Maine Integrated Health Management Solution
Reference Guide for
Valid Provider Type-Specialty Pairs
Version 9.0
For use in conjunction with MIHMS Enrollment Guides
MIHMS_RG_0003_V7.2_20150220.doc
Last updated: 02/20/2015
Maine Integrated Health Management Solution
Reference Guide for Valid Provider Type-Specialty Pairs
Version History
Version / Date / Author / Action/Summary of Changes / Status3.0 / 02/23/2011 / R.J. Roy
C. Eisenhart / Summary:
Updated for remainder of changes made during completion of DDI phases; changes from State meetings and State reviews. Review included a comprehensive three-way comparison and validation of the policy matrices, the actual system configuration, and this document.
Note: Various portions of this document have been previously published as appendices to the different Enrollment Guides. This version 3.0 is the first external publication of this document as a standalone reference.
State approved 2/23/2011. / Final
3.1 / 10/15/2012 / Nicki Paul
C. Eisenhart / Updated Specialties 165, 166, 167 to Provider Type 73 per CR16273. / Draft
3.1 / 11/14/2012 / Nicki Paul
C. Eisenhart / Completed review of document set for CRs/TRs in the Sprint. / Draft
3.2 / 11/19/2012
12/04/2012 / R.J. Roy / Prepped for submission. / Draft
3.2 / 01/11/2013 / Jen Palow / Approved on behalf of State of Maine. / Draft
4.0 / 01/11/2013 / R.J. Roy / Finalized/published / Final
4.1 / 03/14/2013 / Nicki Paul / Changes for CR31175. Rename Provider Type 17 to Community Provider and add 064-IHS as a specialty.
Joint committee reviewed 3/14 and made no further changes. / Draft
4.1 / 04/16/2013 / R.J. Roy / Prepped for submission. / Draft
5.0 / 05/03/2013 / R.J. Roy / Upon State approval conveyed by Marshall Moseson, finalized and published. / Final
5.1 / 02/10/2014 / K. Goldhammer / Change Request (Detail)
· CR24704 (Homeward Bound)
· CR26219 (ORC Waiver)
· CR31969 (Flat Rate Boarding Home)
· CR32223 (Dental Hygienist)
· CR33824, CR25723, and CR30972 (Transportation)
· CR37954 (IID)
Specialties updated per the above CRs. / Draft
5.1 / 02/17/2014 / RJ Roy / QA and submission prep. / Draft
6.0 / 03/04/2014 / RJ Roy / Finalized and published upon receipt of State approval. / Final
6.1 / 05/20/2014 / Karleen Goldhammer / Change Request (Detail)
· CR40976 EMERGENCY: Providers moving from Appendix F to Appendix E
· CR35512 HCB Brain Injury Waiver, Section 18
Specialties updated per the above CRs. / Draft
6.1 / 05/22/2014 / Darcy Casey / QA Review / Draft
7.0 / 06/05/2014 / Darcy Casey / Finalization per State acceptance email dated 06/04/2014 / Final
7.1 / 1/20/2015 / Karleen Goldhammer/Cecile Eisenhart / Change Request (Detail)
· CR42034 Add ST 130-Registered Nurse First Assist to PT 02-APRN
· CR44358 Update Valid Provider Type-Specialty Pairs Reference Guide to include Section of Policy / Draft
7.1 / 02/20/2015 / Cécile Eisenhart / · Shaded every other provider type row
· Updated “MR” with “IID”
· Removed: 39-Non-Hospital Affiliated Clinic/065-Infectious Diseases
· Removed: 14-Case Management Services Provider/115-Physically Disabled Waiver
· Removed: 31-Fiscal Employer Agent/115-Physically Disabled Waiver and 31-Fiscal Employer Agent/141-EADW-FPSO
· Removed: 73-Waiver Services Provider/115-Physically Disabled Waiver
· Updated version
· Spacing to prevent row splitting except for 51-Physician and 73-Waiver Services Provider / Final
7.1 / 02/27/2015 / Darcy Casey / QA review and prep for formal submission to the State / Draft
7.2 / 03/17/2015 / Darcy Casey / Revisions per State comment log v7.1 dated 03/16/2015 / Draft
8.0 / 03/17/2015 / Darcy Casey / Finalization per State acceptance email dated 03/17/2015 / Final
8.1 / 04/19/2016 / Lisa Bongiovanni, Pam Foster / Updates to Section 2, Table 2-1 per ACA Provider Revalidation CR41423
QA review and prep for State submission / Draft
8.2 / 11/10/2016 / Pam Foster / Updates per State comment log v8.1 dated 05/05/2016 / Draft
9.0 / 12/09/2016 / Pam Foster / Finalization per State acceptance email dated 12/09/2016 / Final
MIHMS_RG_0003_v9.0_20161209.docx
Last updated: 12/09/2016
Maine Integrated Health Management Solution
Reference Guide for Valid Provider Type-Specialty Pairs
Usage Information
Documents published herein are furnished “As Is.” There are no expressed or implied warranties. The content of this document herein is subject to change without notice.
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MIHMS_RG_0003_v9.0_20161209.docx
Last updated: 12/09/2016
Maine Integrated Health Management Solution
Reference Guide for Valid Provider Type-Specialty Pairs
Table of Contents
1. Introduction 1
2. Individual Providers 2
3. Provider Groups 7
4. Facility, Agency, and Organization (FAO) Providers 8
4.1 Rendering Providers Required 8
4.2 Rendering Providers Not Required 9
Table of Figures
Table 1: References 1
Table 21: Individual Providers 3
Table 31: Provider Groups 7
Table 41: FAO with Rendering Providers Required 8
Table 42: FAO with Rendering Providers Not Required (“FAO Non-Rendering”) 9
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Maine Integrated Health Management Solution
Reference Guide for Valid Provider Type-Specialty Pairs
1. Introduction
There are three reference guides for Providers to use during Enrollment or Re-Enrollment:
· Standard Abbreviations and Postal Information
· Valid Provider Type-Specialty Pairs
· Allowed Services by Provider Types
In this Reference Guide for Valid Provider Type-Specialty Pairs you will find:
· Table 21 for individual providers;
· Table 31 for provider groups;
· Table 41for FAO with Rendering Providers Required; and
· Table 42 for FAO with Rendering Providers Not Required.
You will need to refer to this information during enrollment and/or reenrollment.
Use this chart below to determine which table to use.
Enrollment applications must contain the correct provider type and specialty (or specialties). Failure to do so could result in delays in application processing or incorrect claim reimbursement. Every enrolling provider will need to use at least one of the tables in this Reference Guide. (See Table 1below.)
Table 1: References
Enrollment Type / Reference Guide Table(s) to Use / In this Guide … /Type 1 – Individual / Individual Providers / See Table 21
Type 1 – Individual as Group or FAO / Provider Groups / See Table 31
FAO with Rendering / See Table 41
FAO Non-Rendering / See Table 42
Type 2 – Incorporated Individual / Provider Groups / See Table 31
Type 2 – Organization as Group or FAO / Provider Groups / See Table 31
FAO with Rendering / See Table 41
FAO Non-Rendering / See Table 42
No NPI Type – Atypical Provider / FAO Non-Rendering / See Table 42
New combinations of provider types and specialty pairs are added from time to time and pairs are also sometimes removed. If you don’t see your PT/SP combination type here and believe it should be here according to a ListServ message or reasonable expectation, you may go on the MIHMS Health PAS Online Portal to see if your provider type is displayed as available (and therefore, valid) in the system or you may call Provider Enrollment for more information.
2. Individual Providers
The following table lists the provider types and specialties that are appropriate and valid for individual providers. For those provider types that do not require a specialty, the specialty listed in the table is 000-No Specialty Required. Table 21 indicates those provider type and specialties which allow Non-billing, Ordering, Prescribing, or Referring (NOPR) providers.
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Maine Integrated Health Management Solution
Reference Guide for Valid Provider Type-Specialty Pairs
Table 21: Individual Providers
Provider Type / Specialty / Allowed Non-billing, Ordering Prescribing, or Referring (NOPR) / MaineCare Benefits ManualSpecific Policies By Service /
02-Advanced Practice Registered Nurse / 014-Certified Clinical Nurse Specialist
015-Certified Nurse Midwife
016-Certified Nurse Practitioner
017-Certified Registered Nurse Anesthetist / 014-Certified Clinical Nurse Specialist
015-Certified Nurse Midwife
016-Certified Nurse Practitioner
O / Section 14: Advanced Practice Registered Nursing Services
130-Registered Nurse First Assist / O / Rendering Provider Only
09-Audiologist / 007-Audiology / O / Section 35: Hearing Aids and Services
Section 109: Speech and Hearing Services
11-Behavioral Health Clinician / 070-Licensed Clinical Professional Counselor
071-Licensed Clinical Social Worker
072-Licensed Marriage and Family Therapist
122-Psychological Examiner
123-Psychology / O / Section 65: Behavioral Health Services
013-Certified Alcohol and Drug Counselor
069-Licensed Alcohol and Drug Counselor
073-Licensed Master Social Worker / N / Rendering Provider Only
16-Chiropractor / 018-Chiropractor / O 018-Chiropractor / Section 15: Chiropractic Services
20-Dental Hygienist / 036-Public Health Supervision Status-RDH
171-Public Health Supervision Status-IPDH
172- Independent Practice Dental Hygiene / O / Section 25: Dental Services
22-Dentist
22-Dentist
(continued) / 028-Dentist-Endodontist
029-Dentist-General
030-Dentist-Oral Pathologist
031-Dentist-Orthodonture
032-Dentist-Pedodontist
033-Dentist-Periodontist
034-Dentist-Prosthodontist
093-Oral/Maxillofacial Surgery / O 028-Dentist-Endodontist
029-Dentist-General
030-Dentist-Oral Pathologist
031-Dentist-Orthodonture
032-Dentist-Pedodontist
033-Dentist-Periodontist
034-Dentist-Prosthodontist
093-Oral/Maxillofacial Surgery / Section 25: Dental Services
23-Denturist / 037-Denturist / O / Section 25: Dental Services
26-Dietician / 000-No Specialty Required / N / Rendering Provider Only
40-Nurse / 074-Licensed Practical Nurse
129-Registered Nurse
/ O / Section 19: Home and Community Benefits for the Elderly and for Adults with Disabilities
Section 96: Private Duty Nursing and Personal Care Services
130-Registered Nurse First Assistant / N / Rendering Provider Only
42-Occupational Therapist / 088-Occupational Therapy / O / Section 19: Home and Community Benefits for the Elderly and for Adults with Disabilities
Section 68: Occupational Therapy Services
43-Occupational Therapy Assistant / 088-Occupational Therapy / N / Rendering Provider Only
45-Optician / 091-Optician / O / Section 35: Hearing Aids and Services
Section 75: Vision Services
46-Optometrist / 092-Optometry / O092-Optometry / Section 75: Vision Services
49-Physical Therapist / 114-Physical Therapy / O / Section 19: Home and Community Benefits for the Elderly and for Adults with Disabilities
Section 85: Physical Therapy Services
50-Physical Therapy Assistant / 114-Physical Therapy / N / Rendering Provider Only
51-Physician
51-Physician
(continued) / 001-Addiction Services
003-Allergy & Immunology
004-Anesthesiology
010-Cardiologist
011-Cardiovascular Surgery
019-Colon and Rectal Surgery
026-Critical Care Medicine
039-Dermatology
043-Emergency Medicine
045-Endocrinology
046-Family Practice
052-Gastroenterology
053-General Practice
054-General Surgery
056-Geriatrics
057-Gynecology
058-Hand Surgery
059-Hematology
065-Infectious Diseases
067-Internal Medicine
080-Nephrology
081-Neurology
082-Neurosurgery
084-Nuclear Medicine
086-Obstetrician and Gynecologist
087-Obstetrics
089-Oncology
090-Opthalmology
093-Oral/Maxillofacial Surgery
094-Orthopedic Surgery
096-Osteopathic Manipulative Therapy
097-Otolaryngologist
098-Otologist
099-Otorhinolaryngologist (ENT)
100-Pathology
102-Pediatric Allergist
103-Pediatric Cardiology
104-Pediatric Dermatology
105-Pediatric Endocrinologist
106-Pediatric Hematologist
107-Pediatric Hematology-Oncology
108-Pediatric Nephrologist
109-Pediatric Neurologist
110-Pediatrics
113-Physical Medicine & Rehabilitation
117-Plastic Surgery
119-Preventive Medicine
121-Psychiatry
124-Pulmonary Diseases
125-Radiation Oncology
126-Radiation Therapy
128-Radiology - Diagnostic
131-Rheumatology
137-Thoracic Surgery
138-Urology
139-Vascular Surgery / O001-Addiction Services
003-Allergy & Immunology
004-Anesthesiology
010-Cardiologist
011-Cardiovascular Surgery
019-Colon and Rectal Surgery
026-Critical Care Medicine
039-Dermatology
043-Emergency Medicine
045-Endocrinology
046-Family Practice
052-Gastroenterology
053-General Practice
054-General Surgery
056-Geriatrics
057-Gynecology
058-Hand Surgery
059-Hematology
065-Infectious Diseases
067-Internal Medicine
080-Nephrology
081-Neurology
082-Neurosurgery
084-Nuclear Medicine
086-Obstetrician and Gynecologist
087-Obstetrics
089-Oncology
090-Opthalmology
093-Oral/Maxillofacial Surgery
094-Orthopedic Surgery
096-Osteopathic Manipulative Therapy
097-Otolaryngologist
098-Otologist
099-Otorhinolaryngologist (ENT)
100-Pathology
102-Pediatric Allergist
103-Pediatric Cardiology
104-Pediatric Dermatology
105-Pediatric Endocrinologist
106-Pediatric Hematologist
107-Pediatric Hematology-Oncology
108-Pediatric Nephrologist
109-Pediatric Neurologist
110-Pediatrics
113-Physical Medicine & Rehabilitation
117-Plastic Surgery
119-Preventive Medicine
121-Psychiatry
124-Pulmonary Diseases
125-Radiation Oncology
126-Radiation Therapy
128-Radiology - Diagnostic
131-Rheumatology
137-Thoracic Surgery
138-Urology
139-Vascular Surgery / Section 90: Physician Services
52-Physician Assistant / 116-Physician Assistant / N116-Physician Assistant / Rendering Provider Only
56-Podiatrist / 118-Podiatry / O118-Podiatry / Section 95: Podiatric Services
63-Speech Language Pathologist / 134-Speech Therapy / O / Section 19: Home and Community Benefits for the Elderly and for Adults with Disabilities
Section 109: Speech and Hearing Services
65-Speech Therapy Assistant / 134-Speech Therapy / N / Rendering Provider Only
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Maine Integrated Health Management Solution
Reference Guide for Valid Provider Type-Specialty Pairs
3. Provider Groups
The following table (Table 31) lists the provider types and specialties that are appropriate and valid for provider groups. Note that the specialties for all provider groups in this table are derived from the rendering providers’ specialties during the enrollment process.
When you enroll a provider group, you will not choose a specialty. The specialty will default to 038-Derived from Rendering Specialties. When you enroll individual providers within the group, their specialties will be assigned to your provider group for as many specialties as you enroll.
For a list of valid rendering providers’ types and specialties for provider groups, refer to the Reference Guide for Allowed Services by Provider Type.
Table 31: Provider Groups
Provider Type / Specialty / MaineCare Benefits ManualSpecific Policies By Service /
03-Advanced Practice Registered Nursing Group / 038-Derived from Rendering Specialties / Section 14: Advanced Practice Registered Nursing Services
10-Audiology Group / 038-Derived from Rendering Specialties / Section 35: Hearing Aids and Services
Section 109: Speech and Hearing Services
12-Behavioral Health Clinician Group / 038-Derived from Rendering Specialties / Section 65: Behavioral Health Services
15-Chiropractic Group / 038-Derived from Rendering Specialties / Section 15: Chiropractic Services
19-Dental Group / 038-Derived from Rendering Specialties / Section 25: Dental Services
21-Dental Hygienist Group / 038-Derived from Rendering Specialties / Section 25: Dental Services
24-Denturist Group / 038-Derived from Rendering Specialties / Section 25: Dental Services
44-Occupational/Physical Therapy Group / 038-Derived from Rendering Specialties / Section 19: Home and Community Benefits for the Elderly and for Adults with Disabilities
Section 68: Occupational Therapy Services
Section 85: Physical Therapy Services
54-Physician Group / 038-Derived from Rendering Specialties / Section 90: Physician Services
57-Podiatry Group / 038-Derived from Rendering Specialties / Section 95: Podiatric Services
64-Speech Language Pathology Group / 038-Derived from Rendering Specialties / Section 19: Home and Community Benefits for the Elderly and for Adults with Disabilities
Section 109: Speech and Hearing Services
67-Speech/Hearing Therapist Group / 038-Derived from Rendering Specialties / Section 35: Hearing Aids and Services
Section 109: Speech and Hearing Services
72-Vision Services Provider Group / 038-Derived from Rendering Specialties / Section 35: Hearing Aids and Services
Section 75: Vision Services
4. Facility, Agency, and Organization (FAO) Providers
4.1 Rendering Providers Required
The following table (Table 41) lists the provider types and specialties that are appropriate and valid for FAO providers for which rendering providers are required. For those provider types that do not require a specialty, the specialty listed in the table is 000-No Specialty Required.