Instructions for Completing the Maine Tick Borne Disease Claim Form Required by 24-A M.R.S.A. § 4302(5) General Instructions: This form is to be completed for all claims made (dates of service) in the previous calendar year for covered individuals in Maine relating to the following diseases and their accompanying ICD-9 codes (ICD-10 codes in parentheses). Lyme Disease (Borreliosis) ICD-9 code 088.81 (A69.2) Babesiosis ICD-9 code 088.82 (B60.0) Ehrlichiosis (Anaplasmosis) ICD-9 code 0.82.4 plus all subcategories: 082.40, 082.41, 082.49 (A79.8, A79.9) Rocky Mountain Spotted Fever ICD-9 code 082.0 (A77.0) Powassan Virus (tick-borne viral encephalitis) ICD-9 code 063.8 (A84.8) To access your online form: Go to the following website: https://gateway.maine.gov/Insurance/. Enter your license number and access code, which were included in the e-mail notification that you received from our office. Then click on the Submit button. This brings you to the Forms Available screen which shows you the forms that you need to complete. Under Forms and Descriptions, click on the Tick Borne Disease Claim Form. This brings you to the Form Status and Periods Available Screen. You will see three categories: Submitted Forms (Those already completed and submitted to our database), Forms Currently in Process (Forms that you have worked on and saved but have not submitted to our database. These are not complete until you submit them), and Forms Available for Completion (Forms that you have not yet worked on. These are not complete until you enter the information and submit them). A blue hyperlink will appear in only one of these three categories. Remember, you are not finished until information has been entered and the form has been submitted. Therefore, if there is a blue hyperlink listed under Forms Currently in Process or Forms Available for Completion, then you must click on the link so you can complete the form and submit it. Doing so will bring up the Tick Borne Disease Claim Form. This online form is comprised of various sections described below. Section: Company and Contact Information This section contains the calendar year that the report covers and your company name, license number and mailing address. You must select a contact person by clicking on the drop down arrow beside Select a Contact. If the name of the person completing this year’s report appears in the drop down list, highlight that name and click on the Attach Contact button. Information such as Title, Address, Phone, Fax and E-Mail appears. If the contact information for that person is not correct, click on the Add/Update Contacts button. Next Click on the Edit Contact button beside the Contact Person for whom you want to update information. Make any necessary changes and click on the Save Contact button. You will see a green message if the changes were successful. Then click on the Return to Form button to continue working on the Tick Borne Disease Claim Form. If the name of the person completing this year’s report does not appear in the drop down list, click on the Add/Update Contacts button. Under Contacts, click on the New Contact button. The New Contact screen appears. Enter information about the new contact and then click on the Save Contact button. When you are finished, click on the Return to Form button. You may then select the contact person by clicking on the drop down arrow beside Select a Contact and then click the Attach Contact button. After attaching the contact to the report, you may continue working on the Tick Borne Disease Claim Form. Section: Number of Claims Submitted for All Tick Borne Diseases Enter the number of claims submitted for the specified Tick Borne Diseases, along with the number of those claims that were denied, those that were paid, and the total amount of payments for those claims. Please include only claims that required treatment. Exclude laboratory, imaging or other claims related to diagnosing tick borne diseases. The data reported should be the number of claims, not the number of enrollees. Section: Number of Claims Submitted for the Types of Treatment for Lyme disease Provide information regarding treatment-for Lyme disease claims. Exclude things like laboratory work and imaging. If an enrollee submitted a claim for an antibiotic on several different occasions within the calendar year, combine the length of time the antibiotic was taken for the purpose of determining if the treatment was for 8 weeks or less or for over 8 weeks. Do this of each enrollee affected. Please list details about what the Other Types of Treatments were in the blank box (comments section) at the bottom of the online form. Other treatment may include non-antibiotic therapies administered for treatment of Lyme disease-- including physical therapy, acupuncture, behavioral health, osteopathic manipulation, or other prescription medications. Note: It is possible for information about one enrollee to be entered in more than one category. For example, an enrollee could have paid claims for some antibiotics for 8 weeks or less during the calendar year. That same enrollee could have a different antibiotic for 8 weeks or less be denied and additionally have a prescription for more than 8 weeks be paid. Therefore, it may be acceptable to enter data for the same enrollee in more than one place. Section: Reasons for Denied Tick Borne Disease Claims Include in your totals all of the denials related to any treatment for all of the tick-borne diseases combined. Denials may fall into more than one category, please include all the denial reasons as appropriate. For Other reasons, please list them in the blank box (comments section) at the bottom of the online form. Number of Appeals/Reconsiderations and External Reviews for All Tick Borne Diseases For Internal Appeals and Reconsiderations and for Independent External Reviews (conducted by you and not by the Bureau of Insurance), enter how many of these were Upheld, Overturned, and Other. For any listed as other, enter the details in the blank box (comments section) at the bottom of the online form. Calculate Totals fields are calculated by the system. In the Appeals/Reconsiderations section, you enter figures for upheld, overturned and other and then you must click on the Calculate button. It will put the sums into the totals field. You cannot enter data directly into this Total field. Save Button If you have begun your report but want to finish it at a later time, you may click on the Save button and all work that you have done on the form thus far will be available when you return to complete the form. Remember, you are not finished until you submit the information to our database. Submit Button When you click on the Submit button, your information will be submitted to the Bureau of Insurance and will no longer be available for editing. You will receive a confirmation email with a PDF file containing your data report. Print PDF When you have finished the report, you may click on the Print PDF button to generate a PDF document of the completed report for your records. Questions If you have specific questions about how to report Tick Borne Disease claims or their treatments, contact Glenn Griswold at Glenn.J.Griswold@maine.gov or (207)-624-8453. If you have technical questions related to completing this report or need to have your report reopened to correct information after it has been submitted, please contact Brad Brown at Bradford.L.Brown@maine.gov or (207)-624-8478.
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