Last updated 11/02/2023
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 Nov. 2023).
Recently Passed Legislation
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 Nov. 2023).
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;
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.
A 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.
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.
SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4. p. 9-10. (Nov. 6, 2023). (Accessed Nov. 2023).
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, p. 23 (May 2, 2021). (Accessed Nov. 2023).
Prior to the provision of telemonitoring services, the Health Care Provider shall document that it has provided the member with choice and educational information 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 Nov. 2023).
Last updated 11/02/2023
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 Nov. 2023).
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 Nov. 2023).
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 Nov. 2023).
Last updated 11/02/2023
Email, Phone & Fax
MaineCare Service Flexibilities Continuing after May 11, 2023
The Department will reimburse providers for telephonic evaluation and management services provided to members. The restrictions set forth in Ch. I, Section 4, Subsection 4.04-3 are waived for this purpose.
SOURCE: MaineCare Update, Flexibilities Continuing: End of Public Health Emergency (PHE), May 16, 2023. (Accessed Nov. 2023).
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
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). (Accessed Nov. 2023).
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 Nov. 2023).
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 Nov. 2023).
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.
Also covered for Multi-Systemic Therapy.
SOURCE: MaineCare Benefits Manual, Behavioral Health Services, 10-44 Ch. II, Sec. 65, p. 4, 12 (Nov. 2022). (Accessed Nov. 2023).
An examination following use of restraint or seclusion can be done by a telephone in consult with a registered nurse. 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 Nov. 2023).
Ongoing Telehealth Medicaid Flexibilities [End Date Not Specified]
The Department will reimburse providers for telephonic evaluation and management services provided to members. The restrictions set forth in Ch. I, Section 4, Subsection 4.04-3 are waived for this purpose. [Note: Manual has been updated since this document published, and subsection referenced no longer correlates to telephonic evaluation and management services. Allowances appear to align with new updated manual policy].
SOURCE: Maine Department of Health and Human Services Office of MaineCare Services, Flexibilities Continuing: End of the Public Health Emergency (PHE), May 16, 2023, (Accessed Nov. 2023).
Last updated 11/02/2023
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 Nov. 2023).
“Synchronous encounters” means a real-time interaction conducted with interactive audio or video connection between a patient and the patient’s provider or between providers regarding the patient.
SOURCE: ME Statute Sec. 22:855.3173-H, Sub. Sec. 1 (Accessed Nov. 2023).
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 Nov. 2023).
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 Nov. 2023)
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 Nov. 2023).
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 Nov. 2023).
Durable Medical Equipment
Face-to-Face Encounter is a mandatory encounter (including encounters through a telehealth system, (as described in Chapter I, §1.06 of this manual) and other than encounters incidental to services involved) between the member and his or her physician, physician assistant, nurse practitioner or clinical nurse specialist that takes place within the six (6) months prior to a written order for Durable Medical Equipment being given. The written order may be prescribed by the physician, physician assistant, nurse practitioner, or clinical nurse specialist who performed the face-to-face encounter.
SOURCE: MaineCare Benefits Manual, Durable Medical Equipment, 60.05, Ch. 101, Ch. II, Sec. 60, p. 4, (6/13/18), (Accessed Nov. 2023).
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 Nov. 2023).
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 Nov. 2023).
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 Nov. 2023).
Home Health Services – Community Care Teams
A comprehensive biopsychosocial assessment, conducted face-to-face or via telehealth.
SOURCE: Maine Care Benefits Manual Home Health Services – Community Care Teams, 10-144, Chapter II, Section 91 (June 21, 2022), p. 15, (Accessed Nov. 2023).
Ongoing Telehealth Medicaid Flexibilities [End Date Not Specified]
The Department, under Bright Futures Health Assessment Visits under Ch. II, Section 94.06-1, will allow for one additional health assessment visit per member within a year following an initial assessment via Telehealth for each age shown on the MaineCare Bright Futures periodic health assessment schedule (MBM, Ch. II, Section 96, Appendix 1).
SOURCE: Maine Department of Health and Human Services Office of MaineCare Services, Flexibilities Continuing: End of the Public Health Emergency (PHE), May 16, 2023, (Accessed Nov. 2023).
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;
- B. 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 Nov. 2023).
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 Nov. 2023).
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 Nov. 2023).
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). (Accessed Nov. 2023).
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 Nov. 2023).
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). (Accessed Nov. 2023).
Last updated 11/02/2023
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. 4.01. p. 9-12. (Nov. 6, 2023). (Accessed Nov. 2023).
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 Nov. 2023).
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 Nov. 2023).
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 Nov. 2023).
Office of MaineCare Services
ME Medicaid has a telehealth resource page to assist providers and consumers.
SOURCE: ME Dept. of Health and Human Services, Office of MaineCare Services, Telehealth, (Accessed Nov. 2023).
The department shall, to the extent funding allows, establish a statewide child psychiatry telehealth consultation service known as the Maine Pediatric and Behavioral Health Partnership Program, referred to in this subsection as “the program,” to support primary care physicians who are treating children and adolescent patients and need assistance with diagnosis, care coordination, medication management and any other necessary behavioral health questions to serve their patients. See statute for program details.
SOURCE: LD 231 (2023 Session) & 34-B MRSA Sec. 15003, Sub. 11, (Accessed Nov. 2023).
Last updated 11/02/2023
Out of State Providers
Healthcare Providers must be licensed or certified to provide medical, behavioral health, and related services to MaineCare Members.
SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4.01. p. 1, (Nov. 6, 2023). (Accessed Nov. 2023).
Last updated 11/02/2023
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.
Last updated 11/02/2023
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). (Accessed Nov. 2023).
“Telemonitoring,” as it pertains to the delivery of MaineCare services, means the use of information technology to remotely monitor a patient’s 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 Nov. 2023).
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. 4.04. p. 6. (Nov. 6, 2023). (Accessed Nov. 2023).
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. 13 (May 2, 2021). (Accessed Nov. 2023).
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.
SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4.02. p.3 (Nov. 6, 2023). & MaineCare Benefits Manual. Ch. II. Home Health Services. Sec. 40.05. p. 10-11. (Aug. 11, 2019). (Accessed Nov. 2023).
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 Nov. 2023).
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 Nov. 2023).
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. 4.01, 4.02 & 4.03. p. 4 (Nov. 6, 2023). (Accessed Nov. 2023).
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 Nov. 2023).
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 Nov. 2023).
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 Nov. 2023).
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 Nov. 2023).
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 Nov. 2023).
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. 4.01. p.12-13, (Nov. 6, 2023). (Accessed Nov. 2023).
Last updated 11/02/2023
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 an enrollee and the enrollee’s provider or between providers regarding the enrollee 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 Nov. 2023).
“Asynchronous encounters” means 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. Pg. 5, (Nov. 6, 2023) (Accessed Nov. 2023).
ELIGIBLE SERVICES/SPECIALTIES
MaineCare will provide reimbursement for two types of store-and-forward:
- 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.
- 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). (Accessed Nov. 2023).
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 Nov. 2023).
GEOGRAPHIC LIMITS
No Reference Found
TRANSMISSION FEE
No Reference Found