Mailing Your Claim - UB 92
If you are a Nursing Facility or an ICF-MR, mail your completed claim form to this address:
MaineCare Claims Processing
M-400
Augusta, ME 04333
If you are Adult Family Care Home or a Private Non-Medical Institution, mail your completed claim form to this address:
MaineCare Claims Processing
M-700
Augusta, ME 04333
If you are any other provider that bills on the UB-92, mail your completed claim form to this address:
MaineCare Claims Processing
M-100
Augusta, ME 04333
Contact Information: Staff is available from 7:00 am to 6:00 pm, Monday through Friday.
• MIHMS Enrollment/Provider Services:
Phone: 866-690-5585 (TTY: 711)
Fax: 877-314-8776
Email at: MainecareEnroll@molinahealthcare.com
• EDI Helpdesk:
Phone: 866-690-5585 (TTY: 711)
Fax: 877-314-8776
Email: MainecareSupport@molinahealthcare.com.
• Prior Authorizations:
Phone: 1-866-690-5585 (TTY: 711)
Fax: 1-866-598-3963 E-mail: MaineCareProvider@molinahealthcare.com
A. GENERAL REQUIREMENTS
1. Conditions of Participation. As a condition of participation or continued participation as a provider in MaineCare, the Provider agrees to comply with the provisions of the Federal and State laws and regulations related to Medicaid, the provisions of the MaineCare Benefits Manual (“MBM”), 10-144 C.M.R. Ch. 101, the terms and conditions of the Provider Enrollment Packet, including all attachments, completed by the Provider, which is incorporated herein by reference, and the terms and conditions of this Provider Agreement (“Agreement”).
2. Changes in Federal or State Laws or Regulations.
a) Any change in Federal or State law or regulation that conflicts with or modifies any term of this Agreement will automatically become a part of this Agreement on the date such a change in statute or regulation becomes effective.
b) If the Provider objects to the application of the change in Federal or State law or regulation, it must notify the Department within thirty (30) calendar days of the effective date of the change that it will terminate the Agreement as set forth in Chapter I of the MBM. Failure to so notify the Department will be deemed acceptance of the change in law or regulation as part of this Agreement.
3. Independent Capacity. The parties agree that in the performance of this Agreement, the Provider, including any officers, directors, agents and employees of the Provider, shall act in an independent capacity and not as officers, agents or employees of the State. The Provider further understands and agrees that it is an independent contractor for whom no Federal or State Income Tax will be deducted by the Department, and for whom no retirement benefits, survivor benefit insurance, life insurance, vacation and sick leave, and similar benefits available to State employees will accrue. The Provider further understands that annual information returns, as required by the Internal Revenue Code or State of Maine Income Tax Law, will be filed by the State Controller with the Internal Revenue Service and the State of Maine Bureau of Revenue Services, copies of which will be furnished to the Provider for his/her Income Tax records.
4. Subletting, Assignment or Transfer.
a) The Provider shall not subcontract, transfer, assign, or otherwise convey this Agreement or any portion thereof, or any of its rights, title, interest, including the Department billing number issued to the Provider, or obligations under the Agreement, without written request to and prior written consent from the Department. The Provider shall not reassign its MaineCare claims in a manner prohibited by 42 C. F. R. § 447.10.
b) No subcontracts, assignments or transfers shall in any case release the Provider of its legal obligations or other liability under this Agreement, unless otherwise provided by law.
c) Any subcontracts approved by the Department will bind the subcontractor to compliance with applicable Federal and State laws and regulations and all legal obligations or other liability under this agreement.
d) The Department, in its sole discretion, will determine whether a change of name, location or ownership may be recognized by the Department by amendment to this Agreement or whether this change will require a new Agreement to be executed.
5. Certification.
a) The Provider certifies that no individual practitioners, owners, directors, officers or employees of the Provider or any other organization on whose behalf the Provider is signing this Agreement, or any contractor retained by the Provider or any of the aforementioned persons, is currently subject to sanction under Medicare or MaineCare or debarred, suspended or excluded under any other Federal agency or program, or is otherwise prohibited from providing services to Medicare or MaineCare members (“Members”).
b) The Provider further certifies that at the time that this Agreement is executed neither it nor any of its employees, group members or agents has engaged in any activities prohibited by 42 U.S.C. § 1320a-7b or has been the subject of a criminal conviction or disciplinary action that would disqualify it, its employees, group members or agents from providing services to Members.
c) The Provider agrees that, should it become aware of information of exclusions, convictions, disciplinary actions or other conduct as described in A. 5. a) and b) above, it will notify the Department of such information within the time prescribed in Chapter I of the MBM.
d) The Provider understands that engaging in activity prohibited by 42 U.S.C. § 1320a-7b may result in sanctions or termination of this Agreement, in accordance with applicable Federal and State laws and regulations.
6. Licensing, Certification and Professional Standards.
a) The Provider will adhere on a continuing basis to all applicable Federal and State laws and regulations related to licensing, accreditation, certification and registration and to adhere to other professional standards governing medical care and services, as well as policies and procedures set forth in the MBM, as these may be amended from time to time.
b) Possession of a valid license, accreditation, certification or registration, where required by statute or regulation, in good standing throughout the duration of the Agreement, is a condition precedent to the Provider’s participation in MaineCare. Failure to obtain and maintain such license, accreditation, certification or registration as required shall constitute grounds for the Department to terminate, or refuse to extend or renew this Agreement.
7. Prohibition of Rebate, Refund or Discount (Kickbacks).
a) The Provider will not offer, give, furnish, or deliver any rebate, refund, commission, preference, patronage dividend, discount or any other gratuitous consideration in connection with the rendering of services to a Member.
b) The Provider will not solicit, request, accept or receive any rebate, refund, commission, preference, patronage, dividend, discount or any other gratuitous consideration in connection with the rendering of services to any Member or take any other action or receive any other benefit prohibited by 42 U.S.C. § 1320a-7b or the MBM.
References:
1. MaineCare Contact Us. Maine.gov. Retrieved from
http://www.cms1500claimbilling.com/2010/10/mailing-address-for-facility-claim.html