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Questions and Answers Regarding the Medical Fee Schedule Effective 10/1/15

SECTION 1. GENERAL PROVISIONS

Q: Does this fee schedule update cover all sections of the fee schedule, or only inpatient?

A: It covers all sections. The entire medical fee schedule effective 10/1/15 is brand new. The

Board combined the periodic and annual inpatient facility updates.

Q: Was this a complete fee schedule update with rules and value changes effective 10/1/2015?

Does this mean that the state will not be having an update effective in January 2016 or was the

10/1/2015 change just to update specific rules to be consistent with the adoption of the ICD-10

changes?

A: It was a complete fee schedule update. There will be an update to the fee schedule effective

1/1/16 to update the professional and outpatient facility fees.

Q: I noticed you have a new fee schedule effective October 1, 2015. I have done some

comparisons and it appears the only change is the addition of the DME codes with fees. Is this

correct?

A: That is not correct. The entire medical fee schedule effective 10/1/15 is brand new. In

addition to the new max fees for DME, the language and appendices were updated.

Q: The definition of “usual and customary charge” was included in the recent amendments to

Chapter 5. Can you please clarify this definition and whether or not the “price list maintained by

the health care provider” may be different from the provider’s billed charges?

A: They should be the same. See law court decision —Leanne Fernald v. Shaw’s Supermarkets,

Inc. and William J. Babine v. Bath Iron Works (2008 ME 81) for more information.

Q: The former medical fee schedule had a rule on charges for examinations for purposes other

than medical treatment (Chapter 5, Section 1.05). Did the Board do away with that language?

A: Yes. The language was removed because it was redundant. Section 1.01 makes it clear that

the fee schedule applies to all medical, surgical and hospital services, nursing, medicines, and

mechanical, surgical aids provided for treatment of a claimed work-related injury or disease on

or after the effective date. It further states that treatment does not include expenses related to

nurse case management services or to examinations performed pursuant to 39A M.R.S.A. §§ 207

and 312.

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Q: I want to make sure that I am clear on the new FS updates, will you please verify the

following:

Effective 10/1/2015- DMEPOS update

Effective 1/1/2016- Physician, inpatient & outpatient hospital FS update

A: The medical fee schedule effective 10/1/15 is brand new. It includes a new DMEPOS

schedule and incorporated the inpatient annual update. The fee schedule will be updated in

December for physician and outpatient facility rates.

Q: We currently have a physician that does some medical file reviews for our office and are

wondering what to use as a CPT code? He is not seeing the claimant, just producing a medical

file review report for us.

A: The medical fee schedule applies to treatment for the work-related injury or illness. Make

sure not to code amounts paid to the physician under medical treatment on Form WCB-11.

Q: What changed in the annual update effective 1/1/16?

A: This update incorporates the new relative weights for professional and outpatient facility fees

as well as the facility base rates effective April 1, 2016.

Q: I have a question on the new fee Schedule effective 1/1/16. It is my understanding that there

are no changes to the inpatient until 4/1/16. So my understanding is that we continue to use the

same version for the DRG – version 33.Does the version that we will use change at that point, on

4/1/16?

A: The only change to IP effective 4-1-16 is a change in the base rate. You change the DRG

grouper at the start of each CMS fiscal year when we adopt the new relative weights, i.e.October.

Q: Is there a summary available of the changes made to the fee schedule for the 2017 annual

update?

A: The annual update revised the fees for professional, inpatient facility and outpatient facility

services to incorporate the relative weights for these services from the CMS final rule. NCCI is

working on a cost analysis.

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Q: Were there any adjustments made to the medical fee schedules effective 10-1-16 and 1-1-17

that were not just the usual rate recalculations?

A: All changes to the MFS other than just updating the relative weights for professional,

inpatient facility and outpatient facility services require rulemaking. The MFS is due for a

periodic update in 2018. Watch for the proposed rules and rulemaking schedule to be posted on

the Board’s website.

Updated 12/19/17


1.06 BILLING PROCEDURES

Q: What are the timely filing requirements for workers’ compensation?

A: An employer/insurer cannot put a time limit on the submission of workers’ compensation

bills. The time for filing petitions is governed by 39A M.R.S.A. § 306. A petition is barred

unless filed within 2 years after the date of injury or the date the employee's employer files a

required first report of injury, whichever is later. If an employer or insurer pays benefits under

the Act, with or without prejudice, within the 2 year period, the period during which an

employee or other interested party must file a petition is 6 years from the date of the most

recent payment.

Q: Certain non-facility providers do not submit HCFA forms. Is there a penalty for requesting

the provider to submit charges on a HCFA?

A: HCFA forms are not required for professional services. If you receive a properly coded bill

from any professional provider, there is no basis to request a HCFA. Properly coded bills must

be paid or denied within 30 days of receipt.

Q: Has the comp board decided to continue use of ICD-9 codes for all payer situations in Maine?

A: The expectation is that all providers (professional and facility) will bill with the ICD-10 code

set for dates of service on or after 10/1/15. There is an exception for those providers that bill

ONLY workers' compensation; these providers may continue to bill with the ICD-9 code set.

Q: With respect to providers that only bill workers’ compensation, even though we may still use

ICD-9 codes, is it ok to submit with ICD-10 as well?

A: Yes. The preference is for all providers to utilize the ICD-10 code set. While the diagnosis

codes do not affect reimbursement, there are many benefits to converting to the updated code set.

Q: Two large carriers said the conversion to ICD-10 is mandatory. Is that true?




Q: Several third party administrators are not prepared to accept ICD-10. Do we have recourse,

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or are they technically not required to accept ICD-10s?

A: Payors must be able to process bills for health care services with either ICD-9 or ICD-10 code

sets. Please inform the Office of Medical/Rehabilitation Services of any reimbursement issues.

Q: We are a Method II Critical Access Hospital that owns our physician practices. Can

physician services now be billed on the UB along with the facility charges?

A: Yes. There is no longer a requirement that facilities bill professional services separately.

Q: Are all workers compensation payors accepting ICD-10 codes or is the rumor true that we

must submit ICD-9 codes?




Payors MUST be able to process bills for health care services with either ICD-9 or ICD-10 code

sets.

Q: The new fee schedule states the provider must include the employer name on the bill. Can

bills without the employer’s name simply be returned to the provider? Is a NOC required?

A: Bills must specify the billing entity’s tax identification number, the license number,

registration number, certificate number, or National Provider Identifier of the health care

provider, the employer, the date of injury/occurrence, the date of service, the work-related injury

or disease treated, the appropriate procedure code(s) for the work-related injury or disease

treated, and the charges for each procedure code. Bills that lack one or more of these data

elements may be returned to the provider for coding. No NOC is necessary.

Q: Do employers have the choice to pay medical bills themselves and not go through their

carrier?

A: Assuming the employer is not self-insured, the answer is no. Even if an employer has a

policy with a deductible, the insurer is still responsible for payment from the first dollar.

Q: How can find out who the correct carrier is for a claim?

A: An employer may be insured or self-insured. Carriers and self-insured employers may process

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their own claims, use one or more third-party administrators to process claims or use a

combination of both. In turn, third party administrators may use one or more other third parties

to conduct managed care services such as case management and bill review.

For every workers’ compensation bill that you send, it is your responsibility to confirm where the

bill should be sent. This ensures that personal information is not sent to the wrong party and

should improve your accounts receivable.

The employer (and not the employee) is the best source of information regarding where workers’

compensation bills should be sent. Many medium to large employers have a human resource

department or safety department responsible for handling its workers’ compensation claims and

can provide you with the required billing information.

The Board also provides a list of authorized self-insured employers and an insurance coverage

verification link for insured employers at:

http://www.maine.gov/wcb/Departments/coverage/verification.html.

Unfortunately, these tools have several limitations. For instance, the list of self-insured

employers provided by the Bureau of Insurance does not include the names of the individual

employers in the various self-insured trusts. On the insured side, the insured name is often not

the same as the employer’s DBA (“doing business as”) name. In addition, the insurance coverage

verification database will only supply the name of the insured employer’s workers’

compensation carrier and not the names of the perhaps one or more third parties actually

handling the workers’ compensation claims and/or medical bills.

The carrier however is ultimately responsible for any claims under an insured policy it

underwrites, therefore medical bills can simply be sent to the carrier using the address on file

with the Bureau of Insurance at:

https://www.pfr.maine.gov/almsonline/almsquery/SearchCompany.aspx.

As always, providers needing assistance may contact the Office of Medical/Rehabilitation

Services with any questions or concerns.

Q: Where can we obtain the list of workers compensation carriers that are linked to self-insured

employer groups. Is there a link on the website or would we need to contact the employer in

these cases to obtain workers comp carrier associated with the self-insured employers. How

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often so self-insured change their associated workers compensation payer if we are dependent on

a list and how often it is updated.

A: There is a list of self-insured employers on the web and that does not change very often as the

requirements to self-insure are quite strict. However, like insured employers, self-insured

employers can and do very often change claim administrators. While you can find out the name

of the insured employer's carrier online, there is no way to verify the claim administrator online.

A phone call to the employer should be made to confirm where the bill, etc. should be sent.

Q: Can you clarify if we need to change our claim forms to bill professional charges on the UB

form now? Is it just an option or will we receive denials if we continue to bill them on the

1500? Are they paid differently if they’re submitted on the UB ?

A: The idea behind eliminating the requirement to bill professional services separately was to

lower the cost of processing WC claims by eliminating the extra paper. Still, it is your

preference how you bill, and if you are sending the 1500 the same time as the UB and the

accompanying medical records, I see no problem. Professional fees are paid pursuant to

Appendix II regardless of the billing form.

Q: How should we handle WC claims that include diagnoses unrelated to the WC case? Do we

suppress the unrelated diagnoses or create different encounters to bill the WC insurer and the

health insurer separately?

A: Both approaches are used by health care providers; however, best practice is to create separate

encounters.

Q: When a patient presents for services claiming it is work-related and we have to call the

employer to request WC insurance information, can we answer any questions the employer asks

(patient name, injury, etc.)? We thought all information regarding the injury would be shared

from the WC insurer to the employer and that we had to protect the patient’s privacy.

A: Worker's Compensation is not subject to the HIPAA privacy laws. Per 39-A M.R.S.A.

Section 208 and Board Rule Chapter 5, Section 1.11, “Authorization from the employee for

release of medical information by health care providers to the employer is not required if the

information pertains to treatment of an injury or disease that is claimed to be compensable under

this Act.

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Q: After we receive a NOC from a WC insurer and if the patient does not have health insurance,

do we transfer the balance to the patient or do we check with the Board first to see if the denial is

being disputed?

A: You can transfer the balance to the patient. The patient may let you know that he/she is

pursuing their case but my understanding is that you would proceed as normal; the patient may

qualify for free care, etc. Attorneys will often ask you to hold off on billing their clients while

the comp case is being pursued but according to our Executive Director, you are not obligated to

do so.

Q: A few providers are not billing with valid ICD-9 or ICD-10 codes. Should their bills be

allowed without this information?

A: The rule does not require diagnosis codes at all. The rule requires that the provider specify

the work-related injury or disease.

Q: If a patient is injured at work but refuses to make a workers’ comp claim, do we have to

report it? And if yes, to whom?

A: A patient injured at work always retains the right not to file a claim with his/her employer. In

such cases, the M-1 form is not required and the patient is 100% responsible for the payment.

The bill may not be submitted to the patient’s health insurer (if any).

Q: Where should the employee SSN, policy number, and claim number be reflected on the

HCFA?

A: Employee SSN, Policy Number and Claim Number are not required billing elements for

Maine WC bills; see the attached newsletter that outlines the billing requirements. With that

said, SSN, Policy Number and Claim Number (if available) definitely can help with bill

processing.

Per the form instructions, these data elements belong in boxes 1a, 11, and 11b respectively.

ITEM NUMBER 1a

TITLE: Insured’s ID Number

INSTRUCTIONS: Enter the insured’s ID number as shown on insured’s ID card for the payer to

which the claim is being submitted. If the patient has a unique Member Identification Number

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assigned by the payer, then enter that number in this field.

FOR TRICARE: Enter the DoD Benefits Number (DBN 11-digit number) from the back of the

ID card.

FOR WORKERS COMPENSATION CLAIMS: Enter the appropriate identifier of the

employee. This would be the SSN for WC.

FOR OTHER PROPERTY AND CASUALTY CLAIMS: Enter the appropriate identifier of the

insured person or entity.

DESCRIPTION: The “Insured’s ID Number” is the identification number of the insured. This

information identifies the insured to the payer.

FIELD SPECIFICATION: This field allows for entry of 29 characters.

ITEM NUMBER 11

TITLE: Insured’s Policy, Group, or FECA Number

INSTRUCTIONS: Enter the insured’s policy or group number as it appears on the insured’s

health care identification card. If Item Number 4 is completed, then this field should be

completed.

Do not use a hyphen or space as a separator within the policy or group number.

DESCRIPTION: The “Insured’s Policy, Group, or FECA Number” is the alphanumeric identifier

for the health, auto, or other insurance plan coverage. The FECA number is the 9-character

alphanumeric identifier assigned to a patient claiming work-related condition(s) under the

Federal Employees Compensation Act 5 USC 8101.

FIELD SPECIFICATION: This field allows for the entry of 29 characters.

ITEM NUMBER 11b

TITLE: Other Claim ID (Designated by NUCC)

INSTRUCTIONS: Enter the “Other Claim ID.” Applicable claim identifiers are designated by

the NUCC.

When submitting to Property and Casualty payers, e.g. Automobile, Homeowner’s, or Workers’

Compensation insurers and related entities, the following qualifier and accompanying identifier

has been designated for use:

Y4 Agency Claim Number (Property Casualty Claim Number)

Enter the qualifier to the left of the vertical, dotted line. Enter the identifier number to the right of

the vertical, dotted line.

FOR WORKERS’ COMPENSATION OR PROPERTY & CASUALTY: Required if known.

Enter the claim number assigned by the payer.

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DESCRIPTION: The “Other Claim ID” is another identifier applicable to the claim.

FIELD SPECIFICATION: This field allows for the entry of the following: 2 characters to the

left of the vertical, dotted line and 28 characters to the right of the dotted line.

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1.07 REIMBURSEMENT

Q: What information is required to be on the explanation of benefits/explanation of review

form?

A: EOBs/EORs are not required. Assuming there is not a valid payment agreement to pay

something other than the amount due per the Maine Workers’ Compensation Medical Fee

Schedule (MWCMFS), the employer/insurer must pay the bill in accordance with the

MWCMFS. If anything less than the amount due under the MWCMFS is paid, a partial denial

must be filed electronically with the Board contemporaneous with the payment. A copy of the

denia/notice of controversy form must be sent to the health care provider from whom the bill

originated.

Q: If a code that is not listed in the fee schedule is billed, must it be paid as usual and customary,

as billed, or is it not covered at all?

A: Workers' Compensation is not like health insurance; there are no “non-covered codes”.

Health care providers may bill for any goods or services with a valid procedure code. Valid

codes for professional services that are not in the professional fee schedule are paid at the

provider’s usual and customary charge pursuant to Section 1.07, Subsection 3.

Q: Network contracts that allow for payment above/below the maximum of the schedule can

only be with a provider for a given employer or insurer business and cannot be under a general

network agreement. Can you confirm this is a correct interpretation?

A: For dates of service on or after 10/1/15, a written payment agreement between a health care

provider and an entity other than the employer/insurer seeking to invoke its terms supersedes the

maximum allowable payment otherwise available only if the employer/insurer was a named

beneficiary of the payment agreement at the time the health care provider signed the payment

agreement.

Q: There are situations when a contracted rate is greater than the fee schedule. Are agreements

which allow payment greater than the fee schedule permissible under Rule 1.07(7)?Updated 12/19/17


A: Yes. Agreements which allow payment above the fee schedule are permissible, however, it

should be a rare occasion when the contracted rate is greater than the fee schedule (the idea of

the fee schedule is to control costs). The provision was meant to address "silent" PPO discounts.

Q: What is the recourse when carriers take an additional PPO discount on the medical fee

schedule without a valid contract?

A: Without a valid payment agreement, payors must pay the maximum amount payable per for

the fee schedule. Providers may file Form 190A – Provider’s Petition for Payment of Medical

and Related Services. Providers may also wish to contact the Board’s Office of

Medical/Rehabilitation Services and/or Office of Monitoring, Audit and Enforcement.

Q: I currently have insurance companies denying the CPT level of service billed on a large

percentage of our invoices. What is our recourse?

A: The employer/insurer must file a notice of controversy to dispute a level of service. A copy

of the notice of controversy must be sent to the health care provider from whom the bill

originated. A health care provider, employee or other interested party is entitled to file a petition

for payment of medical and related services for determination of any dispute regarding the

provision of medical services.

Q: Are there any penalties, interest or other fines if we’re exceeding the date perimeter (i.e. 30

days to pay or deny) but we went ahead and allowed the FS, applied PPO and let the carrier pay

per our standard reduction?

A: If the bill is received via certified mail, the carrier could be subject to a 205.4 penalty up to a

maximum of $1,500 if the bill is not paid or denied within 30 days. In addition, the carrier could

be subject to a $25,000 penalty and a referral to the Bureau of Insurance if there is a pattern of

exceeding the date perimeter.

Q: When an insurance carrier does not pay a bill fully do they need to file a NOC?

A: Yes. When there is a dispute whether the provision of medical, surgical and hospital services,

nursing, medicines, and mechanical, surgical aids is reasonable and proper under §206 of the

Act, the employer/insurer must pay the undisputed amounts, if any, and file a notice of

controversy. A copy of the notice of controversy must be sent to the health care provider from

whom the bill originated. A health care provider, employee or other interested party is entitled to

Updated 12/19/17


file a petition for payment of medical and related services for determination of any dispute

regarding the provision of medical services.

Q: Is there a list of codes that are exempt from the multiple procedure discount?

A: Add-on codes are listed in Appendix D of the CPT codebook available for purchase through

the American Medical Association. All add-on codes found in the CPT codebook are exempt

from the multiple procedure discount.

Q: If a provider bills less than the fee schedule; can you please advise regarding the state’s

position on the appropriate reimbursement to the provider? Reimburse at billed charges (less

than fee schedule) OR Reimburse at the fee schedule (even though it is less than the fee

schedule)?

A: For professional services, you compare the maximum allowable payment per the medical fee

schedule to the charge and pay the lower of the two for each line on the bill. For facility fees,

you compare the maximum allowable payment per the medical fee schedule to the total charges

on the bill and pay the lower of the two.

Q: Does the state recognize the use of the Medicare NCCI (National Correct Coding Initiative)

edits and the MUE (Medically Unlikely Edits) edits when repricing medical bills arising out of

workers’ compensation injuries? I did not see anything in the fee schedule or rules.

A: These edits cannot be applied to Maine WC claims. You only have the authority expressly

granted by statute or rule.

Q: In the Spring 2014 newsletter we were told if lab services are billed without other outpatient

services we shall pay 75% of charges. Was it for the whole year of 2014?

A: Yes. It applies to all of 2014 and all of 2015 until the adoption of the new rule effective

10/1/15.

Q: If we see a patient that has out of state worker’s comp insurance and they pay less than the

Maine fee schedule, do we have to accept or should they pay us according to Maine’s schedule

since the service was provided in Maine?

A: In cases where there is concurrent jurisdiction, you may be able to file a claim in Maine. See

law court decision St. Mary’s v. BIW, 977 A.2d 431; (Me. 2009).

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Q: What qualifies as an institutional health care provider under Chapter 5, Section 4.10– are all

providers that are not qualified as ACH, CAH or ASC now considered institutional health care

providers?

A. Institutional providers are those providers that bill on UBs. Outpatient services rendered by

institutional providers that do not meet the definition of an ACH, CAH or ASC should be paid in

accordance with Chapter 5, Section 4.10.

Q: If we send a workers’ compensation bill and it is returned stating there is “no claim on file”,

what steps can we take as a provider? Do we have the right to bill the employer and/or the

patient?

A: In cases like these, providers have lots of options. As a first step, I recommend sending the

bill and the medical records that support a work-related injury or illness to the employer and/or

claim administrator via certified mail. Contemporaneously, you could contact a Board Claims

Resolution Specialist to start a claim with the Board. Once a claim is created, a letter will be

sent to the claim administrator requesting the filing of a First Report of Injury. While you

always retain the right to bill the patient for services rendered, my experience is that bills sent to

the patient often go ignored.

Q: If we are ordered to pay medical bills per a decree, can we simply pay the medical bill

providers directly and they can reimburse any health insurer(s) that made provisional payments?

A: When a health plan is no longer liable for provisional payments, the employer/workers’

compensation insurer is obligated to reimburse the health plan or make payment directly to the

claimant or health care provider as follows:

If a notice of offset/ lien is in effect (Note: MaineCare has an automatic lien in effect by

statute), the employer/workers’ compensation insurer is obligated to reimburse the health

plan in such amounts and at such times as it would otherwise be obligated to pay on

behalf of the claimant until the amount requested, reduced by any amount the health plan

has not yet paid or has already sought to recover directly from the claimant, has been paid

in full. If additional amounts are due (because the maximum allowable fee under the

workers’ compensation medical fee schedule is greater than the health plan

reimbursement), these amounts must be paid directly to the claimant or health care

provider in accordance with Chapter 5 of the Board’s Rules and Regulations.

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If no notice of offset/lien is in effect, the employer/workers’ compensation insurer must

pay the claimant or health care providers directly in accordance with Chapter 5 of the

Board’s Rules and Regulations.

See Bureau of Insurance Rules and Regulations, Chapter 530 and the Board’ Training Bulletin regarding provisional payments.

Q: We have a patient that Medicare paid for the claim. The patient has a $175.00 copay that is at

a collection agency. The patient is now saying we should have billed the WC insurer. When we

billed the WC insurer we were told that they reimbursed Medicare already. So does the patient

still have the liability of the copay?

A: No. The WC insurer is responsible to pay you the difference between what they reimbursed

Medicare and what is due under the WC fee schedule.

Q: If we propose a service to a WC insurer and they come back saying they will only pay a

certain amount and that amount is below the WC fee schedule, do we have the ability to force

them to honor the fee schedule?

A: You can refuse to provide the service for any amount less than the fee schedule amount if it is

a Maine WC claim.

Q: I have one WC insurer that does not pay for an initial office visit if the patient has been seen

in our office in the last 3 years. These visits are for a new injury to the patient. Is the insurer

correct?

A: Technically the insurer is correct since the Board never adopted a different definition of new

v. established patient in its medical fee rule. Per CPT definitions, a new patient is one that hasn't

been seen for 3 years. It doesn't matter if there is a new injury. The next proposed rule will

include a definition of new v. established that will allow providers to receive a new patient visit

fee when there is a new injury.

Q: I am looking for information regarding refunds. A carrier is requesting a refund due to the

provider network discount that they did not take at the time of payment. Can you please provide

the workers’ comp "law" on this?

A: Per Workers’ Compensation Board Decision No. 96-0: Donald C. Pritchard, Jr. V. S.D.

Warren Company And Sedgwick James Of Northern New England, “The present Act provides

Updated 12/19/17


this employer with no mechanism to recover what the employer regards as an overpayment of

compensation.”

Q: I was verifying how a claim was paid for an employee that was injured on the job at a boat

yard. The representative that I spoke to at the carrier indicated that the claim was paid under the

Longshore fee schedule. We had never heard of the Longshore fee schedule. I did google it and

see that it is a valid fee schedule, however, does this override the Maine Workers’ Comp Fee

Schedule?

A: The Longshore and Harbor Workers’ Compensation Act (LHWCA) is a federal workers’

compensation act that primarily governs workers’ compensation for maritime employers and

employees, but also covers civilian employees on military bases worldwide (under a federal law

called the Defense Base Act). The claim jurisdiction is what determines the payment. Since, the

jurisdiction is Longshore, the OWCP fees apply. Federal Longshore and Maine WC have

concurrent jurisdiction so it is feasible that the employee and/or provider could also make a

claim under the Maine WC Act.

Q: We keep getting bills from a NH health care provider for the difference between the

provider’s charges and the amount due under the Maine WC fee schedule. What do you

suggest?

A: Out-of-state health care providers who treat injured employees pursuant to 39A M.R.S.A. §

206 are paid pursuant to the Maine WC fee schedule. An employer/insurer is not liable for

charges in excess of the maximum allowable per the fee schedule. Please notify the Board’s

Office of Medical/Rehabilitation Services of any provider who is balance billing either you (the

carrier) or the injured employee.

Q: What is the difference between the Jones Act and the LHWCA?

A: The Jones Act (46 U.S.C. § 30104) and the LHWCA (33 U.S.C. § 901-950) are mutually

exclusive regimes providing compensation for work-related injuries suffered by different

categories of maritime employees. The LHWCA excludes from its coverage a "master or

member of a crew of any vessel." Instead, crew members are covered by the Jones Act. The term

"master or member of a crew" is refinement of the term "seaman" in the Jones Act. As a result,

the key requirement for Jones Act coverage appears in the LHWCA. The determination turns

Updated 12/19/17


solely on the employee's connection to a vessel in navigation. It is not necessary that an

employee aid in navigation or contribute to the transportation of the vessel in order to be

"seaman" under the Jones Act, but the employee must be doing the ship's work by contributing to

the function of the vessel or the accomplishment of its mission. Unlike Federal Longshore, the

Jones Act is the exclusive remedy under federal law for covered employees; see law court

decision Lyle DORR, Jr. v. MAINE MARITIME ACADEMY and Maine Bonding & Casualty Co.

670 A.2d 930 (Me. 1996).

Updated 12/19/17


1.08 FEES FOR REPORTS/COPIES

Q: The new M-1 form is no longer called a Practitioners Report. It’s called a Diagnostic Medical

Report. Does this form replace the old one? Does the Board supply the form in a 4 page carbon

copy format?

A: The new title tracks the statute (Section 208). The Board provides the form in a form fillable

PDF format on its website. Quantities of the 4 page carbon copy format are available for purchase

through Gossamer Press Tel: (207) 827-9881, Fax: (207) 827-9861.

Q: Is there a grace period for implementing the new M-1 form?

A: Yes. The Board is allowing a three month grace period. The new M-1 form should be fully

implemented by 1/1/16.

Q: Does the definition of health care provider include provider types other than MD, DO, DC,

DPM, etc.?

A: Yes. Per the definition, health care provider is defined as an individual, group of individuals, or

facility licensed, registered, or certified and practicing within the scope of the health care

provider’s license, registration or certification. Therefore the definition of healthcare provider is

not limited to certain provider types and allows for a variety of professional and institutional

providers.

Q: Can a therapist be considered the primary provider if a doctor's only involvement after

evaluation was to refer the patient to a therapist and the therapist then provided all the rest of the

treatment? If yes, does this then obligate the therapist to complete the M-1 form when

appropriate?

A: The M-1 form is not limited to primary health care providers. It must be completed by all health

care providers treating the employee per 39-A M.R.S.A Section 208.

Q: Can a therapist complete and submit the M-1? If yes and a therapist is responsible for

completing the M-1 form when needed, can he/she also be responsible for taking the employee

out of work if the condition warrants it?

A: Yes. The definition of a health care provider is an individual, group of individuals, or facility

licensed, registered, or certified and practicing within the scope of the health care provider’s

license, registration or certification. Health care providers must complete the M-1 form in

Updated 12/19/17


accordance with 39A M.R.S.A. §208. The form must include the employee's work capacity, likely

duration of incapacity, return to work suitability and treatment required.

Q: Can a therapist’s M-1 form differ from the M-1 form completed by the doctor?

A: Yes. The fact that different healthcare providers may render different opinions is recognized in

the rules in Chapter 8, Section 11 which allows an employer to discontinue benefits regardless of

the employee’s actual earnings if the employee returns to work without restrictions or limitations,

due to the injury for which benefits are being paid, according to the employee’s treating health care

providers; and there are no conflicting medical records with respect to the lack of restrictions or

limitations due to the injury for which benefits are being paid.

Q: Is an M-1 required for an inpatient stay? What if a patient is being seen by a doctor but then

has nurse visits for wound care only, would those visits require an M-1?

A: Except for claims for medical benefits only, within 5 business days from the completion of a

medical examination or within 5 business days from the date notice of injury is given to the

employer, whichever is later, an M-1 form is due. Additional M-1s are due every thirty days when

ongoing treatment is being provided. A final M-1 form is due within 5 working days of the

termination of treatment. An M-1 is not completed for each visit.

Q: If a patient is being seen by one of our practices and the doctor does an M-1 that is current,

then the patient does a follow-up with their PCP but it is still within the 30 days is a new M-1

needed?

A: Each health care provider has the same duties under 39-A M.R.S.A. Section 208.

Q: If a person is brought in directly to the ER for a WC injury, is an M-1 done at the hospital or

only once they see a PCP with a plan of care?

A: There is one due within 5 business days of the examination for each health care provider.

Q: If a person is at a practice with a doctor but has PT do you need an M1- from the doctor and

the PT that they referred to?

A: Each health care provider must complete the M-1s in accordance with Section 208. Q: The rules state providers may charge for completing an initial M-1. Can you please clarify if

this is a one-time charge per claim or a one-time charge per provider.

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A: One time charge per provider per claim.

Q: In the lower part of the M-1 form it has Body Parts and Activity/Use fields, should these be

filed in with a check?

A: Yes. Please indicate the affected body parts as well as the restrictions with a check. There is

also space to write in additional body parts/restrictions if needed.

Q: How do you complete the lower part of the M-1 with respect to restrictions?

A: Restrictions must be indicated in this section whenever modified work capacity is indicated

on the form. Check the body parts affected in the left column. In the right column, indicate the

specific restrictions. This section should be blank if the employee is released to regular duty or

has no work capacity.

Q: Can we now charge for the transcription that accompanies our initial bills for services?

A: Correct. Health care providers may charge for copies of the health care records required to

accompany the bill. The charge is to be identified on the bill for service using CPT® Code S9981

(units equal total number of pages). The maximum fee for copies is $5 for the first page and 45¢

for each additional page, up to a maximum of $250.00.

Q: What if a payor requests records after the bill has already been sent with the records attached?

What if the payor requests them several times?

A. Health care providers may charge for copies of the health care records each time they are

requested. The maximum fee for copies is $5 for the first page and 45¢ for each additional page,

up to a maximum of $250.00.

Q: Do the fees for copies of health care records apply to any request after 10/1/15 regardless of

date of service or do the new fees only apply when the request is for records with a dos after

10/1/15?

A: The new fees apply to any request on or after 10/1/15.

Q: An out of state provider charged a $21.00 processing fee plus a $5.00 mailing fee when

providing copies of medical records. Is the insurer obligated to pay those fees?

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A: No. For requests on or after 10/1/15, health care providers are expressly prohibited from

charging a fee for postage/ shipping, sales tax, or a fee for researching a request that results in no

records.

Q: Certain insurers require us to send our records with our 1500/UB claims, but for all other

insurers we have to supply them within 10 days only when requested?

A: That is incorrect. For dates of service on or after 10/1/15, records related to the injury must

be submitted with the bill to all payors and can be charged for on the billing form. Otherwise,

medical records must be furnished within 10 days of the request pursuant to subsections 4 and 5.

Q: Can providers now charge for copies of the employee’s medical bills?

A: Yes when bills are part of a written request for records.

Q: The rule is confusing. When is Form 220 required to obtain medical records?

A: Form 220 is designed to be a HIPAA compliant form submitted to the provider when the

employer/insurer wants heath care records before or after the date of injury. Records must be

furnished within 10 days of a properly completed form.

Q: Form 220 states that it “may NOT be altered”. How do we obtain access to mental health

records? Are we to use a different medical release?

A: Nothing has changed regarding access to mental health records. Per Chapter 12, Section 18,

Subsection 2, this information may be obtained as agreed upon among represented parties or by

authorization from the Hearing Officer. Once you have an agreement or authorization, you will

need to comply with whatever the terms of release are from the provider.

Q: If I submit a UB and a 1500 with accompanying medical records in the same envelope can the

insurance company deny payment for one of the bills for not duplicating the medical records?

A: No. If the one set of medical records substantiates the services rendered on both bills, you

have complied with Chapter 5, Section 1.06, Subsection 3. If a claim administrator insists on

two sets of medical records as support, you have the right to charge them for both sets under

Chapter 5, Section 1.08, Subsection 3.

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Q: We are reviewing the rule changes effective October 1, 2015 and have a question about

billing for records fees and M-1 forms. Can you confirm if the fees for these services need to be

included on the health care claim itself or if they can be billed on a separate claim and sent in the

same envelope?

A: The rule currently allows them to be billed either way but the intent was to have the charges

for the completion of the M-1 form and/or copies of the medical records on the health care claim

form along with the other charges. The idea was to reduce the number of pieces of paper, etc.

and therefore reduce the cost of processing workers’ compensation claims.

Q: We received a subpoena from the employer/insurer’s representative to provide medical

records for a patient. We have never seen one of these before. How do we know if this is a valid

legal document issued by the Board?

A: The Board does not issue blank signed evidence subpoenas to attorneys. The party requesting

the information fills out the subpoena and submits it to the Administrative Law Judge (ALJ).

The ALJ reviews the request and signs the request if approved. Therefore, a valid order of the

Board will contain an ALJ’s original signature. If there is ever a question about the validity of an

order, contact the ALJs legal secretary at the applicable regional office.

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1.10 EXPENSES

Q: Is the WCB-206 a required form? Specifically, can the employee use any form? Can the

employer use alternate forms?

A: The rule does not mandate the use of a particular form for the reimbursement of expenses.

Q: Would you give permission for us to add a few fields to the WCB-206 form?

A: Yes. You may modify this form to address your business needs. This is not a Board

mandated form.

Q: The rule specifically states that expenses “includes travel to the pharmacy”. Is this something

new and can you point me to the authority for the reimbursement?

A: The specific language is new. See Hearing Officer decision Floros v. Healthsouth/New

England Rehabilitation Hospital, WCB # 10-007366A, decided January 28, 2014 and law court

decision Chaples v. Gilco, Inc., 280 A.2d 546 (Me. 1971).

Q: Is the mileage rate changing for 2017?

A: Mileage rates are not part of the MFS. Mileage rates are set by rule in Chapter 17.

Updated 12/19/17


SECTION 2. PROFESSIONAL SERVICES

2.02 ANESTHESIA GUIDELINES

Q: Does our bill need to show only the conversion of time from minutes to units or do we also

need to incorporate the base units with our units billed on the claim. A simple example: our

anesthesia time is 45 minutes and the ASA code has a base unit of 4. Does our 1500 claim need

to show 3 units (45/15) or 7 units (45/15 + 4 base units)?

A: Per the rule, you should bill 3 units.

Q: We used to note the start and stop times on our anesthesia claims, is this necessary moving

forward?

A: Anesthesia time has to be substantiated with the health care record.

Q: Please confirm the following: 1) Anesthesia will stay on a 1500 claim form. 2) All other

charges may be billed on a UB.

A: The expectation is that facilities will include all charges on the UB (both professional and

facility charges). There is no longer a requirement that facilities bill professional services

separately.

Q: Is there is a specific requirement regarding the order of procedures for 1500 billing? A certain

insurer stated workers comp will reimburse based on the order of the procedures so that the first

pro fee billed on line one would be paid at 100% of the fee schedule, the second at 50%, the third

at 25% and then the remaining at 10%.

A: An employer/insurer cannot require you to list procedures in any particular order since neither

the 1500 instructions nor the WC Board rules requires such. The medical fee rule only addresses

the reimbursement of multiple procedures as follows: the total reimbursement for all services is

the maximum allowable payment under this chapter for the primary procedure in addition to 50%

for the secondary procedure, 25% for the tertiary procedure and 10% for each lesser procedure

thereafter. The primary procedure is the one billed without the 51 modifier. The remaining

procedures performed on the same day by the same individual at the same session (that are not

add-on codes or modifier 51 exempt) should each be reported with modifier 51. In its current

form, the medical fee rule does not address how to determine the secondary, tertiary, and other

lesser procedures. This is an area that the Board may wish to address in its next revision of

Chapter 5.

Updated 12/19/17


Q: Could there be multiple primary procedures on the same claim for codes within the same

family when billed on the same claim? For example, if we have codes for the nervous system

and then codes for the skeletal system, etc. Or is there only one primary procedure per claim

based on the RVUs?

A: There should be one primary procedure per claim. Per the AMA guidelines for modifier 51,

“When multiple procedures, other than E/M services, Physical Medicine and Rehabilitation

services or provision of supplies (eg, vaccines), are performed at the same session by the same

individual, the primary procedure or service may be reported as listed. The additional

procedure(s) or service(s) may be identified by appending modifier 51 to the additional

procedure or service code(s).” Modifier 51 should not be appended to codes designated by the

AMA as “add-on” codes or codes exempt from modifier 51.

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2.04 DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND SUPPLIES

Q: Could you please advise if it is allowed to deny DME and/or supply services (e.g. procedure

A9150) for an invoice when the code is not listed in the Maine Fee Schedule or should this be

reimbursed at the medical provider’s usual and customary charge?

A: DME or supply items should never be denied for an invoice. The medical fee schedule hasn’t

had cost-based reimbursement for DME & supplies since October of 2015, so any such denial

would likely be defined as unreasonable pursuant to Board Rules Chapter 15, Section 8.3 as

requesting an invoice would be contrary to law or rule.

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SECTION 3. INPATIENT FACILITY FEES

Q: How should I pay this inpatient bill? It was sent back once to request a DRG and they sent a

letter back stating that they are a critical access hospital and are paid via a per diem rate.

A: Providers are not required to supply the DRG for the very reason that some are not paid by

Medicare under the Inpatient Prospective Payment System. You have to utilize a DRG grouper

to determine the appropriate DRG based on the date of discharge.

Q: Just want to confirm for the New Fee Schedule will we be using ICD-10 Version 33 as of

October 1, 2015?

A: Correct for IP claims with dates of discharge on or after 10/1/15.

Q: Under the old fee 3.08 states between 2 acute hospitals. The new fee 3.09 states between 2

hospitals. So transfers can be from critical to acute does not have to be acute to acute correct?

A: Correct. Section 3.09 applies when a patient is transferred for continuation of medical

treatment between two hospitals.

Q: I need a bit a advice regarding the version to be used with the new ICD-10 for DRG grouping.

For ICD-9 we were using version 25 for the grouping of the DRG. With ICD-10 now in place

that obviously is no longer an option. Would you be able to steer me in the right direction?

A: The appropriate grouper is based on the CMS fiscal year +17. For example, for fiscal year

2015 (dates of discharge 10/1/14 - 9/30/15), you need version 32. For dates of discharge 10/1/15

- 9/30/16, use version 33. Etc.

Q: Question on implantables during an Inpatient stay:.

Example:

Rev Code 278

12 units

Total charges of 33,880.84

The verbage in the fee schedule is that the implantable has to exceed $10,000 in cost for the

additional reimbursement. We interpret that to be of the 12 implantables billed, any additional

reimbursement would be due for only the ones that exceed $10,000 in cost. In this instance –

the provider did submit the cost invoices, and none of the 12 implantables units billed exceed

$10,000. We do not feel additional reimbursement is warranted – is this accurate? .

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A: The definition of implantable includes any related equipment necessary to operate, program,

and recharge the implantable:

“Implantable: An object or device that is made to replace and act as a missing biological

structure that is surgically implanted, embedded, inserted, or otherwise applied. The term

also includes any related equipment necessary to operate, program, and recharge the

implantable.”

So, you look at the total cost of the implantables, not the individual costs. If the total cost

exceeds $10,000, the provider is entitled to cost plus $500.

Updated 12/19/17


SECTION 4. OUTPATIENT FACILITY FEES

Q: I have a question regarding out-patient hospital, ASC bills. If multiple surgeries are billed

how does the outlier apply to the second procedure code paid at 50%? Say billed second

procedure 10,000.00, appendix is 6000.00 and this is the second surgical procedure.

A: The 50% doesn't come into play for outlier calculations after 10/1/15. As of 10/1/15, the

outlier threshold is $2,500.00 plus the amount in the appendix. Any charge that exceeds the

threshold is eligible for an outlier payment. In your example the outlier threshold is $8,500

therefore the amount above the threshold ($10,000-$8,500 = $1,500) should be paid at 75% of

charges for an outlier payment of $1,125.

If this example was for a date of service before 10/1/15, the threshold is $5,500 (($6,000/2)+

$2,500), resulting in an outlier payment of $3,375 (.75($10,000-$5,500)).

Q: How should home health and skilled nursing facility services be reimbursed?

A: As of October 1, 2015, outpatient services provided by institutional health care providers

other than hospitals and ambulatory surgical centers must be paid at 75% of the provider’s usual

and customary charge (See Board Rules Chapter 5, Section 4.10). Other institutional providers

include: Community Mental Health Centers; Comprehensive Outpatient Rehabilitation Facilities;

End-Stage Renal Disease Facilities; Federally Qualified Health Centers; Histocompatibility

Laboratories; Home Health Agencies; Hospice Organizations; Indian Health Service Facilities;

Organ Procurement Organizations; Outpatient Physical/Occupational Therapy/Speech-Language

Pathology Services; Religious Non-Medical Health Care Institutions; Rural Health Clinics; and

Skilled Nursing Facilities.

Q: I have an outpatient facility bill in which they are billing below the fee schedule allowable.

Do we allow this as billed or pay the additional per the fee schedule? They are billing for code

63030 $5738.00 and the allowable is higher than that.

A: Facility line charges are irrelevant. The charge for procedure code 63030 merely represents

the charge for time spent in the OR and is just one of the many charges for the procedure as a

whole. The other charges are spread across the other lines i.e. pharmacy, supplies, recovery

room, etc. Just like with IP facility bills, you compare the max per the MFS to the total charges

and pay the lower of the two.

Q: I believe there is some confusion regarding the outpatient facility reimbursement of x-rays.

Maine’s outpatient fee schedule is based on Medicare and must reflect the Medicare

Updated 12/19/17


methodology in accordance with 39-A M.R.S.A. §209-A and we believe our reviews emulate

Medicare’s methodology. Our methodology does not arbitrarily bundle radiology or any other

service; however, we do follow Medicare’s status indicator reimbursement methodology as

directed in 39-A M.R.S.A. §209-A and the Maine Workers’ Compensation Board Medical Fee

Schedule. On the two bills in question, the billed radiology codes have a Status Indicator of Q1

and Medicare’s methodology considers any codes with a Q1 status bundled when billed on the

same date of service as a S, T, V, J1 or J2. Following Medicare’s methodology, our review

considered the codes with a Q1 Status Indicators bundled into the code with a J2 Status Indicator

since both were billed on the same date of service. Had the codes with a Q1 Status Indicators

had been billed with a code with a Status indicator other than a S, T, V, J1 or J2 or billed

separately, these codes would have been reimbursed separately at the Outpatient Facility fee

schedule reimbursement. After reviewing both the 1/1/2016 and 10/1/16 Maine Fee Schedule, I

am unable to find any rules or laws concerning radiology that indicate a different process. Can

you point me to the radiology or outpatient fee schedule written rule in question?

A: The very short answer to your question is we did adopt Medicare’s methodology, i.e. weight x

base rate = fee. That is as far as the adoption of Medicare goes. Workers' compensation is a

"creature of statute" meaning that the parties only have the authority expressly granted to them

via statute or by rule. The State has its own reimbursement guidelines as outlined in Board Rules

Chapter 5. Additionally, the Board has repeatedly made it clear that Medicare edits, etc. cannot

be applied. See the Spring 2015 MAE Newsletter as an example.

Updated 12/19/17

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