Reference Guide for Allowed Services by Provider Types

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Maine Integrated Health Management Solution

Reference Guide for

Allowed Services by Provider Types

Version 6.0

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MIHMS_RG_0004_v6.0_20150312.doc Last updated: 03/12/2015

Version History

Version Date

Author

Action/Summary of Changes Status

3.0 02/09/2010 R.J. Roy

C. Eisenhart

Summary: 8/2010 to present.

Updated for remainder of

changes made during

completion of DDI, changes

from State meetings and State

reviews. Review included a

comprehensive 3-way

comparison and validation of

the policy matrices, the actual

system configuration, and this

document.

Note: Various portions of this

document have been previously

published as appendices to the

different Enrollment Guides.

This version 3.0 is the first

external publication of this

document as a standalone

reference.

State approved 2/7/2011.

Final

3.1 04/27/2011 R.J. Roy

Included PT 89 and associated

specialties under

FAO-Rendering, correcting an

omission.

Draft

4.0 04/28/2011 R.J. Roy

Finalized upon State

acceptance.

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4.1 03/04/2014 K. Goldhammer CR26529: Added Provider

Type: ‘40-Nurse’ Specialty:

‘130-Registered Nurse First

Assistant’ under FAO with

Rendering for Pay-To of

35-Hospital.

Draft

4.1 03/07/2014 R.J. Roy

QA and submission prep.

Draft

5.0 04/09/2014 Darcy Casey

Finalization per State

acceptance email dated

04/09/2014

Final

5.1 02/04/2015 K. Goldhammer CR42034 Add ST

130-Registered Nurse First Assist to

PT 02-APRN

Draft

5.1 03/03/2015 Crystal Hinton

QA’d for State submission

Draft

6.0 03/12/2015 Crystal Hinton

Finalization per State

acceptance email dated

03/12/2015

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MIHMS_RG_0004_v6.0_20150312.doc Last updated: 03/12/2015

Usage Information

Documents published herein are furnished “As Is.” There are no expressed or implied warranties. The content of this document herein is subject

to change without notice.

HIPAA Notice

The Maine Health PAS Online Portal is for the use of authorized users only. Users of the Maine Health PAS Online Portal may have access to

protected and personally identifiable health data. As such, the Maine Health PAS Online Portal and its data are subject to the Privacy and security

Regulations within the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 (HIPAA).

By accessing the Maine Health PAS Online Portal, all users agree to protect the privacy and security of the data constrained within as required by

law. Access to information on this site is only allowed for necessary business reasons, and is restricted to those persons with a valid user name

and password.

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Maine Integrated Health Management Solution Reference Guide for Allowed Services by Provider Type

1. Introduction ... 1

2. Mapping Tables ... 2

Table of Figures

Figure 2-1: Provider Groups ... 3

Figure 2-2: FAO with Required Rendering Providers ... 6

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Maine Integrated Health Management Solution Reference Guide for Allowed Services by Provider Types

MIHMS_RG_0004_v6.0_20150312.doc Page 1

Last updated: 03/12/2015

1. Introduction

There are three Reference Guides for Providers to use during Enrollment or Re-Enrollment:

Standard Abbreviations and Postal Information

Valid Provider Type-Specialty Pairs

Allowed Services by Provider Types

In this Reference Guide for Allowed Services by Provider Types you will find:



Figure 2-1 for allowed rendering providers for provider groups, and



Figure 2-2 for Facility, Agency, and Organization (“FAO”) providers that require rendering providers.

You will need to refer to this information during enrollment and/or re-enrollment.

Use this chart below to determine which table to use. Individual Providers and Facility, Agency, and Organization providers without renderings

do not need this Reference Guide.

Enrollment Type

Reference Guide

Table(s) to Use

In this Guide …

Type 1 – Individual

Individual Providers This Guide does not

apply

Type 1 – Individual

as Group or FAO

Provider Groups

See Fig 2-1

FAO with

Rendering

See Fig 2-2

FAO Non-Rendering This Guide does not

apply

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Enrollment Type

Reference Guide

Table(s) to Use

In this Guide …

Type 2 –

Incorporated

Individual

Provider Groups

See Fig 2-1

Type 2 –

Organization as

Group or FAO

Provider Groups

See Fig 2-1

FAO with

Rendering

See Fig 2-2

FAO Non-Rendering This Guide does not

apply

No NPI Type –

Atypical Provider

FAO Non-Rendering This Guide does not

apply

2. Mapping Tables

The mapping tables begin on page 3. It is imperative that providers indicate the correct provider type and specialty (or specialties) on their

applications. Failure to do so could result in incorrect claim reimbursement.

To use this table, do the following:

1. Choose the correct table for the enrollment type for which you need more information.

2. In the Pay-To Providers column, find the provider type-specialty pair for which you need information about Allowed Rendering Providers.

3. In the corresponding Allowed Rendering Providers, locate the appropriate provider type-specialty pair for the provider you are enrolling.

Note the following:



When you go online, if only one specialty is shown in the Allowed Rendering Providers Specialty cell, the provider must designate

this specialty on their enrollment application assuming they are credentialed for this specialty.

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

If more than one specialty is shown in the Allowed Rendering Providers Specialty cell, the provider must choose the specialty that is

correct based on their credentials and enroll that specialty online.



If the text No specialty required appears in the MIHMS Specialty cell, the provider should not designate a specialty on the enrollment

application.

4. New provider types and specialties are added from time to time and occasionally provider types and/or specialties are also sometimes

removed. If you don’t see your provider type here and believe it should be here according to a ListServ message or reasonable

expectation, you may go on the MIHMS Health PAS Online Portal to see if your provider type is displayed as available (and therefore,

valid) in the system or you may call Provider Enrollment for more information.

Figure 2-1: Provider Groups

Pay-To Providers for Provider Groups Allowed Rendering Providers

Provider Type Specialty Provider Type Specialty

03-Advanced Practice Registered Nursing Group

038-Derived from Rendering Specialties

02-Advanced Practice Registered Nurse

014-Certified Clinical Nurse Specialist 015-Certified Nurse Midwife

016-Certified Nurse Practitioner

017-Certified Registered Nurse Anesthetist 130-Registered Nurse First Assistant 42-Occupational Therapist 088-Occupational Therapy

49-Physical Therapist 114-Physical Therapy

63-Speech Language Pathologist 134-Speech Therapy

10-Audiology Group 038-Derived from Rendering

Specialties

09-Audiologist 007-Audiology

12-Behavioral Health Clinician Group 038-Derived from Rendering Specialties

11-Behavioral Health Clinician 070-Licensed Clinical Professional Counselor 071-Licensed Clinical Social Worker

072-Licensed Marriage and Family Therapist 123-Psychology

15-Chiropractic Group 038-Derived from Rendering

Specialties

16-Chiropractor 018-Chiropractor

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50-Physical Therapy Assistant 114-Physical Therapy

19-Dental Group 038-Derived from Rendering

Specialties 22-Dentist 028-Dentist-Endodontist 029-Dentist-General 030-Dentist-Oral Pathologist 031-Dentist-Orthodonture 032-Dentist-Pedodontist 034-Dentist-Prosthodontist 093-Oral/Maxillofacial Surgery 23-Denturist 037-Denturist

21-Dental Hygienist Group 038-Derived from Rendering Specialties

20-Dental Hygienist 036-Dentistry

24-Denturist Group 038-Derived from Rendering

Specialties

23-Denturist 037-Denturist

44-Occupational/Physical Therapy Group

42-Occupational Therapist 088-Occupational Therapy 43-Occupational Therapy Assistant 088-Occupational Therapy

54-Physicians Group 038-Derived from Rendering

Specialties

02-Advanced Practice Registered Nurse

017-Certified Registered Nurse Anesthetist 130-Registered Nurse First Assistant

073-Licensed Master Social Worker

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40-Nurse 129-Registered Nurse

130-Registered Nurse First Assistant 54-Physicians Group

(continued)

42-Occupational Therapist 088-Occupational Therapy

51-Physician Any Allowed Specialty

52-Physician Assistant 116-Physician Assistant

56-Podiatrist 118-Podiatry

63-Speech Language Pathologist 134-Speech Therapy

57-Podiatry Group 038-Derived from Rendering

Specialties

64-Speech Language Pathology Group

63-Speech Language Pathologist 134-Speech Therapy 65-Speech Therapy Assistant 134-Speech Therapy 67-Speech/Hearing Therapist Group 038-Derived from Rendering

Specialties

63-Speech Language Pathologist 134-Speech Therapy 65-Speech Therapy Assistant 134-Speech Therapy 72-Vision Services Provider Group 038-Derived from Rendering

Specialties

45-Optician 091-Optician

46-Optometrist 092-Optometry

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Figure 2-2: FAO with Required Rendering Providers

Pay-To Providers for FAOs with Required Rendering Providers Allowed Servicing Providers

30-Family Planning Agency 086-Obstetrician and Gynecologist 02-Advanced Practice Registered Nurse

015-Certified Nurse Midwife 016-Certified Nurse Practitioner

26-Dietician 000-No Specialty Required

51-Physician 046-Family Practice

053-General Practice 057-Gynecology 067-Internal Medicine

086-Obstetrician and Gynecologist 087-Obstetrics

35-Hospital 062-Hospital Based Professionals 02-Advanced Practice Registered

Nurse

11-Behavioral Health Clinician 013-Certified Alcohol and Drug Counselor 069-Licensed Alcohol and Drug Counselor 070-Licensed Clinical Professional Counselor 071-Licensed Clinical Social Worker

072-Licensed Marriage and Family Therapist 073-Licensed Master Social Worker

123-Psychology

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35-Hospital (continued)

062-Hospital Based Professionals (continued) 22-Dentist 028-Dentist-Endodontist 029-Dentist-General 030-Dentist-Oral Pathologist 031-Dentist-Orthodonture 032-Dentist-Pedodontist 033-Dentist-Periodontist 034-Dentist-Prosthodontist 093-Oral / Maxillofacial Surgery

40-Nurse 130-Registered Nurse First Assistant

36-Indian Health Services Provider 064-IHS 02-Advanced Practice Registered

Nurse

11-Behavioral Health Clinician 069-Licensed Alcohol and Drug Counselor 070-Licensed Clinical Professional Counselor 071-Licensed Clinical Social Worker

073-Licensed Master Social Worker 123-Psychology

16-Chiropractor 018-Chiropractor

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22-Dentist 029-Dentist-General

36-Indian Health Services Provider (continued)

064-IHS (continued)

130-Registered Nurse First Assistant 42-Occupational Therapist 088-Occupational Therapy

43-Occupational Therapy Assistant 088-Occupational Therapy

45-Optician 091-Optician

46-Optometrist 092-Optometry

63-Speech Language Pathologist 134-Speech Therapy 65-Speech Therapy Assistant 134-Speech Therapy 38-Mental Health Clinic 008-Behavioral Health Services 02-Advanced Practice Registered

Nurse

014-Certified Clinical Nurse Specialist 016-Certified Nurse Practitioner

122-Psychological Examiner 123-Psychology

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42-Occupational Therapist 088-Occupational Therapy 38-Mental Health Clinic

(continued)

008-Behavioral Health Services (continued)

020-Community Support Services 02-Advanced Practice Registered Nurse

39-Non-Hospital Affiliated Clinic 065-Infectious Diseases 02-Advanced Practice Registered Nurse

53-School Health Center 000-No Specialty Required 02-Advanced Practice Registered

Nurse

015-Certified Nurse Midwife 016-Certified Nurse Practitioner

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123-Psychology

53-School Health Center (continued)

000-No Specialty Required (continued)

61-Psychiatric Hospital 062-Hospital Based Professionals 02-Advanced Practice Registered Nurse

017-Certified Registered Nurse Anesthetist

123-Psychology

20-Dental Hygienist 036-Dentistry

22-Dentist 028-Dentist-Endodontist 029-Dentist-General 030-Dentist-Oral Pathologist 031-Dentist-Orthodonture 032-Dentist-Pedodontist 033-Dentist-Periodontist 034-Dentist-Prosthodontist 093-Oral / Maxillofacial Surgery

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61-Psychiatric Hospital (continued)

062-Hospital Based Professionals (continued)

68-State Agency 035-Public Health 20-Dental Hygienist 036-Dentistry

69-Substance Abuse Provider 001-Addiction Services 02-Advanced Practice Registered

Nurse

11-Behavioral Health Clinician 013-Certified Alcohol and Drug Counselor 069-Licensed Alcohol and Drug Counselor 070-Licensed Clinical Professional Counselor 071-Licensed Clinical Social Worker

51-Physician 001-Addiction Services

87-Public School 164-Therapy Services 09-Audiologist 007-Audiology

072-Licensed Marriage and Family Therapist 122-Psychological Examiner

123-Psychology

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50-Physical Therapy Assistant 114-Physical Therapy 63-Speech Language Pathologist 134-Speech Therapy 65-Speech Therapy Assistant 134-Speech Therapy

88-Special Purpose Private School 164-Therapy Services 09-Audiologist 007-Audiology

123-Psychology

50-Physical Therapy Assistant 114-Physical Therapy 63-Speech Language Pathologist 134-Speech Therapy 65-Speech Therapy Assistant 134-Speech Therapy

89-Intermediate Education Unit 164-Therapy Services 09-Audiologist 007-Audiology

123-Psychology

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63-Speech Language Pathologist 134-Speech Therapy 65-Speech Therapy Assistant 134-Speech Therapy