Reference Guide for Allowed Services by Provider Types

Transcription

1 Reference Guide for Allowed Services by Provider Types Version 6.0 For use in conjunction with MIHMS Enrollment Guides MIHMS_RG_0004_v6.0_ doc

2 Version History Version Date Author Action/Summary of Changes Status /09/2010 R.J. Roy C. Eisenhart Summary: 8/2010 to present. Updated for remainder of changes made during completion of DDI, changes from State meetings and State reviews. Review included a comprehensive 3-way comparison and validation of the policy matrices, the actual system configuration, and this document. Note: Various portions of this document have been previously published as appendices to the different Enrollment Guides. This version 3.0 is the first external publication of this document as a standalone reference. State approved 2/7/2011. Final /27/2011 R.J. Roy Included PT 89 and associated specialties under FAO- Rendering, correcting an omission /28/2011 R.J. Roy Finalized upon State acceptance. Draft Final MIHMS_RG_0004_v6.0_ doc

3 4.1 03/04/2014 K. Goldhammer CR26529: Added Provider Type: 40- Specialty: 130-Registered First Assistant under FAO with Rendering for Pay-To of 35- Hospital. Draft /07/2014 R.J. Roy QA and submission prep. Draft /09/2014 Darcy Casey Finalization per State acceptance dated 04/09/2014 Final /04/2015 K. Goldhammer CR42034 Add ST 130- Registered First Assist to PT 02-APRN Draft /03/2015 Crystal Hinton QA d for State submission Draft /12/2015 Crystal Hinton Finalization per State acceptance dated 03/12/2015 Final MIHMS_RG_0004_v6.0_ doc

4 Usage Information Documents published herein are furnished As Is. There are no expressed or implied warranties. The content of this document herein is subject to change without notice. HIPAA Notice The Maine Health PAS Online Portal is for the use of authorized users only. Users of the Maine Health PAS Online Portal may have access to protected and personally identifiable health data. As such, the Maine Health PAS Online Portal and its data are subject to the Privacy and security Regulations within the Health Insurance Portability and Accountability Act of 1996, Public Law (HIPAA). By accessing the Maine Health PAS Online Portal, all users agree to protect the privacy and security of the data constrained within as required by law. Access to information on this site is only allowed for necessary business reasons, and is restricted to those persons with a valid user name and password. MIHMS_RG_0004_v6.0_ doc

5 Reference Guide for Allowed Services by Provider Type Table of Contents 1. Introduction Mapping Tables... 2 Table of Figures Figure 2-1: Provider Groups... 3 Figure 2-2: FAO with Required Rendering Providers... 6 MIHMS_RG_0004_v6.0_ doc Page i

6 1. Introduction There are three Reference Guides for Providers to use during Enrollment or Re-Enrollment: Standard Abbreviations and Postal Information Valid Provider Type-Specialty Pairs Allowed Services by Provider Types In this you will find: Figure 2-1 for allowed rendering providers for provider groups, and Figure 2-2 for Facility, Agency, and Organization ( FAO ) providers that require rendering providers. You will need to refer to this information during enrollment and/or re-enrollment. Use this chart below to determine which table to use. Individual Providers and Facility, Agency, and Organization providers without renderings do not need this Reference Guide. Enrollment Type Reference Guide Table(s) to Use In this Guide Type 1 Individual Individual Providers This Guide does not apply Type 1 Individual as Group or FAO Provider Groups See Fig 2-1 FAO with Rendering FAO Non-Rendering See Fig 2-2 This Guide does not apply MIHMS_RG_0004_v6.0_ doc Page 1

7 Enrollment Type Type 2 Incorporated Individual Type 2 Organization as Group or FAO No NPI Type Atypical Provider Reference Guide Table(s) to Use In this Guide Provider Groups See Fig 2-1 Provider Groups See Fig 2-1 FAO with Rendering FAO Non-Rendering FAO Non-Rendering See Fig 2-2 This Guide does not apply This Guide does not apply 2. Mapping Tables The mapping tables begin on page 3. It is imperative that providers indicate the correct provider type and specialty (or specialties) on their applications. Failure to do so could result in incorrect claim reimbursement. To use this table, do the following: 1. Choose the correct table for the enrollment type for which you need more information. 2. In the Pay-To Providers column, find the provider type-specialty pair for which you need information about Allowed Rendering Providers. 3. In the corresponding Allowed Rendering Providers, locate the appropriate provider type-specialty pair for the provider you are enrolling. Note the following: When you go online, if only one specialty is shown in the Allowed Rendering Providers Specialty cell, the provider must designate this specialty on their enrollment application assuming they are credentialed for this specialty. MIHMS_RG_0004_v6.0_ doc Page 2

8 Maine Integrated Health Management Solution If more than one specialty is shown in the Allowed Rendering Providers Specialty cell, the provider must choose the specialty that is correct based on their credentials and enroll that specialty online. If the text No specialty required appears in the MIHMS Specialty cell, the provider should not designate a specialty on the enrollment application. 4. New provider types and specialties are added from time to time and occasionally provider types and/or specialties are also sometimes removed. If you don t see your provider type here and believe it should be here according to a ListServ message or reasonable expectation, you may go on the MIHMS Health PAS Online Portal to see if your provider type is displayed as available (and therefore, valid) in the system or you may call Provider Enrollment for more information. Figure 2-1: Provider Groups Pay-To Providers for Provider Groups Allowed Rendering Providers 03-Advanced Practice Registered Nursing Group 02-Advanced Practice Registered 014-Certified Clinical Specialist 015-Certified Midwife 017-Certified Registered Anesthetist 130-Registered First Assistant 49-Physical Therapist 63-Speech Language Pathologist 10-Audiology Group 09-Audiologist 007-Audiology 12-Behavioral Health Clinician Group 072-Licensed Marriage and Family Therapist 15-Chiropractic Group 16-Chiropractor 49-Physical Therapist 018-Chiropractor MIHMS_RG_0004_v6.0_ doc Page 3

9 Pay-To Providers for Provider Groups Allowed Rendering Providers 50-Physical Therapy Assistant 19-Dental Group 22-Dentist 028-Dentist-Endodontist 029-Dentist-General 030-Dentist-Oral Pathologist 031-Dentist-Orthodonture 032-Dentist-Pedodontist 034-Dentist-Prosthodontist 093-Oral/Maxillofacial Surgery 23-Denturist 037-Denturist 21-Dental Hygienist Group 20-Dental Hygienist 036-Dentistry 24-Denturist Group 23-Denturist 037-Denturist 44-Occupational/Physical Therapy Group 43-Occupational Therapy Assistant 49-Physical Therapist 50-Physical Therapy Assistant 54-Physicians Group 02-Advanced Practice Registered 014-Certified Clinical Specialist 015-Certified Midwife 017-Certified Registered Anesthetist 130-Registered First Assistant 09-Audiologist 007-Audiology 073-Licensed Master Social Worker 22-Dentist 029-Dentist-General MIHMS_RG_0004_v6.0_ doc Page 4

10 Pay-To Providers for Provider Groups Allowed Rendering Providers Registered 130-Registered First Assistant 54-Physicians Group 49-Physical Therapist Any Allowed Specialty 52-Physician Assistant 116-Physician Assistant 56-Podiatrist 118-Podiatry 63-Speech Language Pathologist 57-Podiatry Group 56-Podiatrist 118-Podiatry 64-Speech Language Pathology Group 63-Speech Language Pathologist 65-Speech Therapy Assistant 67-Speech/Hearing Therapist Group 09-Audiologist 63-Speech Language Pathologist 007-Audiology 65-Speech Therapy Assistant 72-Vision Services Provider Group 45-Optician 46-Optometrist 091-Optician 092-Optometry 090-Ophthamology MIHMS_RG_0004_v6.0_ doc Page 5

11 Figure 2-2: FAO with Required Rendering Providers Pay-To Providers for FAOs with Required Rendering Providers Allowed Servicing Providers 30-Family Planning Agency 086-Obstetrician and Gynecologist 02-Advanced Practice Registered 26-Dietician 52-Physician Assistant 35-Hospital 062-Hospital Based Professionals 02-Advanced Practice Registered 09-Audiologist 20-Dental Hygienist 015-Certified Midwife 000-No Specialty Required 046-Family Practice 053-General Practice 057-Gynecology 067-Internal Medicine 086-Obstetrician and Gynecologist 087-Obstetrics 116-Physician Assistant 014-Certified Clinical Specialist 015-Certified Midwife 017-Certified Registered Anesthetist 130-Registered First Assistant 007-Audiology 013-Certified Alcohol and Drug Counselor 069-Licensed Alcohol and Drug Counselor 072-Licensed Marriage and Family Therapist 073-Licensed Master Social Worker 036-Dentistry MIHMS_RG_0004_v6.0_ doc Page 6

12 Pay-To Providers for FAOs with Required Rendering Providers Allowed Servicing Providers 35-Hospital 062-Hospital Based Professionals 22-Dentist 028-Dentist-Endodontist 029-Dentist-General 030-Dentist-Oral Pathologist 031-Dentist-Orthodonture 032-Dentist-Pedodontist 033-Dentist-Periodontist 034-Dentist-Prosthodontist 093-Oral / Maxillofacial Surgery 23-Denturist 037-Denturist 26-Dietician 000-No Specialty Required Registered First Assistant Any Allowed Specialty 52-Physician Assistant 116-Physician Assistant 56-Podiatrist 118-Podiatry 36-Indian Health Services Provider 064-IHS 02-Advanced Practice Registered 09-Audiologist 16-Chiropractor 20-Dental Hygienist 014-Certified Clinical Specialist 015-Certified Midwife 017-Certified Registered Anesthetist 130-Registered First Assistant 007-Audiology 069-Licensed Alcohol and Drug Counselor 073-Licensed Master Social Worker 018-Chiropractor 036-Dentistry MIHMS_RG_0004_v6.0_ doc Page 7

13 Pay-To Providers for FAOs with Required Rendering Providers Allowed Servicing Providers 22-Dentist 029-Dentist-General 23-Denturist 037-Denturist 36-Indian Health Services Provider 064-IHS 26-Dietician No Specialty Required 129-Registered 130-Registered First Assistant 43-Occupational Therapy Assistant 45-Optician 091-Optician 46-Optometrist 092-Optometry 49-Physical Therapist 50-Physical Therapy Assistant Any Allowed Specialty 52-Physician Assistant 116-Physician Assistant 56-Podiatrist 118-Podiatry 63-Speech Language Pathologist 65-Speech Therapy Assistant 38-Mental Health Clinic 008-Behavioral Health Services 02-Advanced Practice Registered 014-Certified Clinical Specialist 072-Licensed Marriage and Family Therapist 073-Licensed Master Social Worker 122-Psychological Examiner MIHMS_RG_0004_v6.0_ doc Page 8

14 Pay-To Providers for FAOs with Required Rendering Providers Allowed Servicing Providers Registered 38-Mental Health Clinic 008-Behavioral Health Services 52-Physician Assistant Any Allowed Specialty 116-Physician Assistant 020-Community Support Services 02-Advanced Practice Registered 014-Certified Clinical Specialist 073-Licensed Master Social Worker Registered Any Allowed Specialty 52-Physician Assistant 116-Physician Assistant 39-Non-Hospital Affiliated Clinic 065-Infectious Diseases 02-Advanced Practice Registered Physician Assistant 53-School Health Center 000-No Specialty Required 02-Advanced Practice Registered 129-Registered Any Allowed Specialty 116-Physician Assistant 015-Certified Midwife MIHMS_RG_0004_v6.0_ doc Page 9

15 Pay-To Providers for FAOs with Required Rendering Providers Allowed Servicing Providers 069-Licensed Alcohol and Drug Counselor Registered Any Allowed Specialty 53-School Health Center 000-No Specialty Required 52-Physician Assistant 116-Physician Assistant 61-Psychiatric Hospital 062-Hospital Based Professionals 02-Advanced Practice Registered 09-Audiologist 20-Dental Hygienist 22-Dentist 23-Denturist 26-Dietician 014-Certified Clinical Specialist 015-Certified Midwife 017-Certified Registered Anesthetist 007-Audiology 069-Licensed Alcohol and Drug Counselor 072-Licensed Marriage and Family Therapist 073-Licensed Master Social Worker 036-Dentistry 028-Dentist-Endodontist 029-Dentist-General 030-Dentist-Oral Pathologist 031-Dentist-Orthodonture 032-Dentist-Pedodontist 033-Dentist-Periodontist 034-Dentist-Prosthodontist 093-Oral / Maxillofacial Surgery 037-Denturist 000-No Specialty Required MIHMS_RG_0004_v6.0_ doc Page 10

16 Pay-To Providers for FAOs with Required Rendering Providers Allowed Servicing Providers 49-Physical Therapist Any Allowed Specialty 52-Physician Assistant 116-Physician Assistant 61-Psychiatric Hospital 062-Hospital Based Professionals 56-Podiatrist 118-Podiatry 68-State Agency 035-Public Health 20-Dental Hygienist 036-Dentistry 69-Substance Abuse Provider 001-Addiction Services 02-Advanced Practice Registered Certified Clinical Specialist 013-Certified Alcohol and Drug Counselor 069-Licensed Alcohol and Drug Counselor 073-Licensed Master Social Worker 129-Registered 001-Addiction Services 87-Public School 164-Therapy Services 09-Audiologist 007-Audiology 43-Occupational Therapy Assistant 49-Physical Therapist 072-Licensed Marriage and Family Therapist 122-Psychological Examiner MIHMS_RG_0004_v6.0_ doc Page 11

17 Pay-To Providers for FAOs with Required Rendering Providers Allowed Servicing Providers 50-Physical Therapy Assistant 63-Speech Language Pathologist 65-Speech Therapy Assistant 88-Special Purpose Private School 164-Therapy Services 09-Audiologist 007-Audiology 43-Occupational Therapy Assistant 49-Physical Therapist 50-Physical Therapy Assistant 63-Speech Language Pathologist 65-Speech Therapy Assistant 072-Licensed Marriage and Family Therapist 122-Psychological Examiner 89-Intermediate Education Unit 164-Therapy Services 09-Audiologist 007-Audiology 43-Occupational Therapy Assistant 49-Physical Therapist 50-Physical Therapy Assistant 072-Licensed Marriage and Family Therapist 122-Psychological Examiner MIHMS_RG_0004_v6.0_ doc Page 12

18 Pay-To Providers for FAOs with Required Rendering Providers Allowed Servicing Providers 63-Speech Language Pathologist 65-Speech Therapy Assistant MIHMS_RG_0004_v6.0_ doc Page 13