Rounding Rule Changes Effective January 1, 2023

Jan 03, 2023

On May 29, 2022, MaineCare adopted changes to the rounding rule in Chapter I, Section 1.03-8(J), effective January 1, 2023. MaineCare provided a delayed effective date to give providers time to make necessary system changes and has not further extended the effective date. If you have questions about these changes or concerns regarding your ability to comply at this time, please contact your Provider Relations Specialist. 

See below for a list of frequently asked questions: 

1. What is the rounding rule? 

Under the rounding rule that was effective prior to January 1, 2023, providers would round up a unit of service if the unit delivered was equal to or greater than fifty percent, or round down if the unit of service delivered was less than fifty percent. The changes to the rounding rule effective January 1, 2023, allow providers to bill for partial units of service and increases the rounding threshold from fifty percent to eighty percent of a unit of service. For example, providers may round up 1.8 units of service and bill for two units, and providers may bill 1.7 units of service as 1.7 units. The rule retains the ability to round up if fifty percent of the unit of service was delivered when unforeseen circumstances prevent a provider from delivering a whole unit of service.  

2. What units of service does the rounding rule apply to? 

The rounding rule applies to all units of service that are measured in minutes (e.g., 15-, 30-, and 60-minute units). The rounding rule does not apply to per diem, per week, or per member per month services. 

3. Which provider types does the rounding rule apply to? 

The rounding rule applies to all provider types, but it is only applicable to units of service that are measured in minutes, which some providers do not bill.  

4. Is there a minimum time requirement for billing a partial unit? For example, can you bill for two minutes of a service? 

No, there is no minimum time requirement to bill. Providers could bill for a partial unit that equates to the two minutes delivered. 

5. How should providers round partial units? Can providers bill using the first or second decimal place? 

Providers may bill partial units of service delivered to one or two decimal places, and providers may round partial units of service to the first or second decimal place. For example, to bill ten minutes of a 15-minute service (.667 units), providers may choose to use the first decimal place, not round, and bill .6 units; use the second decimal place, not round, and bill .66 units; round to the second decimal place and bill .67 units; or round to the first decimal place and bill .7 units.  

Providers may not round up to .8 units and then round up again to bill the whole unit. For example, if a provider delivers 45 minutes of a 60-minute service, they could round .75 units up to .8 units, but they cannot then round .8 units up to a whole unit. 

6. How does the rounding rule affect Atrezzo? 

Atrezzo does not communicate with the billing system, so there is no impact on a provider's ability to bill for partial units. 

7. If MaineCare prior authorizes a certain number of units, and a provider delivers a partial unit of that authorized service, will MaineCare’s systems deduct the appropriate partial unit from the total authorized units? 

Yes, MaineCare’s systems will deduct partial units from the total authorized amount. 

8. What happens if a provider cannot implement system changes by January 1, 2023, to bill for partial units? 

If a provider cannot implement the necessary system changes to bill for partial units, providers must deliver and bill for whole units of a service or submit claims directly on the HealthPAS Online Portal, which allows providers to submit partial units. If systems changes prevent you from complying with the rounding rule at this time, please contact your Provider Relations Specialist to let them know.  

9. Does the CMS Total Time Rule apply for these covered services?  For example, if a provider bills for 8 minutes of code 97110 and 5 minutes of code 97530, can the provider aggregate the 2 units to equal 13 total minutes as allowed by the CMS Total Time Rule?  

The CMS Total Time Rule is not a MaineCare promulgated rule, so it does not apply. 

10. Should a provider add up all the time they delivered a service to a member throughout a week or day and bill for the combined total?  

No, if a service is not delivered continuously, providers should bill separately for each instance a service is provided. 

11. Does the rounding rule apply to Section 13, Targeted Case Management (TCM)? 

The rounding rule provides that specific language in other Chapters or Sections supersedes the rounding rule. Section 13.09-1 states that “providers of services reimbursed on a quarter hour basis under this Section will be reimbursed for any substantive contact at a minimum of fifteen (15) minutes.” Section 13 providers may continue to bill in accordance with Section 13.09-1. For example, if a provider delivers less than 15 minutes of TCM, they could bill for the whole 15-minute unit. If they deliver more than 15 minutes, they could bill for one unit plus any partial units in accordance with the rounding rule but could not bill for a second whole unit. 

12. What does MaineCare consider a substantive contact under Section 13, and when does the rounding rule come into play? 

A substantive contact is any contact related to the member’s goals as listed on the individual service plan. If a case manager calls and says they cannot make a scheduled appointment, that does not count as a substantive contact. If a provider delivers less than 15 minutes, they could bill for the whole 15-minute unit. If they deliver more than 15 minutes, they could bill for one unit plus any partial units in accordance with the rounding rule. 

13. Does the rounding rule impact claims subject to electronic visit verification (EVV)? 

The rounding rule does not impact EVV requirements during claims processing. MaineCare does not match the duration of the visit record to the units billed during claims processing. However, this match could happen in a post-payment review. 

14. How should providers track partial units in EIS? 

Only Section 13 providers serving members with developmental disabilities must indicate the units of service they deliver on EIS. Since Section 13 providers may continue to bill for a whole 15-minute unit for any substantive contact, they would only bill for partial units if they deliver more than 15 minutes of a service that does not equate to a whole unit. Section 13 providers who use EIS and bill partial units can notate the partial units delivered in the narrative portion of the application. Evergreen, the system that will replace EIS in the future, will track billable time to the minute. 

15. Does the rounding rule apply when MaineCare is the secondary payer? 

No, providers should bill the primary payer in accordance with that payer’s billing requirements. As a secondary payer, MaineCare will pay for the copayment, coinsurance, and/or deductible required by the primary payer.