Medical billing services in Maine

Billing in Maine: what's different

The rules below change how a claim is filed and paid in Maine. Each line links to the official page it was read from, and the date at the top of this page is when it was last checked.

Rules that change how Maine claims are billed

• One payer pays every medical claim⁴

  CMS's 2024 state tables list a single managed care program for Maine, the NET non-emergency transportation brokerage, and no health plan of any kind. The brokerage is statewide, started August 1, 2011 under 1915(b) authority, has its waiver approved through March 31, 2028, enrolls aged, blind and disabled members, children, full dual eligibles, children with special health care needs, Native American members and foster children on a mandatory basis, and covers nothing but transportation. For a practice that means one enrollment, one fee schedule and one remittance stream for MaineCare, with prior authorization handled by the Department rather than a plan.

• The one-year clock has three starting points²

  Section 1.10-2 of the MaineCare Benefits Manual, Chapter I, gives a provider one year from the date of service to file a claim correctly, whatever the date eligibility was verified. The year runs instead from the date eligibility was granted when MaineCare eligibility is determined after the service, and from the date on the carrier's explanation of benefits when another insurer or Workers' Compensation is involved. Section 1.10-1 requires the provider's NPI on every claim and denies a claim based on an order or referral when the ordering, prescribing or referring provider is not enrolled with MaineCare or its NPI is missing, and Section 1.10-3 accepts original paper claims, direct data entry and the 837 electronic format, with billing instructions on the MaineCare provider site.

• Mid-coast rides moved to Modivcare on July 1, 2026⁷

  An Office of MaineCare Services bulletin dated June 24, 2026 announced that Modivcare Solutions LLC became the non-emergency transportation broker for Waldo, Knox, Lincoln and Sagadahoc counties and the towns of Brunswick and Harpswell in Cumberland County from July 1, 2026, and that providers can schedule rides through Modivcare's TripCare platform online or by phone. The DHHS broker list updated the same day shows the result: Modivcare in every county except Kennebec, Somerset, Piscataquis and most of Penobscot, which stay with Penquis CAP. A transportation company serving those counties bills a different broker for a trip on July 1 than for one on June 30.

• The state EVV system is Sandata; alternate systems connect to MIHMS¹¹

  MaineCare's EVV page describes an open platform where providers may use the state-offered system or their own system connected to MIHMS. An OMS bulletin of January 16, 2025 addresses missing clients in Sandata, the EVV system: it reports that Sandata resolved the missing client error and sends providers with continuing EVV problems to Gainwell's MaineCare EVV mailbox. Personal care and home health visits have had to be verified since January 1, 2021, with Section 40 home health following on January 1, 2024, so a claim for either service is matched against a visit record before it pays.

• Undisputed claims owe 1.5 percent a month after 30 days⁸

  Under 24-A M.R.S. 2436 a claim that is neither disputed nor paid within 30 days is overdue, and the overdue amount bears interest at 1.5 percent per month. For health care claims the statute defines an undisputed claim as one containing all required data elements, not materially deficient, with no unusual circumstances preventing payment, and an insurer that disputes a claim must say so in writing with the grounds after a reasonable investigation. A claimant who is paid after giving notice of representation can also recover a reasonable attorney's fee, which gives an escalation letter real weight.

• Gainwell runs provider services and the Health PAS portal¹

  The Office of MaineCare Services directs providers to the Health PAS Online Portal for fee schedules and to Gainwell Technologies for provider inquiries by email or at 1-866-690-5585, lists provider enrollment, pharmacy, dental and value-based purchasing among its provider resources, and runs a separate member services line. Because there is no plan layer, the portal, the remittance and the policy bulletins all come from that one program office, and the same Gainwell team answers EVV questions.

Services for Maine practices

Remitwright serves Maine practices remotely, inside the practice management or EHR system the practice already uses. A dedicated biller works the account; nothing is pooled. Each service below explains what that biller does.

• Medical billingClaims worked by one named biller
• CredentialingEnrollment, CAQH and PECOS kept current
• Eligibility verificationCoverage and benefits checked before visits
• Prior authorizationAuths requested, tracked, attached to claims
• Denial managementEvery denial read, worked and appealed
• A/R follow-upUnpaid claims chased before filing limits