benefits for the Elderly and for Adults with Disabilities

Assistive Technology-Remote Monitoring means real time remote support monitoring of the member with electronic devices to assist them to remain safely in their homes. Remote monitoring services may include a range of technological options including in-home computers, sensors, and video camera linked to a provider that enables 24/7 monitoring and/or contact as necessary.

SOURCE: MaineCare Benefits Manual, Home and Community Benefits for the Elderly and for Adults with Disabilities, 10-144 Ch. II, Sec. 19.04-2, p. 2 (May 2, 2021). (Accessed May. 2024).

CONDITIONS

In order to be eligible for telemonitoring a member must:

• Be eligible for home health services;
• Have a current diagnosis of a health condition requiring monitoring of clinical data at a minimum of five times per week, for at least one week;
• Have documentation in the patient’s medical record that the patient is at risk of hospitalization or admission to an emergency room OR have continuously received Telemonitoring Services during the past calendar year and have a continuing need for such services, as documented by an annual note from a health care provider;
• Have telemonitoring services included in the Member’s plan of care. A notation from a Health Care Provider, dated prior to the beginning of service delivery, must be included in the Member’s Plan of Care. MaineCare shall not
  reimburse for Telemonitoring Services if they began prior to the date recorded in the Provider’s note.
• Reside in a setting suitable to support telemonitoring equipment; and
• Have the physical and cognitive capacity to effectively utilize the telemonitoring equipment or have a caregiver willing and able to assist with the equipment.
• Have telemonitoring services included in the member’s plan of care. A notation from a Health Care Provider, dated prior to the beginning of service delivery, must be included in the member’s plan of care. If telemonitoring Services begin prior to the date recorded in the provider’s note, services shall not be reimbursed. [last bullet only in Home Health Services Manual].

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4.02-2. p.3 (Nov. 6, 2023). Adoption 10-144 C.M.R. Chapter 101, Chapter I, Section 4, Telehealth Services (Nov 6, 2023) & MaineCare Benefits Manual. Ch. II. Home Health Services. Sec. 40.05. p. 10-11. (Aug. 11, 2019). (Accessed May 2024).

Home and Community Benefits for the Elderly and for Adults with Disabilities Final approval must be obtained from the Department, Office of Aging and Disability Services upon a recommendation by the ASA or SCA. In making such a recommendation the ASA or the SCA must consider and document the following information:

• Number of hospitalizations in the past year;
• Use of emergency room in the past year;
• History of falls in the last six months resulting from injury;
• Member lives alone or is home alone for significant periods of time;
• Service access challenges and reasons for those challenges;
• History of behavior indicating that a member’s cognitive abilities put them at a significant risk of wandering; and
• Other relevant information.

SOURCE: MaineCare Benefits Manual, Home and Community Benefits for the Elderly and for Adults with Disabilities, 10-144 Ch. II, Sec. 19.04-2, p. 23 (May 2, 2021). (Accessed Feb. 2024).

PROVIDER LIMITATIONS

Telemonitoring will be reimbursed only when provided by a certified Home Health Agency. See regulations for specific requirements of Home Health Agencies utilizing telemonitoring services.

SOURCE:  MaineCare Benefits Manual. Ch. II. Home Health Services. Sec. 40.05. p. 16. (Aug. 11, 2019). (Accessed May 2024). 

In order to be eligible for reimbursement for Telemonitoring Services, a Health Care Provider must be a certified Home Health Agency pursuant to the MBM Chapter II, Section 40, Home Health Services. Compliance with all applicable requirements listed in Chapter II, Section 40, Home Health Services, is required.

The Health Care Provider ordering the service must be a Health Care Provider with prescribing privileges (physician, nurse practitioner or physician’s assistant).

Health Care Providers must document that they have had a face-to-face encounter with the Member before a physician may certify eligibility for services under the home health benefit. This may be accomplished through interactive telehealth services, but not by telephone or e-mail.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec.  4.03. p. 4 (Nov. 6, 2023). (Accessed May 2024).

OTHER RESTRICTIONS

Telemonitoring services are intended to collect a member’s health-related data, such as pulse and blood pressure readings, that assist healthcare providers in monitoring and assessing the member’s medical conditions.

A note, dated prior to the beginning of service delivery, and demonstrating the necessity of home telemonitoring services, must be included in the member’s file. In the event that services begin prior to the date recorded on the provider’s note, services delivered in that month will not be covered.

Telemonitoring services must be included in the member’s plan of care.  See page 16-17 for responsibilities of home health agencies utilizing telemonitoring.

SOURCE:  Mainecare Benefits Manual. Ch. II. Home Health Services. Sec. 40.05. p. 16. (Aug. 11, 2019). (Accessed May 2024). 

Services shall not be duplicate of any other services.  See regulation for examples of duplication.

SOURCE:  Mainecare Benefits Manual. Ch. II. Home Health Services. Sec. 40.06.p. 17-18.  (Aug. 11, 2019). (Accessed May 2024). 

See home health manual for list of non-covered services.

SOURCE:  Mainecare Benefits Manual. Ch. II. Home Health Services. Sec. 40.07. p. 18-19. (Aug. 11, 2019). (Accessed May 2024).

Department required to adopt regulations that comply with the following:

• May not include any requirement that a patient have a certain number of ER visits or hospitalizations related to the patient’s diagnosis in the criteria for a patient’s eligibility for telemonitoring services;
• Except as provided in the last bullet point (see below), must include qualifying criteria for a patient’s eligibility of telemonitoring services that include documentation in a patient’s medical record that the patient is at risk of hospitalization or admission to an ER
• Must provide that group therapy for behavioral health or addiction services covered by the MaineCare program may be delivered through telehealth;
• Must include requirements for providers providing telehealth and telemonitoring services; and
• Must allow at least some portion of case management services covered by the MaineCare program to be delivered through telehealth, without requiring qualifying criteria regarding a patient’s risk of hospitalization or admission to an emergency room.

SOURCE: ME Statute Sec. 3173-H, (Accessed May 2024).

Home and Community Benefits for the Elderly and for Adults with Disabilities

Use of remote monitoring requires sufficient Back Up Plans and the SCA will be responsible for ensuring that the member has at least two adequate back-up plans prior to making a referral for this service.

SOURCE: MaineCare Benefits Manual, Home and Community Benefits for the Elderly and for Adults with Disabilities, 10-144 Ch. II, Sec. 19, p. 23 (May 2, 2021). (Accessed Feb. 2024).

Telemonitoring Services

Only the Health Care Provider at the Receiving (Provider) Site will be reimbursed for Telemonitoring Services.

No Originating Facility Fee will be paid for Telemonitoring Services.

Only a Home Health Agency may receive reimbursement for Telemonitoring Services.

Telemonitoring Services shall be billed using code S9110, which provides for a flat monthly fee for services, which is inclusive of all Telemonitoring Services, including, but not limited to:

• Equipment installation;
• Training the Member on the equipment’s use and care;
• Monitoring of data;
• Consultations with the primary care physician; and
• Equipment removal when the Telemonitoring Service is no longer medically necessary.

Except as described in this policy, no additional reimbursement beyond the flat fee is available for Telemonitoring Services.

MaineCare will not reimburse separately for Telemonitoring equipment purchase, installation, or maintenance.

If in-person visits are required, these visits must be billed separately from the Telemonitoring Service in accordance with Chapters II and III, Section 40, Home Health Services, of the MBM.

If an interpreter is required, the Home Health Agency may bill for interpreter services in accordance with another billable service and the requirements of Chapter I, Section 1, of the MBM.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4.07-3. p.12, (Nov. 6, 2023). (Accessed May 2024).

Last updated 05/20/2024

Store and Forward

POLICY

“Store and forward transfers” means transmission of a patient’s recorded health history through a secure electronic system to a health professional.

“Asynchronous encounters” means the interaction or consultation between a patient and the patient’s provider or between health professionals regarding the patient through a system with the ability to store digital information, including, but not limited to, still images, video, audio and text files, and other relevant data in one location and subsequently transmit such information for interpretation at a remote site by health professionals without requiring the simultaneous presence of the patient or the health professionals.

SOURCE: ME Statute Sec. 22:855.3173-H, Sub. Sec. 1 (Accessed May 2024).

Asynchronous encounter – The interaction or consultation between a Member and the Member’s Health Care Provider or between Health Care Providers regarding the Member through a system with the ability to store digital information, including, but not limited to, still images, video, audio and test files, and other relevant data in one location and subsequently transmit such information for interpretation at a remote site by Health Care Providers without requiring the simultaneous presence of the Member or the Health Care Provider. The term “Store-and-Forward Telehealth” is also used for the term “Asynchronous encounters” in this rule.

Store-and-Forward (asynchronous) Telehealth is only permitted for established patients and involves the transmission of recorded clinical information (including, but not limited to radiographs, photographs, video, digital impressions, and photomicrographs of patients) through a secure electronic communications system to a Health Care Provider. All health information must be transmitted via secured email. In order for the Health Care Provider to be reimbursed for a covered service delivered via Store-and-Forward Telehealth, a Member must not be present.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4. (Nov. 6, 2023).  Adopted 10-144 C.M.R. Chapter 101, Chapter I, Section 4, Telehealth Services. (Nov. 6, 2023).  (Accessed May 2024).

ELIGIBLE SERVICES/SPECIALTIES

MaineCare will provide reimbursement for two types of store-and-forward:

1. Virtual Transfer of Health Information: The Health Care Provider uses health information that has been virtually transferred to evaluate a Member’s condition or render a covered MaineCare service separate from Telehealth Services. The Health Care Provider uses a computer or a mobile device, such as a smartphone, to gather and send the information. Information is transmitted by electronic mail, uploaded to a secure website, or a private network. Only the Health Care Provider who receives and reviews the recorded clinical information is eligible for reimbursement.
2. Remote Consultation Between Treating Provider and Specialist: A Specialist provides interprofessional telecommunications assessment and management services to a Treating Provider. The interaction includes discussion (via telephone or internet) of a written report by the Specialist to assess the Member’s Electronic Health Record and/or diagnoses/treatment. Duration of this service must be a minimum of five minutes and no greater than thirty minutes. The Treating Provider must document that they have informed the Member as to results and conclusions following the Remote Consultation.
   • The Treating Provider must document in the Member’s medical record the Member’s written, electronic, or verbal consent for each Remote Consultation. Billing for interprofessional services is limited to those practitioners who can independently bill MaineCare for evaluation and management services.
   • Remote Consultation may be utilized as often as medically necessary, per the terms of these rules.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4. (Nov. 6, 2023).  Adopted 10-144 C.M.R. Chapter 101, Chapter I, Section 4, Telehealth Services. (Nov. 6, 2023).  (Accessed May 2024).

Teledentistry

Providers may deliver diagnostic services via telehealth in accordance with Chapter I, Section 4, of the MaineCare Benefits Manual (MBM) and current Board rules and guidance. When delivering services via telehealth, providers shall bill for the underlying service and include, for tracking purposes only, the appropriate teledentistry CDT code that indicates a synchronous real-time encounter or an asynchronous encounter in which information is stored and forwarded to the dentist for subsequent review.

SOURCE: ME Benefits Manual, Dental Services and Reimbursement Methodology, 10-144, Ch. II, Sec. 25, pg. 3-4, (Sept. 28, 2022), (Accessed May 2024).

Interprofessional Codes for Medication Management Providers

Medication management providers and other treating providers of Section 65 of the MaineCare Benefits Manual (MBM) may deliver and bill MaineCare for interprofessional consultations in alignment with MBM Chapter 1, Section 4.04-2(B). As described in CMS state health official letter #23-001, interprofessional consultations are assessments and management services in which a patient’s treating provider requests the opinion and/or treatment advice of a consultant with specific specialty expertise to assist the treating provider in the diagnosis and/or management of the patient’s condition without the need for the patient’s face-to-face contact with the consultant.

The consulting provider and the provider requesting the consultation must be able to independently bill for evaluation and management services. Examples of these provider types include physicians, nurse practitioners, clinical nurse specialists, physician assistants, and licensed clinical social workers. A registered nurse, for example, is not an eligible provider type.

The following examples illustrate when medication management providers may deliver and bill for interprofessional consultations:

• A medication management provider provides consultation to a primary care provider (PCP) on cross-tapering a patient from one antidepressant to another due to concerning side-effects.
• A medication management provider provides consultation to a PCP regarding antipsychotic medications because the PCP has a symptomatic patient who has been off of medications, and the PCP has never prescribed antipsychotic medication before.
• The PCP has been treating a behavioral health patient who was previously stabilized and who is now reporting increased symptoms with active substance use. The PCP is not sure of what to do about medications in the context of active substance use and consults a medication management provider.

Providers must bill for interprofessional consultations using common procedural terminology (CPT) codes 99446-99449, 99451, and 99452. However, CPT code 99452 is different. Interprofessional consultation code 99452 applies when the patient’s PCP or other qualified health professional interacts with a consultant via telephone, the Internet, or an electronic health record to provide the consultant with the patient’s clinical data so that the consultant can form an opinion regarding further management of the patient’s condition. For example, a PCP would bill CPT code 99452 if they send a patient to a medication management provider and the PCP provided background information.

SOURCE: State of Maine Department of Health and Human Services, Bulletin:  Interprofessional Codes for Medication Management Providers, Nov. 13, 2024, (Accessed May 2024).

GEOGRAPHIC LIMITS

No Reference Found

TRANSMISSION FEE

No Reference Found