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131st MAINE LEGISLATURE
FIRST SPECIAL SESSION-2023
Legislative Document No. 1533H.P. 988 House of Representatives, April 5, 2023
An Act to Provide for Consistent Billing Practices by Health Care
Providers
Reference to the Committee on Health Coverage, Insurance and Financial Services
suggested and ordered printed.
ROBERT B. HUNT
Clerk
Presented by Representative MORRIS of Turner. Page 1 - 131LR1436(01)
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2 is enacted to read:
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4 For the purposes of this section, unless the context indicates otherwise,
5 the following terms have the following meanings.
6 A. "Campus" means the physical area immediately adjacent to a health care provider's
7 main buildings, other areas and structures that are not strictly contiguous to the main
8 buildings but are located within 250 yards of the main buildings and any other areas
9 determined on a case-by-case basis by the regional office of the federal Department of
10 Health and Human Services, Centers for Medicare and Medicaid Services for this State
11 to be part of the health care provider's campus.
12 B. "Carrier" has the same meaning as in Title 24-A, section 4301-A, subsection 3.
13 C. "Covered person" means a policyholder, subscriber, enrollee or other individual,
14 including a dependent of the policyholder or subscriber, participating in a health plan.
15 D. "Facility" means an institution providing health care services or a health care setting,
16 including but not limited to hospitals, and includes the ultimate parent company of a
17 health care system.
18 E. "Health care services" means services, including imaging, for the diagnosis,
19 prevention, treatment, cure or relief of a health condition, illness, injury or disease.
20 F. "Health plan" has the same meaning as in Title 24-A, section 4301-A, subsection 7.
21 G. "Items" means health care-related objects used in conjunction with the delivery of
22 health care services to a covered person, including but not limited to durable medical
23 equipment.
24 H. "National Provider Identifier" or "NPI" means the standard, unique health identifier
25 for a health care provider that is issued by the National Plan and Provider Enumeration
26 System in accordance with 45 Code of Federal Regulations, Part 162.
27 I. "Off-campus outpatient department of a facility" means a location:
28 (1) Whose operations are directly or indirectly owned or controlled by, in whole
29 or in part, or affiliated with a facility, regardless of whether the operations are under
30 the same governing body as the facility;
31 (2) That is located more than 250 yards from a facility's campus;
32 (3) That provides services that are organizationally and functionally integrated
33 with a facility; and
34 (4) That is an outpatient facility providing preventive, diagnostic, treatment or
35 emergency services.
36 J. "Superintendent" means the Superintendent of Insurance.
37 This section applies to claims filed on or after January 1, 2024 for
38 health care services or items by a facility or off-campus outpatient department of a facility
39 in this State or any designee of a facility or off-campus outpatient department of a facility. Page 2 - 131LR1436(01)
1 Notwithstanding any provision of law to the contrary,
2 for claims filed with a carrier, an off-campus outpatient department of a facility must apply
3 for, obtain and use a unique National Provider Identifier that is distinct from the NPI used
4 by the campus of the facility and any other off-campus location of the facility in order to
5 be reimbursed or paid for health care services or items provided in that off-campus
6 outpatient department of a facility.
7 A facility or its designee may not, with respect to health care
8 services or items furnished to a covered person at an off-campus outpatient department of
9 a facility, submit a claim to a carrier for such health care services or items and may not
10 hold a covered person liable for such health care services or items unless those health care
11 services or items are billed:
12 A. Using the distinct NPI established for the off-campus outpatient department of a
13 facility; and
14 B. Using the standardized claims form for professional services approved by the
15 Federal Government or the equivalent claims form used for an electronic claims
16 transaction.
17 A carrier is not required to pay any claim for health care services or items furnished to a
18 covered person at an off-campus outpatient department of a facility that is not billed in
19 accordance with the requirements of this subsection.
20 A facility, or its designee, that does not bill for health care services
21 or items rendered to a covered person at an off-campus outpatient department of a facility
22 as required by this section may not hold the covered person liable to pay for such health
23 care services or items. A violation of this subsection constitutes a violation of the Maine
24 Unfair Trade Practices Act and the Attorney General may take action pursuant to Title 5,
25 section 209.
26 The superintendent may refer to the Department of Health
27 and Human Services for enforcement any facility for a violation of this section. The
28 Department of Health and Human Services may take any enforcement action provided in
29 Title 22 against a licensed facility for a violation of this section.
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31 Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5,
32 chapter 375, subchapter 2-A.
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34 This bill establishes consistent billing requirements for providers of outpatient health
35 care services delivered in off-campus outpatient departments owned by or affiliated with a
36 health care system. The bill's requirements must be followed by health care facilities and
37 health insurance carriers and apply to claims submitted to a health insurance carrier on or
38 after January 1, 2024.
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