Provider Transitional Loss Mitigation Program
The PTLMP is administered by the following special claims serving agent. All questions related to the PTLMP should be addressed as follows:
Claim Form Instructions (.doc) | Reference Forms (.pdf) | Final Forms (.pdf)
Provider Transitional Loss Mitigation Program or PTLMP
PO Box 6794
Scarborough, Maine 04070-6794
Tel: Toll-Free (877)885-9788
Email: Steven Hoxsie - email@example.com, or
Kevin Cyr - firstname.lastname@example.org
If you are a Maine Provider who administered vaccines to minors between January 1, 2012 and April 30, 2012, and reimbursement was denied by an Insurer, then you may be eligible for reimbursement by the Maine Vaccine Board under its Provider Transitional Loss Mitigation Program.
The Maine Vaccine Board (MVB) recognizes that as the new universal vaccine program begins on January 1, 2012 providers may have unused vaccine which they previously purchased for use in children under the age of 19. The MVB is concerned about transitional costs borne by providers as this new program is implemented. Many insurers will continue to reimburse providers for use of purchased vaccine, but some may not. To lessen the potential financial burden on providers, we have established a process to reimburse providers at least a portion of the cost of purchased vaccine if reimbursement is denied by an insurance carrier. This applies only to vaccines administered to children from January 1, 2012 and through April 30, 2012.
The Maine Vaccine Board (MVB) seeks to provide financing of vaccines to facilitate (i) universal purchase and (ii) increase vaccines available to providers for Maine children, and also (iii) to do so at rates below those which would have been available for direct purchase (as indicated by the CDC price surveys). MVB has addressed transitional issues and worked hard to make the program as efficient as possible for access and administration by payers
To address those transitional costs, in September 2011, the MVB wrote to payers requesting them to voluntarily honor all properly-filed provider claims for vaccines, in accordance with standards prior to formation of MVB, through April 30, 2012. This request was made notwithstanding the fact that payers have commenced building of funds for Maine State purchase of vaccines with the first assessment payments made in November 2011. It is anticipated that free vaccines will be shipped to providers under this program starting in January 2012. Meanwhile, of course, responsible providers have sought to remain prepared for customary vaccine cycles including the opportunity to catch up on vaccines, as needed, during the school break around the year-end holiday season.
The Maine State Center for Disease Control and Prevention has alerted providers to the upcoming change in vaccine delivery statewide and advised them that there can be no assurance that payers will continue to reimburse for privately purchased stock once the universal state supply is available to providers. Providers have been urged to reduce remaining inventories to minimum levels pending the commencement of shipments under the universal childhood vaccine purchase program.
The MVB has established the following provider transitional loss mitigation program (PTLMP) to partially offset any losses of providers for inventories of vaccines at responsible levels for which properly-submitted claims are denied by payers. The program will function as follows:
Up to $400,000 in aggregate statewide will be made available to reimburse Maine-based provider groups for properly-filed vaccine claims that were denied by payers.
Payments will be made for properly-filed claims for privately-insured Maine resident children who have received vaccinations at a provider’s office in the state of Maine between (and including) the dates of January 1, 2012 and April 30, 2012.
Payments will be made one time for each eligible provider group. Providers are required to submit claim forms in accordance with procedures outlined on the MVB website with respect to such claims.
All claims will include at a minimum the date of service, the administering provider’s name, a reference number for denial along with the PCP code, the vaccination code, and the vaccine claim cost set forth in the provider’s claim. All claims shall be presented on MVB approved claim forms and submitted in accordance with the procedures governing submission of provider transitional loss mitigation claims listed on the MVB website, www.MEvaccine.org.
For each provider group, claims will be grouped and then aggregated by amounts (units and dollars) for each vaccine code to sum to a total claim. Email, telephone number, and address for the contact person for follow up must be included as well as the Taxpayer ID and entity name for any check issued by MVB.
The actual notice of denial must accompany the claim submittal form.
Any denial based upon provider administrative errors, such as improper coding, lack of coverage, etc. will not be reimbursed under the MVB program but rather should be submitted to the payer with corrections.
Initial claims submission shall be completed no later than June 30, 2012. Submissions should be accompanied by a cover sheet which includes the aggregate data and the number of units for each vaccine multiplied by the CDC contract price payable by MVB commencing January 1, 2012. That price will be posted on the MVB website. The reimbursement rate by MVB will be the lesser of (i) the CDC contract price or (ii) the price on the claim form as submitted by the provider to the payer.
Providers will certify the accuracy of data supplied and timely respond to any inquiries by the MVB PLMP claims administrator to facilitate clarification of filings or completion of any requested supportive documentation. The claims administrator is expected to advise the submitter of any claims denials and the reasons for denials on or before July 9, 2012. In the event of such a denial, the provider is required to amend its claim submission and provide any other information requested by the Maine Vaccine Board, or file notice of appeal with the claims administrator no later than July 30, 2012.
In the event that the total of approved and pending claims exceeds $400,000, the amount to be paid on each claim will be reduced by multiplying the otherwise approved claim amount by a fraction, the numerator of which is $400,000 and the denominator of which is the total amount of claims approved and under review as of the date of such calculation.
The MVB anticipates that a listing of the payments approved under the PTLMP will be forwarded to the State Treasurer’s office with request for payment the week of September 3, 2012. The claims administrator will advise the providers at the time that the information authorizing payment has been forwarded to the State Treasurer’s office. That listing also will be posted on MVB’s website to afford public notice of final determinations under the PTLMP.
It is anticipated that payment will be made from MVB funds by the State Treasurer in due course within a reasonable period of time.
Providers will not pursue further reimbursement from claims for which payment is made under the PTLMP, but will assign any remaining rights for such claims payments to the MVB.
Any appeal from a final determination under the PTLMP must be made in writing directly to the MVB at its address on www.MEvaccine.org no later than 15 days after the receipt of a claim denial from the MVB , except that, in the event of an appeal from an adjusted reimbursement prorated in accordance with the methodology identified in ¶ 10, a provider must appeal in the manner described above no later than 15 days of receipt of notice of the adjusted reimbursement. A provider is deemed to have received notice of a claim denial or claim adjustment as of the third day from the mailing of the denial decision or reimbursement adjustment decision. In no event will any claim for any amount in excess of the amounts submitted by the July 30, 2012 cutoff date be considered in any appeal process. Any final award will be reduced by the same proportionate reduction, if any, applied under step 10 above.
Any appeal filed pursuant to ¶14 will be conducted in accordance with the relevant provisions of the Maine Administrative Procedure Act, 5 M.R.S.A. Ch. 375, Subchapter 4 and the Department of Health and Human Services Administrative Hearings Regulations, 10-144 C.M.R.Ch.1. A provider aggrieved by a final administrative decision shall have recourse to judicial review in accordance with the relevant provisions of the Maine Administrative Procedure Act, 5 M.R.S.A. Ch. 375, Subchapter 7.