ࡱ> uwtq`  bjbjqPqP :P::'''8$($H([8)8)8)8)8)+++ZZZZZZZ$ \hr^`ZA,++A,A,Z8)8)Zs.s.s.A,8)8)Zs.A,Zs.s.6I K8),) @bi2',pIiV4Z0[J^Q-^8 K K^)K@ +>F+,s.r+$++++ZZ.d+++[A,A,A,A,d($($ CODEHCPCS *** CODE DESCRIPTIONMAXIMUM ALLOWANCE082190999HEMODIALYSIS/COMPOSITEBY REPORT082590993, 90989sUPPORT sERVICES (HEMODIALYSISBY REPORT083190999PERITONEAL DIALYSIS/COMPOSITEBY REPORT083590993, 90989SUPPORT SERVICES (IP)BY REPORT084190999CAPD/COMPOSITEBY REPORT084590993, 90989SUPPORT SERVICES/CAPDBY REPORT084990945OTHER CAPD DIALYSISBY REPORT085190999CONTINUOUS CYCLING PERITONEAL DIALYSIS (CCPD)BY REPORT0855 90993, 90989SUPPORT SERVICES (CCPD)BY REPORT0634 *EPO- INJECTION, EPOETIN ALFA, under 10,000 UNITSBY REPORT0635 *EPO- INJECTION, EPOETIN ALFA, above 10,000 UNITS0636**ARANESP- INJECTION, DARBEPOETIN ALFA, 1 MCGBY REPORT * Providers must also put HCPCS Q4081 on claim form. * * Providers must also put HCPCS JO882 on claim form. *** These HCPCS codes will become effective upon implementation of MIHMS. (APA Office Note: This occurred on September1, 2010.)     10-144 CH. 101 MAINECARE BENEFITS BANUAL CHAPTER III SECTION 7 FREE-STANDING DIALYSIS SERVICES Effective 10/1/09 10-144 CH. 101 MAINECARE BENEFITS MANUAL CHAPTER III SECTION 7 FREE-STANDING DIALYSIS SERVICES Effective 7/26/10 1   5679:;@ͺ~haS>a- hB4hc8CJOJQJ^JaJ(hB4hc8CJOJQJ^JaJmH sH hc8CJOJQJmH sH  hB4hc8+hB4hJ5CJOJQJ^JaJmH sH %hc85CJOJQJ^JaJmH sH +h*ah*a5CJOJQJ^JaJmH sH %h5CJOJQJ^JaJmH sH %h5CJOJQJ^JaJmH sH %hJ5CJOJQJ^JaJmH sH +hB4hc85CJOJQJ^JaJmH sH hc8CJOJQJ"+5$If 56789OIII$Ifkd$$Ifl4 r$ R&0*.2 0444 la49:;@F]gtnnnnn$Ifkd$$Ifl44F.0*/v04    44 la4f4@Eghijkmnost    ! & + E F G I J K P п򿓁pпппппппп h@hJCJOJQJ^JaJ#h@hJ;CJOJQJ^JaJhJ;CJOJQJ^JaJ hB4hJ+hB4hJ5CJOJQJ^JaJmH sH  hB4hJCJOJQJ^JaJhJCJOJQJ hB4hc8 hB4hc8CJOJQJ^JaJhJCJOJQJ^JaJ,ghijklmRLLCLL $Ifgdi$Ifkd$$Iflr$ R&0*.2 0444 la4mnotRLLLLL$Ifkd$$Iflr$ R&0*.2 0444 la4RLLL$Ifkd$$Iflr$ R&0*.2 0444 la4uooooo$Ifkdy$$Ifl4F.0*/v04    44 la4f4RLLL$Ifkd8$$Iflr$ R&0*.2 0444 la4  uooooo$Ifkd$$Ifl4F.0*/v04    44 la4f4     RLLL$Ifkd$$Iflr$ R&0*.2 0444 la4 ! & , ; E uooooo$Ifkd$$Ifl4F.0*/v04    44 la4f4E F G H I RLLL$Ifkd$$Iflr$ R&0*.2 0444 la4I J K P ] s } uooooo$Ifkde $$Ifl4F.0*/v04    44 la4f4P \ } ~   0 1 2 4 5 6 = o y z {     ڑhCJOJQJ(hB4hJCJOJQJ^JaJmH sH hCJOJQJ^JaJ#hB4hJ:CJOJQJ^JaJhJCJOJQJ hB4hJ hB4hJCJOJQJ^JaJhJCJOJQJ^JaJ6} ~  RLLL$Ifkd$ $$Iflr$ R&0*.2 0444 la4 uooooo$Ifkd $$Ifl4F.0*/v04    44 la4f4 RLLL$Ifkd $$Iflr$ R&0*.2 0444 la4 uooooo$Ifkd $$Ifl4F.0*/v04    44 la4f4 RLLL$Ifkdl $$Iflr$ R&0*.2 0444 la4   & 0 uooooo$IfkdQ$$Ifl4F.0*/v04    44 la4f40 1 2 3 4 RLLL$Ifkd$$Iflr$ R&0*.2 0444 la44 5 6 = > o y smmddd $Ifgd2.$Ifkd$$Ifl4F.0*/v04    44 la4f4y z { | } ~  RLLLLL$Ifkd$$Iflr$ R&0*.2 0444 la4 RLLLLL$Ifkd$$Iflr$ R&0*.2 0444 la4 RLLLLL$Ifkd|$$Iflr$ R&0*.2 0444 la4  RLLCCL $Ifgd,m$Ifkda$$Iflr$ R&0*.2 0444 la4   8 o p PGGB5 ]gdAgdB4 gdB4kdF$$Iflr$ R&0*.2 0444 la4 n o p s u o p q ҹ~~x~ h,CJh,h,CJOJQJh,OJQJhS(jhS(Uh!.jh&[O6OJQJ^Jh!.j6OJQJ^Jh!.jh!.j6OJQJ^Jh5OJQJ^Jh!.j5OJQJ^Jh5OJQJ^JhOJQJ^Jh"h"CJOJQJp ' 3 o p q $ !a$gd+b  !v/ !v/$d&dNP $ !a$  ]^` gd!.j   ]^` gd!.j$a$  !v/gd+b! !^2$d&dNP^gd+b8 01h0:p+b= /!0"@#$% $$If4!vh5*555.52 #v*#v#v#v.#v2 :V l4 04,,5*555.52 / / / a4$$If4!vh5*5/5v#v*#v/#vv:V l4404,,5*5/5v/ a4f4$$If4!vh5*555.52 #v*#v#v#v.#v2 :V l04,,5*555.52 / a4$$If4!vh5*555.52 #v*#v#v#v.#v2 :V l04,,5*555.52 / a4$$If4!vh5*555.52 #v*#v#v#v.#v2 :V l04,,5*555.52 / a4$$If4!vh5*5/5v#v*#v/#vv:V l404,,5*5/5v/ a4f4$$If4!vh5*555.52 #v*#v#v#v.#v2 :V l04,,5*555.52 / a4$$If4!vh5*5/5v#v*#v/#vv:V l404,,5*5/5v/ a4f4$$If4!vh5*555.52 #v*#v#v#v.#v2 :V l04,,5*555.52 / a4$$If4!vh5*5/5v#v*#v/#vv:V l404,,5*5/5v/ a4f4$$If4!vh5*555.52 #v*#v#v#v.#v2 :V l04,,5*555.52 / a4$$If4!vh5*5/5v#v*#v/#vv:V l404,,5*5/5v/ a4f4$$If4!vh5*555.52 #v*#v#v#v.#v2 :V l04,,5*555.52 / a4$$If4!vh5*5/5v#v*#v/#vv:V l404,,5*5/5v/ a4f4$$If4!vh5*555.52 #v*#v#v#v.#v2 :V l04,,5*555.52 / a4$$If4!vh5*5/5v#v*#v/#vv:V l404,,5*5/5v/ a4f4$$If4!vh5*555.52 #v*#v#v#v.#v2 :V l04,,5*555.52 / a4$$If4!vh5*5/5v#v*#v/#vv:V l404,,5*5/5v/ a4f4$$If4!vh5*555.52 #v*#v#v#v.#v2 :V l04,,5*555.52 / a4$$If4!vh5*5/5v#v*#v/#vv:V l404,,5*5/5v/ a4f4$$If4!vh5*555.52 #v*#v#v#v.#v2 :V l04,5*555.52 / a4$$If4!vh5*555.52 #v*#v#v#v.#v2 :V l04,,5*555.52 / a4$$If4!vh5*555.52 #v*#v#v#v.#v2 :V l04,,5*555.52 / a4$$If4!vh5*555.52 #v*#v#v#v.#v2 :V l04,,5*555.52 / a4$$If4!vh5*555.52 #v*#v#v#v.#v2 :V l04,,5*555.52 / a4-000\@\ kNormal5$7$8$9DH$$CJOJQJ^J_HaJmH sH tH d@d " Heading 1 $ Fx5$7$8$9D@&H$5CJOJQJ^JaJd@d " Heading 2#$ & Fx5$7$8$9D@&H$CJOJQJ^JaJn@n " Heading 3.$ & FxX 5$7$8$9D@&H$CJOJQJ^JaJd@d " Heading 4#$ & Fx5$7$8$9D@&H$CJOJQJ^JaJf@f " Heading 5&$ & Fx5$7$8$9D@&H$a$CJOJQJ^JaJr@r  " Heading 61$ & Fxp5$7$8$9D@&H$a$CJOJQJ^JaJ\@\ !" Heading 7$ & F<5$7$8$9D@&H$ OJQJ^Jb@b "" Heading 8$ & F<5$7$8$9D@&H$6OJQJ]^JX @X #" Heading 9$ & F<5$7$8$9D@&H$CJaJDA@D Default Paragraph FontRi@R 0 Table Normal4 l4a (k( 0No List 4@4  0Header !BB &&0 Char Char6CJOJQJ^JaJ4 @4  0Footer !B!B &&0 Char Char5CJOJQJ^JaJz3z   Table Grid7:V05$7$8$9DH$:U@A: y Hyperlink>*B*^JphRP@RR y0 Body Text 25$7$8$9DH$CJOJQJ^J:Oa: y0 Char Char4 CJ^JaJRB@rR y0 Body Text5$7$8$9DH$]hCJOJQJ^J:O: y0 Char Char3 CJ^JaJT>@T "Title5$7$8$9DH$a$5CJOJQJ\^JaJ8O8 " Char Char2 5CJ\8O8 " Char Char155CJ4O4 " Char Char14CJ4O4 " Char Char13CJ4O4 " Char Char12CJ4O4 " Char Char11CJ4O4 " Char Char10CJ6O6 " Char Char9CJaJ<O!< " Char Char86CJ]aJBO1B " Char Char7CJOJQJ^JaJX/@BX "List$x5$7$8$9DH$^h`5CJOJQJ^JaJ\2@R\ "List 2!%x5$7$8$9D@&H$^8`0CJOJQJ^JaJt<@bt " List Number 4,&x5$7$8$9D@&H$^`PCJOJQJ^JaJhC@rh ("Body Text Indent'x5$7$8$9DH$^CJOJQJ^JaJ2O2 '" Char Char1CJlR@l *"Body Text Indent 2)x5$7$8$9DH$^CJOJQJ^JaJ0O0 )" Char CharCJR^@R " Normal (Web) +dd5$7$8$9DH$[$\$H@H D Balloon Text,CJOJQJ^JaJ P"+56789:;@F]ghijklmnot !&,;EFGHIJKP]s}~&0123456=>oyz{|}~8op '3opq0 0 000 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000I0I04I0I04I0I04I0I04I0I0I0I0I0I0@0@0@0@0@0I0@0I0I04456yz{|}~8opI0 I0 .I0Lq,I K0^I0 I0 I0 I0 I0 I0 I0I0  K0  I0  ^I0I0qI0I0 K0 t^I0 I0 I0I0I0K0I0 @P   %59gm  E I } 0 4 y   p   !"#$&' P# AA@H L0(  L0(  B S  ?_|`ya bԑ xx{{B*urn:schemas-microsoft-com:office:smarttagscountry-region9*urn:schemas-microsoft-com:office:smarttagsplace Ȗd {rz3su  s`Jp@n t0% I%H!vF)`]C=f5&~5N&DrkQ` ue4$o>FvY{X^`.pp^p`.@ L@ ^@ `L.^`.^`.L^`L.^`.PP^P`. L ^ `L.xx^x`o(.HH^H`.L^`L.^`.^`.L^`L.X X ^X `.(#(#^(#`.%L%^%`L.0^`0^Jo(0^`0^Jo(.0^`0^Jo(..0^`0^Jo(... 88^8`^Jo( .... 88^8`^Jo( ..... `^``^Jo( ...... `^``^Jo(....... ^`^Jo(........  ^ `o(.xx^x`o(.HLH^H`L.^`.^`.L^`L.^`.X X ^X `.(#L(#^(#`L.hh^h`^Jo()^`^Jo()88^8`^Jo()^`^Jo(.^`^Jo(()pp^p`^Jo(()  ^ `^Jo(.@ @ ^@ `^Jo(.  ^ `^Jo(.0^`0^Jo(0^`0^Jo(.040^`0^Jo(..0^`0^Jo(... 88^8`^Jo( .... 88^8`^Jo( ..... `^``^Jo( ...... `^``^Jo(....... ^`^Jo(........@ @ ^@ `o(.^`.L^`L.^`.^`.PLP^P`L.  ^ `.^`.!L!^!`L.^^Jo(65.01p0p^p`0^Jo(65.05-2@ 0@ ^@ `056B*^Jo(ph.  ( ^ `(7S*^Jo(^`^Jo(.^`^Jo(.^`^Jo()pPp^p`P^Jo(. p ^ `p^Jo(.88^8`o(^`o(.^`o(.-pp^p`o(.-.   ^ `o( .-.. @ @ ^@ `o( .-... `^``o( .-.... x`x^x``o(.-..... HH^H`o(.-......88^8`^Jo(.^`^J. L ^ `L^J.  ^ `^J.xx^x`^J.HLH^H`L^J.^`^J.^`^J.L^`L^J.pp^p`^Jo(.^`^J.pLp^p`L^J.@ @ ^@ `^J.^`^J.L^`L^J.^`^J.^`^J.PLP^P`L^J. F)kQC=f5$o% vY{s`Jue@n I%~5N          ֪        # ^%       `BX        2"2E        t-        &V\'V\ $nh?Vc7~I!+ R%4sV5A. @Iob &,H R5/?^/ QU ~u  >  t  T 4 " #zHnB)M(87U[]$/&0~+dpO{~+-tfS{s B'XX} 8Ms)0Sd l&8]L\h",0JRUEn4W ~ 5!j!)!J!" #z#"h$k$ %S%&-&:&M&*'S(**,*S*8m*n*2+)+(4+#t+,,7&,-,j'-*-=-~D-.2.}T.k.//0000#E0\L0 1#17>1]12H(2Dy3" 4B4E\4#5T 5J.56{7H7)7A7Qn78B8,&9::V;?;O;a;B=Z/>A>8>??8?;䰪9-5C|8<+D=D$FD|D<$E+ET]E&FrF|Fp~F GH$HBHQH+XHfHgHzI;Jj J=KGKhKxKWLLL$LM N,)N^N2O(O&[O$PDP{P'QPQPQ\QuQSRtSkS_S#S5S:S TT!T_U U:UIU[Un V#V&V:+VTVC8WeWWXdZ0ZBHZYZoZ [#!\>\b\w\j]@^{*^C^___"_,_x|_z`*aZ_a2bbb"b+Obszbv#c&dSdryekfzf,g)fgNiii :i?iGBiPwi!.jZPjdzjRkkP=k,ckG1l,mK-m^mwimimjmqm5ymYBndn-oNobo=po[pFpAq8q/q\{qT#rKNrNsS}sITtUuIv }v16wg8wJwQ\w@xElx(vx#:yGy%1{7{5u|}E}ee}Q ~M)~A~c~{j~"`h=@co o0dU]Bqe28}T#Bi :UV+2EPS"i ||nWps}<K EIaQo?u+JpV; 'umE2D;Ra%;[g.s:$Z/&e/KjBN> O+bK lvCN$p&]Bf|oXKG\*bkn~j x6+XsZz605Cx1E!<Vf7_q4_/XyW> <&T sCY;#DCELNw%#  2 K>/<v,&0QTO7 Ys^uR~Q4rTHB'A+L6NU NF[1mAXJ=wx'dv|#2k Mfkr}W(C&b7a{!9Vk8GpvW_?r.CR[(3CFZ^BWw$+Z )I='KrZ;[bJmMpBKWn%,KZ4n \ C_Wp cu:Vc 65<@Je{] B<q C(B!rFC@^nI0c8!i?Y g*7 UXlu#[&)[ #?@D[:wB.Z`w 2<>gQsBwOu>t(_w ja;+3@xJcet@YN|"Yf^ot)(@OhC1DOrk"56789:;@F]ghijklmnot !&,;EFGHIJKP]s}~&0123456=>oyz{|}~@ jF @UnknownGz Times New Roman5Symbol3& z Arial5& zaTahoma"3h6{F;{F;{F\\)#0x42HX ?CODE Peggie.L.Dore don.wismer8         Oh+'0   @ L X dpxCODEPeggie.L.Dore Normal.dot don.wismer6Microsoft Office Word@^в@"G2@Ӕ1@"G2\՜.+,D՜.+,P  hp  $Dept. of Health and Human Services CODE TitleP <D_NewReviewCycle  !"#$%&'(*+,-./012356789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcefghijkmnopqrsvRoot Entry F0i2xData )/1Table4 _WordDocument:PSummaryInformation(dDocumentSummaryInformation8lCompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q