2013 Archives Hot Tip of the Week

“After Hours” and “Holiday Hours” Billing

December 30, 2013

Holidays are quickly approaching, a review of “after hours” and “holiday hours” billing is necessary.

Information regarding physician services after hours may be found in Section 13.21 A and 13.21 B of the physician manual.

For those physician office/clinic services requested on Sundays or on one of the following specified holidays, the physician may bill procedure code 99051 “Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours”, in addition to the appropriate procedure code for the service performed.

The following holidays are recognized:

  • Memorial Day
  • Independence Day
  • Labor Day
  • Thanksgiving Day
  • Christmas Day
  • New Year's Day

Medicare/Medicaid Name Mismatches May Delay Crossover Claim Processing

December 23, 2013

Claims for dual eligible individuals with Medicare and Medicaid coverage crossover from Medicare to Medicaid for payment. A delay in crossover claim processing could occur when the participant’s demographic information from Medicare does not match information on the Medicaid file. The participant’s name identified on the Medicare and Social Security Administration (SSA) forms may not correlate with the name on the Family Support Division (FSD) and Medicaid records.

Providers should obtain a copy of the person’s Medicaid and Medicare cards. These forms of identification should indicate if there is a discrepancy with the name given to the provider. The proper identification will assist in filing of crossover claims. If there is a discrepancy, the provider should communicate with the participant, at the time of service, and direct the participant to contact all applicable agencies to resolve the name discrepancy.

How to Get Ready for ICD-10

December 16, 2013

Please be advised that extensive ICD-10 training is not provided by Centers for Medicare and Medicaid Services (CMS) or MO HealthNet. However, there are many resources available based on your practice, clinic, and organization size. CMS has compiled some useful information to assist in the transition.

The American Health Information Management Association (AHIMA) offers actual ICD-10 training. Much of their training provides CEU’s and certificates for use with professional licensures.

Other helpful links:

In the search section of any of these websites, just type in ICD-10.

Please read the Provider Bulletin, dated October 16, 2013, for ICD-10 Updates.

How to Access MO HealthNet Managed Care Contracts

December 9, 2013

MO HealthNet Managed Care contracts may be accessed on the Office of Administration (OA) website. The information most commonly requested can be found in the following sections:

Prior Authorizations 2.5.5; Transition of Care 2.5.9; Eligibility, Enrollment and Disenrollment 2.12

The following contract number or RFP number will assist you in accessing the information on OA’s website.

Contract Numbers
HealthCare USA - C312055001
Missouri Care - C312055002
Home State Health Plan - C312055003
RFP Number
B3Z12055

The steps to Obtain Contracts and RFPs from OA’s website are indicated below:

  1. On the OA Budget & Planning page, select the menu button on the far right that says “Purchasing”
  2. Select “Awarded Bids and Contract Search”
  3. Select “Please Enter Here” at bottom of page
  4. Go to the box that says “Select a saved search” and select “Search by Contract Number” Enter the contract number.
  5. You should get several observations. If you want to download the entire contract,
  6. Select the “Edit” button
  7. Select the “Select All” option
  8. Then hit “view”

The e-mail address to send inquiries/reports regarding issues after trying to work with the managed care plan directly is ask.mhd@dss.mo.gov.

Claims that Require Special Handling Clarified

December 2, 2013

Clarification for November 12, 2013, Hot Tip,
“Special Claims for Special Handling—Medical Denials and/or Medicare Part C Non-QMB”

The Hot Tip dated November 12, 2013, appeared to imply that all Medicare Part C Non-QMB claims required special handling. However, this is not all inclusive and not all Medicare Part C Non-QMB claims require special handling. Most Medicare Part C Non-QMB claims may be submitted over eMOMED using the appropriate claim form. There are Medicare Part C Non-QMB claims that require special handling. For example, Ambulance Providers on prepayment review must send paper claims for special handling and must have the trip sheet and narrative attached.

When an enrolled MO HealthNet Division (MHD) provider sends claims directly to MHD staff for special handling, a cover sheet that includes the directions for the special handling must be attached.

When submitting a claim that requires special handling by MHD staff or a claim denied for Medicare services, please follow the instructions below:

  • A provider contact person and telephone number must be included in case there are questions regarding the request or additional documentation is needed for processing.
  • Complete the appropriate paper claim form (i.e. CMS-1500 Medical claim form, UB-04 Inpatient claim form, UB-04 Outpatient claim form).
  • Staple the claim, attachments, the Medicare denial and/or Medicare Part C, Explanation of Medical Benefits, and other applicable documentation together.
  • If you have discussed your claim issue with a specific individual at MHD, please address your correspondence to the specific individual and send to:

    MO HealthNet Division
    P. O. Box 6500
    Jefferson City, MO 65102

  • If the required information is not included with the claim, the request will not be processed and will be returned.

Incarcerated Participants

November 25, 2013

There is no MO HealthNet coverage for an individual that is an inmate residing in a public institution. An individual is an inmate when serving time for a criminal offense or confined involuntarily to a state or federal prison, jail, detention facility or other penal facility. An individual voluntarily residing in a public institution is not an inmate. A facility is a public institution when it is under the responsibility of a government unit, or a government unit exercises administrative control over the facility.

However, if an inmate is admitted as an inpatient in a hospital, nursing facility, juvenile psychiatric facility or intermediate care facility, the Family Support Division office in the county in which the penal institution is located, may accept the appropriate type of application for MO HealthNet benefits. If approved, MO HealthNet eligibility is limited to the days in which the individual was an inpatient in the medical institution.

Complete information regarding MO HealthNet coverage for inmates of a public institution is found in Section 1.5.L, Section 1.5.L(1) and 1.5.L(2) of your MO HealthNet provider manual.

November 18, 2013

General claim billing, claim denials, Remittance Advices, and participant eligibility questions should be directed to the Provider Communications Unit at (573) 751-2896. The Provider Education Unit should be contacted for program training, proper billing methods, and procedures for MO HealthNet Claims, and questions regarding policy clarification.

Requests for provider training can be made by email to mhd.provtrain@dss.mo.gov or by telephone at (573) 751-6683. All information, including the provider NPI number, must be readily available.

When calling the Provider Education Training Unit, ask for the appropriate representative shown below. If you need to leave a message be sure to include your name, the provider name, provider NPI, telephone number, extension number if necessary, and the type of training needed. The entire list is not shown below for all the MO HealthNet programs. However, by providing the pertinent information described above, your request for assistance can be directed to the appropriate staff.

The names of the Provider Education representatives and some of their training programs are listed below:

Becky Rickard – personal care/homemaker-chore, home health, private duty nursing, behavioral health, adult day health care, speech/occupational/physical therapy, including these providers within a group or clinic.

Katherine Hinkle-Black – durable medical equipment, ambulance, audiologist (hearing aid) , nursing homes, private home, dental, hospice, optical (optometrists), including these providers within a group or clinic.

Gina Overmann – nurse practitioners, podiatrists, hospitals, physician/clinics, professional medical billing concerning Federally Qualified Health Centers and Rural Health Clinics. NOTE: Responsible for providers West of MO Hwy. 63. For providers on Hwy. 63, Gina has Jefferson City and South.

Kim Morgan – nurse practitioners, podiatrists, hospitals, physician/clinics, professional medical billing concerning Federally Qualified Health Centers and Rural Health Clinics. NOTE: Responsible for providers East of MO Hwy. 63. For providers on Hwy. 63, Kim has North of Jefferson City.

Special Claims for Special Handling—Medical Denials and/or Medicare Part C Non-QMB

Nov. 12, 2013

When an enrolled MO HealthNet Division (MHD) provider sends claims directly to MHD staff for special handling, a cover sheet that includes the directions for the special handling must be attached. A provider contact person and telephone number must be included in case there are questions regarding the request or additional documentation is needed for processing. If the required information is not included with your claim, the request will not be processed and will be returned to you.

When submitting a claim that requires special handling by MHD staff, such as a participant who has Medicare Part C but is not QMB eligible or a claim denied for Medicare services, please follow the instructions below to send the claim(s) for special handling.

  • Provide a contact person and telephone number for questions regarding the request.
  • Complete the appropriate paper claim form (CMS-1500 Medical claim form, UB-04 Inpatient claim form, UB-04 Outpatient claim form).
  • Staple the claim, attachments, the Medicare denial and/or Medicare Part C, Explanation of Medical Benefits and other applicable documentation together.
  • If you have discussed your claim issue with a specific individual at MHD, please address your correspondence to the specific individual and send to:

    MO HealthNet Division
    P. O. Box 6500
    Jefferson City, MO 65102

Dental Services: Outpatient Hospital and Emergency Room

November 04, 2013

Dental services provided to an adult in an outpatient hospital or emergency room setting, must be related to trauma of the mouth, jaw, teeth, or other contiguous sites as a result of injury or for treatment of a medical condition without which the health of the individual would be adversely affected.

Facility and ancillary charges can only be billed for an adult if those services are related to trauma of the mouth, jaw, teeth, or other contiguous sites as a result of injury or treatment of a medical condition without which the health of the individual would be adversely affected.

MO HealthNet Provider Manuals

October 28, 2013

The MO HealthNet Division (MHD) publishes 32 provider manuals and 7 billing layout manuals for viewing on the Internet. Provider manuals may be accessed via the Provider Manual Home Page at http://manuals.momed.com/manuals/ and billing manuals may be accessed at http://dss.mo.gov/mhd/providers/education/. Save these sites to "Favorites" for a quick reference.

In order to view and/or print the MO HealthNet Provider Manuals, Appendixes, and/or Forms you must have Adobe Acrobat Reader. If you do not have Adobe Acrobat Reader installed, click on the "Get Acrobat Reader" icon at the bottom of the Provider Manual Home Page or the MO HealthNet home page, and follow the instructions for downloading the Reader to your computer. There are multiple ways to find the information you need. You may:

  • Search by word or phrase.
  • View by Date, or
  • Archive Files Search

You may search for information within a single manual or all manuals. You may also find all available forms in alphabetical order.

Where Can Providers Obtain MO HealthNet Program Assistance?

October 21, 2013

Providers may contact the MO HealthNet Interactive Voice Response System (IVR) telephone number for MO HealthNet program assistance at 573-751-2896. The IVR provides answers to such questions as participant eligibility, last two check amounts, and claim status using a touch-tone telephone.

MO HealthNet providers may follow the prompts in order to check participant eligibility, obtain check amount information, claim information, and to talk with a MO HealthNet specialist at Provider Communications. Provider Communications staff assist providers with inquiries, concerns, or questions regarding proper claim filing instructions, claims resolution and disposition, and participant eligibility file problems.

Providers may send and receive secure e-mail inquiries through the MO HealthNet web portal at emomed.com. Once you have logged on to the e-provider page, click on Provider Communications Management to send inquiries, or questions regarding proper claim filing instructions, claims resolution and disposition, and participant eligibility file problems. Providers may send one inquiry per e-mail.

Written inquiries are also handled by the Provider Communications Unit and can be mailed to the following address:

Provider Communications Unit
P.O. Box 5500
Jefferson City, MO 65102-5500

Remittance Advice Remark Codes and Claim Adjustment Reason Codes

October 15, 2013

A reminder that MO HealthNet edits and EOBs do not appear on Remittance Advices. The Washington Publishing Company web site is a helpful resource for providers when working with remittance advice and claim adjustments. Remittance Advice Remark Codes and Claim Adjustment Reason Codes are available on Washington Publishing Company's web page at http://www.wpc-edi.com/reference/

Claims Processing Schedule for Fiscal Year 2014

October 7, 2013

When processing a claim, be advised that a claim must be processed by the "Financial Cycle Date," in order to be posted by the "Provider Check Date." The chart below assists providers in determining when checks will be posted to provider accounts. Notice that the check dates are not strictly on the 5th and 20th of each month.

For example, if a claim is filed by 09/13/13, it will cycle on 09/13/13, and the provider check date will be 09/24/13.
If a claim is filed after 09/13/13, financial cycle date, it will not cycle until 09/27/13; therefore, the provider check date will be 10/7/13.

Financial Cycle Date Provider Check Date
Note 1: Closeout  is 5:00 PM on the date shown
Friday 06/21/2013 Friday 07/05/2013
Friday 07/12/2013 Friday 07/19/2013
Friday 07/26/2013 Tuesday 08/06/2013
Friday 08/16/2013 Friday 08/23/2013
Friday 08/30/2013 Tuesday 09/10/2013
Friday 09/13/2013 Tuesday 09/24/2013
Friday 09/27/2013 Monday 10/07/2013
Friday 10/11/2013 Tuesday 10/22/2013
Friday 10/25/2013 Tuesday 11/05/2013
Friday 11/08/2013 Wednesday 11/20/2013
Friday 11/22/2013 Thursday 12/05/2013
Friday 12/13/2013 Friday 12/20/2013
Friday 12/27/2013 Tuesday 01/07/2014
Friday 01/10/2014 Thursday 01/23/2014
Friday 01/24/2014 Wednesday 02/05/2014
Friday 02/07/2014 Thursday 02/20/2014
Friday 02/21/2014 Wednesday 03/05/2014
Friday 03/07/2014 Thursday 03/20/2014
Friday 03/21/2014 Friday 04/04/2014
Friday 04/04/2014 Friday 04/18/2014
Friday 04/18/2014 Friday 05/02/2014
Friday 05/09/2014 Friday 05/16/2014
Friday 05/23/2014 Thursday 06/05/2014
Friday 06/06/2014 Friday 06/20/2014

Important HCAC & POA Reporting Tips

September 30, 2013

Attention Inpatient Hospital Billing and Utilization Review Staff:

The editing for Health Care-Acquired Conditions (HCAC) only occurs on inpatient claims. When reporting a HCAC, either on the claim or during the inpatient certification process, the Present on Admission (POA) indicator must be used to indicate whether or not the condition was present at the time of admission. Below is a list of quick tips to use when reporting HCACs with the POA indicator.

  • Transfers within the same hospital are considered one continuous stay. If a HCAC occurs in one wing of the hospital followed by the patient transfer to another wing, the POA indicator must be N-No even if the claim is split billed for the different wings.
  • HCACs that occur in the outpatient hospital setting prior to the order to admit the patient to an inpatient status would be reported with a POA indicator of Y-Yes when submitting the inpatient certification and on the inpatient claim. Since the illness or injury occurred prior to the inpatient admission, it is considered present at the time of admission and would not be considered a HCAC.
  • When a patient is admitted as a result of an injury or illness that occurred one or more days prior to the patient being admitted as an inpatient, it must be reported with the POA indicator of Y-Yes because the condition or injury was present at the time of admission.
  • When reporting a HCAC during the inpatient certification process, the Diagnosis Onset Date is the date the HCAC occurred or is first documented in the patient's medical record.
  • Additional questions may be emailed to clinical.services@dss.mo.gov for response.

Billing Office Medical Supplies

September 23, 2013

Physicians may bill for supplies and materials in addition to an office visit if these supplies are over and above those usually included with the office visit. Appropriate supplies may be billed by the provider with the appropriate procedure code. Refer to Section 19.5 for a list of supply and material procedure codes. Supplies such as gowns, drapes, gloves, specula, pelvic supplies, urine cups, swabs, jelly, etc., are included in the office visit and may not be billed separately. Providers may not bill for any reusable supplies.

An invoice of cost showing the cost and the description of the supply must be submitted with the claim when procedure code 99070 is billed. This information is found in Section 13.22 of the Physician Provider Manual.

An electronic invoice of cost attachment is available to providers through the billing website.

MO HealthNet Medicaid Program Webinars

September 16, 2013

The MO HealthNet Provider Education Unit schedules webinars on a quarterly basis for many of the MO HealthNet Medicaid programs. If a provider has registered for a MO HealthNet webinar and cannot attend for any reason, the webinar participant should contact MO HealthNet Provider Education and cancel their registration. Only 12 participants are allowed to register for each webinar and at times there is a waiting list. By notifying MO HealthNet of the cancellation, providers on the waiting list will be contacted and given the opportunity to register.

When Providers register for a webinar, their names and/or agency information is entered on an attendance sheet. At the time the webinar begins, the education representative will ask who has called in so the names can be checked off the registration list even though the name appears in a box on the screen. The name list can sometimes be quite long and the representative may not always see late sign-ins. With this in mind, providers are asked to verbally inform the representative they have called in to assure they receive credit for attendance.

Retrieving an Aged/Older Remittance Advice

September 09, 2013

A provider may occasionally need an older Remittance Advice (RA). Older RAs are available through the MO HealthNet Internet billing web site at emomed.com. A provider can request multiple older RAs per day but only one can be requested at a time. Access to older RAs is limited to the past three years based on the date the request is submitted.

On the new Welcome to eProvider Home Page, click on File Management and make sure to choose the appropriate NPI for the Remittance Advice to be requested. On the File Management page, click on "Request Aged RA". Enter the month (MM), year (CCYY) and cycle one (1) for the first cycle of the month or two (2) for the second cycle of the month. Click on Save and then on Finished.

The requested aged RA is available the next business day following the day the request is submitted. To obtain an aged RA, go to the emomed.com Home Page and under File Management, choose "Printable Aged RA". The dates of all the RAs requested will be displayed in the Results box. Clicking on the Adobe icon on the right side of the date brings up the RA in the standard RA Adobe format. To print, click on the printer icon or select print from "File" on the tool bar at the top of the page. Additionally, it can be saved to your computer system for future reference. The aged RAs stay on this page for five (5) calendar days following the date of the request and then are deleted from the page.

Transportation for Hospital Discharge

September 03, 2013

Transportation for hospital discharges for eligible participants can be arranged by calling the Non-Emergency Medical Transportation (NEMT) broker for MO HealthNet, toll free at (866)269-5927. Hospital staff, discharge planners, social workers and case managers must call the broker to arrange the hospital discharge for the most appropriate mode of transportation based on the participant's medical needs. NEMT services are available 24 hours per day, 7 days per week.

When individuals are transported by ambulance to an emergency room for treatment and then released without admission to the hospital, the return trip to the participant's home is only covered under the Non-Emergency Medical Transportation (NEMT) Program. The same holds true for a nursing home resident who is discharged from a hospital stay. Participants will be picked up from hospital discharge no more than three (3) hours from notification of the non-emergency transportation need from the discharging hospital.

Neither the participant nor MO HealthNet are responsible for payment if physicians, hospital staff or others arrange ambulance transports for non-emergency trips that are covered under the NEMT program without authorization from the NEMT broker. Missouri Code of State Regulations 13 CSR 70-4.030 (2) states a "service will not be the liability of the participant if the service would have been otherwise payable by the MO HealthNet agency at the MO HealthNet allowable amount had the provider followed all of the policies, procedures and rules applicable to the service as of the date provided."

For more information on NEMT and all the modes of transportation under NEMT, providers can reference Section 22 of any provider manual.

Routine Foot Care/Debridement of Nails

August 26, 2013

MO HealthNet does not cover routine foot care. This involves the removal of corns, calluses or growths, trimming of toenails (grinding, debridement or reduction), and other hygienic or preventive maintenance.

Foot care is not considered routine when the claim indicates the participant has a diagnosis of diabetes mellitus or other peripheral vascular disease (e.g., diabetes with peripheral circulatory disorders, Raynaud's Syndrome, thromboangiitis obliterans and other specified peripheral vascular disease).

When coding unilateral or bilateral debridement of nails, procedure code 11720 (debridement of nail(s) any method, one to five) or procedure code 11721 (same, six or more), the number of units of service (quantity) should be one for each procedure code. This information can be found in Section 13.33.C of the Physician Provider Manual.

Refer to Section 13.62 of the Physician Provider Manual for information on limitations for certain podiatry services.

Pharmacy Claims, APRN Prescribers

August 19, 2013

Providers have been experiencing pharmacy claim denials for Advance Practice Nurses (APRN) when claims are submitted using the APRN's NPI number in the prescribing ID field. Following established national standards for claims submission, MO HealthNet made a system change on April 14, 2013, to allow the APRN's NPI number in the prescribing ID field of pharmacy claims. This system update was announced in the February bulletin, HIPAA and CORE Phase I and II System Enhancements. Before April 14, 2013, MO HealthNet required the practitioner's DEA number or the legacy MO HealthNet ID to be in the prescribing ID field in order for the claim to be reimbursed.

In order to submit pharmacy claims for reimbursement using the NPI number, all APRNs, regardless of specialty or location of services provided, must be an enrolled MO HealthNet provider and their enrollment status must include a specialty code which designates them as having prescriptive authority, or pharmacy claims with APRNs as prescribers will be reimbursed if the APRN has a DEA number associated with their NPI number on the HCIdea file, as referenced in the HIPAA and CORE Phase I and II System Enhancements bulletin. If an APRN is not an enrolled MO HealthNet provider and does not possess the prescriptive authority code, or does not have a DEA number associated with their NPI number on the HCIdea file, the pharmacy claims will deny.

Question 19 of the enrollment application must be answered yes in order to have the prescriptive authority specialty code added to the record. Additionally, a copy of the collaborative practice agreement which delegates prescriptive authority must accompany the application.

To add the prescriptive authority to a current enrollment record, a Provider Update Request form must be submitted along with a copy of the collaborative practice agreement that delegates prescriptive authority.

If a pharmacy receives a claim rejection for "Provider number missing or invalid" or "Provider not eligible to perform service/dispense product", they should contact the MO HealthNet Pharmacy Help Desk at 573-751-6963 for assistance.

Infusion Therapy

August 19, 2013

The following infusion therapy procedures are covered in the office setting and require the presence of the physician during the infusion. They are not to be used for intradermal, subcutaneous, intramuscular or routine IV drug injections. Physicians may bill a maximum of eight units of IV services using procedure code 96361 in addition to one hour of 96360, making a total of nine units of infusion therapy, which is also referred to as intravenous therapy (IV).

The services of the physician supervising infusion therapy in the inpatient or outpatient hospital setting are to be billed using the appropriate Evaluation and Management procedure codes. Infusion therapy by nurses in an inpatient or outpatient setting is included in the facility charge and is not separately billable (e.g., chemotherapy, antibiotic therapy, hydration therapy, immune globulin therapy, IV rate change, pitocin, etc.).

This information can be found in Section 13.23.H of the Physician Provider Manual.

How Do Providers Stay Current On MO HealthNet Policy

August 12, 2013

Providers can check MO HealthNet policy changes by visiting the Provider Bulletins page and MO HealthNet News Archives located under Featured Links on MO HealthNet's provider page.

Providers can also choose to be notified by e-mail when updates occur to the MO HealthNet web site by subscribing to MO HealthNet News.

The provider can receive notification when a new bulletin or e-mail blast is issued or new information is published to the web site. This enables providers to be up-to-date on the latest MO HealthNet changes.

Submitting Prior Authorization Requests For Orthodontic Treatment

August 5, 2013

The MO HealthNet Division has been receiving numerous Prior Authorization (PA) requests for comprehensive orthodontic treatment which are incomplete. It is the responsibility of the treating dentist/orthodontist to properly screen the participants and send in a PA request. MO HealthNet encourages the treating dentist/orthodontist to exclude submitting cases that obviously do not qualify for treatment.

The determination whether or not a participant will be approved for orthodontic treatment is done by initially screening using the Handicapping Labio-Lingual Deviation (HLD) Index. The HLD Index must be fully completed in accordance with the instructions in Subsection 14.3.B of the MO HealthNet Dental Provider Manual, signed and dated by the treating orthodontist/dentist, and must be submitted with the PA request form. MO HealthNet will approve orthodontic services when the participant meets all the criteria stated in Subsection 13.42.A of the dental manual and one (1) of the criteria listed below:

  1. Has a cleft palate;
  2. Has a deep impinging overbite when the lower incisors are damaging the soft tissue of the palate (lower incisor contact only on the palate is not sufficient);
  3. Has a cross-bite of individual anterior teeth when damage of soft tissue is present. If this does not show on the models, photos must be provided;
  4. Has severe traumatic deviations;
  5. Has an over-jet greater than nine millimeters (9mm) or reverse over-jet of greater than three and one-half millimeters;
  6. Has an impacted maxillary central incisor; or
  7. Scores twenty-eight (28) points or greater on the HLD Index.

Common errors for PA requests:

  1. Deep bite without signs of tissue damage is not an automatic approval;
  2. Cross-bite without signs of tissue damage is not an automatic approval;
  3. Crowding and ectopic anterior teeth in the same arch cannot be scored at the same time;
  4. Models are trimmed incorrectly so overjet/overbite cannot be determined;
  5. Requests for medical necessity approval do not have the required additional documentation; or
  6. Requests when the score is less than 28 points on the HLD and the patient does not have an automatic qualifier and no documentation has been provided supporting a medical necessity exemption.

Participants meeting criteria as stated in Subsection 13.42.A in the MO HealthNet Dental manual but not one of the above criteria may still be considered for orthodontic services based on evidence of medical necessity described in 13 CSR 70-35.010. Section 13.42.C of the Dental manual outlines detailed medical necessity criteria. Please note, orthodontic treatment shall not be considered to be medically necessary when:

  1. The orthodontic treatment is for aesthetic or cosmetic reasons only;
  2. The orthodontic treatment is to correct crowded teeth only, if the child can adequately protect the periodontium with reasonable oral hygiene measures; or
  3. The child has demonstrated a lack of motivation to maintain reasonable standards of oral hygiene and oral hygiene is deficient.

The MO HealthNet Dental manual can be found at http://manuals.momed.com/

We Need Your Suggestions

July 29, 2013

The Provider Education Unit of the MO HealthNet Division (MHD) wants to provide weekly hot tips that are beneficial to you, the provider. Hot tips are often developed based upon MHD observations and reports that indicate trends in billing errors or areas of misunderstandings regarding program policies and procedures.

Provider Education encourages and welcomes your input to the topics you would like to see as hot tips you believe would benefit the provider community. If you have suggestions, please send them by E-mail to: MHD.provtrain@dss.mo.gov.

MO HealthNet Resources

July 22, 2013

Provider Communications
The phone number is available for MO HealthNet providers to call with inquiries, concerns or questions regarding proper claim filing, claims resolution & disposition, and participant eligibility questions and verification. (573) 751-2896.
Provider Education
This unit is available to educate providers and other groups on proper billing methods and procedures for MO HealthNet Claims. Contact this unit for training information and scheduling, (573) 751-6683 or e-mail mhd.provtrain@dss.mo.gov.
Provider Enrollment
Providers can contact Provider Enrollment via e-mail for questions regarding enrollment applications mmac.providerenrollment@dss.mo.gov.
Pharmacy & Clinical Services
This unit is responsible for program development and clinical policy decision-making for MO HealthNet. Policy development, benefit design and coverage decisions are made by this unit using best practices and evidence-based medicine. (573) 751-6963 or email clinical.services@dss.mo.gov.
Wipro Infocrossing Healthcare Services
Wipro Infocrossing is the fiscal agent for MO HealthNet. Contact the fiscal agent for technical assistance in establishing the required electronic claims and remittance advice formats, network communication, HIPAA trading partner agreements and Internet billing service. (573) 635-3559.
MO HealthNet Pharmacy and Medical Pre-certification Help Desk

MO HealthNet requires pre-certification for certain radiological procedures. Also certain drugs require a Prior Authorization (PA) or Edit Override (EO) and must be obtained prior to dispensing. To obtain these pre-certifications, PA's or EO's you can either call (800) 392-8030 or use CyberAccess, a web tool that automates this process for MO HealthNet providers.

To become a CyberAccess user, contact Xerox Care and Quality Solutions help desk at (888) 581-9797 or (573) 632-9797 or send email to cyberaccesshelpdesk@xerox.com.

Non-emergency service or equipment exception requests only: fax line is (573) 522-3061. For Drug PA's: fax line is (573) 636-6470.

Participant Services
This unit assists participants regarding access to providers, eligibility, covered and non-covered services and unpaid medical bills. (800) 392-2161 or (573) 751-6527.
Third Party Liability (TPL)
Contact TPL unit to report injuries sustained by MO HealthNet participants, problems obtaining a response from an insurance carrier, or unusual situations concerning third party insurance coverage for a MO HealthNet participant. (573) 751-2005.
Missouri Medicaid Audit & Compliance (MMAC)
Enhances the integrity of the Missouri State Medicaid program by preventing and detecting fraudulent, abusive and wasteful practices within the Medicaid program and recovering improperly expended Medicaid funds while promoting high quality patient care (573) 751-3399.
MO HealthNet Division Services and Programs
For MO HealthNet questions or concerns not mentioned above, please send an email to Ask.MHD@dss.mo.gov.

Independent Laboratory/Radiology Providers Checking Participant Eligibility

July 15, 2013

Laboratory and Radiology providers are not exempt from checking participant eligibility. All MO HealthNet providers must check participant eligibility prior to rendering services. This provision is located in the Provider Manual in General Section 1.2 and states in part:

Providers must verify the participant’s eligibility status before rendering services as the ID card only contains the participant’s identifying information (ID number, name and date of birth). As stated on the card, holding the card does not certify eligibility or guarantee benefits.

Participant Liability and Casualty Insurance

July 8, 2013

Medicaid (MO HealthNet) is payer of last resort (208.215, RSMo).

The state monitors possible accident-related claims to determine if another party may be liable (contingent liability); therefore, information given on the claim form and the Accident Report Form is very important in assisting the state in researching accident cases. State regulations, 13 CSR 70-4.030 and 13 CSR 70-4.040, require the provider to report information the provider has regarding a MO HealthNet participant's accident or injury to the MO HealthNet Division.

Often the final determination of liability is not made until long after the accident. In these instances, claims for services may be billed directly to MO HealthNet prior to final determination of liability; however, it is important that MO HealthNet be notified of the following:

  • details of the accident (i.e., date, location, approximate time, cause);
  • any information available about the liability of other parties;
  • possible other insurance resources;
  • if a lien was filed prior to billing MO HealthNet.

This information may be submitted to MO HealthNet on the MO HealtNet Accident Report form or by calling the TPL Unit at (573) 751-2005.

MO HealthNet Participants With Other Insurance

July 1, 2013

MO HealthNet participants may have commercial health insurance coverage in addition to MO HealthNet benefits. When commercial health insurance information is known, it is reported to the provider when the provider verifies eligibility. In these cases, MO HealthNet is payor of last resort; commercial insurance must be billed first.

Often providers learn of a change in the participant's insurance information prior to the MO HealthNet Division since the provider has immediate contact with their patients. If the provider learns of new insurance information or of a change in the information, they may submit the information to the MO HealthNet Division to be verified and updated on the participant's eligibility file.

The provider may report this new information to the MO HealthNet agency using the MO HealthNet Insurance Resource Report. Complete the form as fully as possible to facilitate the verification of the information. Do not attach claims to process for payment to the MO HealthNet Insurance Resource Report. Claims should be submitted through the normal process after the commercial insurance has been billed.

Reasons to Check MO HealthNet Eligibility

June 24, 2013

It is the desire of every MO HealthNet enrolled provider, as well as the MO HealthNet Division, that payment be made on the initial claim submission for timely reimbursement of services. An important step for providers in meeting this goal is to make sure MO HealthNet participant eligibility is verified prior to services being rendered and billed. Following are reasons to check participant eligibility to avoid claim denials:

  • Medical Eligibility (ME)/Codes — MO HealthNet utilizes a system of categories, or ME codes, to indicate the category under which a participant is eligible. Covered services and benefits are based on the ME code. Many categories of assistance have limited coverage or categories in which participants are responsible for co-payments.

    The ME codes and their descriptions are found in the MO HealthNet Provider Manual, Section1.1.A, Description of Eligibility Categories. Descriptions of the ME codes can also be found in a quick reference guide titled 'Puzzled by the Terminology'.

  • Lock-in participant or managed care participant — If a participant is locked-in to a certain provider(s) or enrolled in a MO HealthNet managed care plan, providers are given this information when eligibility is checked. If a participant is locked-in to a provider(s) or enrolled in a managed care plan, services must be obtained through the assigned provider or managed care plan.
  • Medicare coverage — By checking eligibility, providers are informed if the participant has Medicare. The claims must be filed to Medicare first.
  • Commercial insurance — A claim must be filed to the commercial insurance plan first if the MO HealthNet eligibility file reflects commercial coverage.
  • Participant Name or Number Mismatch — Checking eligibility will verify the patient's name and MO HealthNet ID number as it appears on the enrollment file. The claim must be filed with the patient's current file name.

Providers can check eligibility by calling the Interactive Voice Response system at 573-751-2896 or through the Internet at emomed.com.

Physician Prior Authorization Requirements

June 17, 2013

Several surgical procedures require a Prior Authorization (PA). MO HealthNet has found that many of the surgical procedures requiring a PA are being performed without obtaining prior approval. Physicians are required to obtain a PA for these procedures before the surgical procedure is performed. If a PA is not obtained for the procedure performed, the surgeon's charges and any related hospital charges are not payable and the participant cannot be held responsible. Surgical procedures requiring PA can be identified on MO HealthNet's fee schedule page. Please allow ample time for medical review of the PA request.

Reference Section 8 of the Physician manual for more information regarding Prior Authorizations.

Claim Processing Schedule FY 2014

June 10, 2013

The provider claim processing schedule has been updated for state fiscal year 2014 which begins July 1, 2013. The schedule lists the dates the cycles are run and their corresponding check dates.

The claim processing schedule is available from the MO HealthNet provider page under ‘Featured Links’.

Prior Authorization Requests

June 4, 2013

Some services covered by the MO HealthNet Program require Prior Authorization (PA). This hot tip is to help you with key fields when completing the PA form and also help you learn how to check the status.

  • The PA form can be downloaded from the MO HealthNet forms site, choose Prior Authorization Request.
  • If you are enrolled as a clinic, you should use your clinic/group name, address and NPI in Section IV of the PA form; otherwise you may not be able to check the status of the PA online or the PA disposition may be sent to another address. The prescribing/performing provider information should be entered in Section V.
  • The completed paper PA request form describing those services or items requiring prior authorization and the reason the service or items are needed, along with any supporting documentation, must be submitted to the address on the PA form.
  • Providers have the ability to check the status of a PA request online at emomed.com. The provider will log into emomed using the NPI entered on the PA and choose the Prior Authorization Status option on the eProvider page. The provider will then type in the participant's MO HealthNet ID number and search; this will display the status of the PA: Approved, Closed, Denied, Incomplete or Pending.

Prior authorization does not guarantee payment, only the medical necessity of the requested service or items.

Whether the PA is approved or denied, a disposition letter will be returned to the provider containing all of the detail information related to the PA request. The disposition letter is mailed to the “Primary” address on the MO HealthNet provider file. If the provider “Primary” address has changed, a Provider update request must be completed and submitted via fax to 573-751-5065, scanned and e-mailed to Provider Enrollment, or mailed to:

Missouri Medicaid Audit and Compliance
Provider Enrollment
P.O. Box 6500
Jefferson City, MO 65102-6500

For more information on prior authorizations, you can reference Section 8 of the Mo HealthNet Provider Manuals.

Manually Priced Durable Medical Equipment

May 20, 2013

The majority of all items in the MO HealthNet Durable Medical Equipment (DME) program have an established allowed amount; however there are items that continue to require manual pricing.  Section 19 of the MO HealthNet DME provider manual contains a list of all covered procedure codes.  Manually priced items are noted in the “Allowed Amount” column with a ‘MP‘ and in many cases have ‘IOC’ (Invoice of Cost) in the “Reimbursement Guidelines” column.

In order to price these claims correctly, providers need to provide accurate and up-to-date information.  An invoice of cost can be submitted electronically through an attachment within the CMS-1500 claim form on the eMomed billing web site or may be submitted as a paper attachment to the CMS-1500 claim form.  Orthotics, prosthetics, ostomy supplies, HCY items (Healthy, Children & Youth), and any other item requiring an invoice, is reimbursed at the provider's cost plus 20%. Should a provider bill their actual cost and attach a valid invoice, MO HealthNet would only reimburse the provider their cost as the system cannot reimburse a dollar amount greater than the provider's billed amount.  Examples are provided for your convenience.

  1. Unit Cost - $100     Billed Charge - $150     Reimbursement - $120
  2. Unit Cost - $100     Billed Charge - $105     Reimbursement - $105

Please keep in mind a provider’s billed charge should be their usual and customary charge to the public.

Essure Product Reimbursement

May 13, 2013

The family planning product, Essure, CPT procedure code 58565, can be billed in either the office or outpatient setting.

In the office setting, use CPT procedure code 58565 with place of service 11.

For the professional services performed in an outpatient setting, providers must bill using CPT procedure code 58565 with a 52 modifier and place of service 22.

Professional Same-Day Services

May 6, 2013

Professional medical claims submitted for a hospital visit on the same day as a surgical procedure performed by the same provider is noncovered. This information can be found in Section 13.30.C of the Physician Manual.

Recovery Audit Contractor Sends Out Initial Overpayment Letters; RAC Contact Information

April 29, 2013

In an effort to help states reduce improper payments for Medicaid health care claims, the Centers for Medicare and Medicaid Services (CMS) issued a final rule to implement section 6411 of the Affordable Care Act.

Section 6411 of the Affordable Care Act, Expansion of Recovery Audit Contractor (RAC) Program, amends section 1902(a)(42) of the Social Security Act and requires states to contract with a RAC vendor allowing states to reimburse contractors who assist in the identification and recovery of improper payments. The RAC program has been used in the Medicare program and is now being required for Medicaid. The mission of the RAC program is to reduce improper payments in Medicaid through the efficient detection and collection of overpayments, the identification of underpayments, and the implementation of actions that will prevent future improper payments.

The State of Missouri, Department of Social Services (DSS), Missouri Medicaid Audit and Compliance Unit (MMAC), contracted with Cognosante, LLC, to be the Medicaid Recovery Audit Contractor.

Cognosante has begun sending overpayment letters. Providers are directed to the telephone number for Cognosante's Customer Service Center (855) 667-2212, for questions concerning the audits.

Claim Submission for Procedures Performed Multiple Times on the Same Date of Service

April 22, 2013

The MO HealthNet Division (MHD) continues to see a large volume of claims deny as duplicates because the same procedure is filed on multiple lines on the claim. Many procedure codes allow for multiple units. If the procedure code allows for multiple units, the procedure code should be billed on one line of the claim with the appropriate number of units indicated. Example: procedure code 87400 should only be billed on one line of the claim showing “2” in the days/units field if two labs were performed. Another example is x-rays. X-rays should not be billed with modifiers RT and LT. If two are performed, bill the appropriate procedure code and enter “2” in the days/units field. The only time a procedure code should be shown on multiple lines of a claim is if the procedure has a maximum allowed quantity of “1”. The MO HealthNet provider fee schedule should be referenced for MHD maximum quantities. Read more information below on how to reference the fee schedule.

A bilateral procedure is when the same procedure is performed on both sides of the body. To correctly bill this claim, a 50 modifier must be used along with the procedure code. The 50 modifier allows the system to identify the service as a bilateral procedure. It is to be billed with a quantity of “1”. The provider's billed amount should represent the cost for the whole service. MO HealthNet policy on bilateral procedures is detailed in Section 13.68 of the Physician Provider Manual.

Hospitals should only file one facility code (0450, 0459, 0490, and 0510) per date of service. If several physicians or clinics are seen, the charges must be combined into one facility code billed with a unit of “1”. Only one supply code (0260, 0270, and 0274) should be billed per date of service. The unit must be “1”. Outpatient medications billed under revenue code 250 must be billed with a quantity of “1” per date of service when a HCPCS or CPT code is not available. The charges for the medications must be totaled together for that line charge.

If a claim was filed incorrectly resulting in payment for one procedure and additional lines with the same procedure denying as duplicates, the paid claim must be replaced. Providers are urged to replace their claims electronically.

To replace a paid claim, go to emomed.com and log-in with your user ID and password. This opens the “Welcome to e-Provider” screen.

  • Click on “Claim Management”.
  • In “Search Scope”, enter the participant DCN and the date of service on the claim to be voided or replaced and click on “Search”. Be sure the correct NPI is displayed in the NPI box.
  • A list of claims matching the search criteria will be displayed in the “Results” box. Click on the Internal Control Number (ICN) of the claim to be voided or replaced.
  • To replace a paid claim, click on “Replacement”. This will bring up the claim. Enter the corrected information, such as the units and billed charges then click on “Submit Claim”.

Provider Fee Schedule

Providers have access to the MO HealthNet provider fee schedule online. At this site, you must read the LICENSE FOR USE OF PHYSICIANS' CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (CPT ™) agreement before you can view the fee schedule information. To accept the terms and conditions, click on the 'Accept' button at the bottom of the page.

You have the option of downloading an entire fee schedule for your provider type or you can do an online search.

When performing a “full search”, you must first click on a category on the left side of the screen. For instance, if you are a physician looking for the fee on a surgical code, you should click on “Surgery and Epidurals”. If you are looking for the fee of an evaluation and management code, click on “Medical Services”. After selecting a category, the quickest way to find a specific code is to enter the code under the search option. The next page displayed shows the procedure code along with any recognized modifiers for the code. By moving your pointer over a series of boxes on a specific code, you will be able to determine if a code has any program restrictions, the maximum quantity and reimbursement fee.

The fee schedule is updated quarterly on a calendar year basis. The Web site is dated to show when the fee schedule was last updated. Any procedure codes added to the fee schedule or updated during a quarter will not appear until the next quarterly update. Until codes are updated, providers should refer to provider bulletins.

The fee schedule is intended as a reference and not a guarantee of payment. Please refer to program specific MO HealthNet provider manuals and bulletins for benefit and limitations.

Using Locum Tenens

April 15, 2013

The MO HealthNet Division (MHD) occasionally receives inquiries regarding the use of “locum tenens” for physician offices and clinics.

A locum tenen is a physician who substitutes temporarily for another physician. MHD does not reimburse for locum tenens who submit claims using the absent physician’s National Provider Identifier (NPI). It is a violation of MHD policy to submit claims for services not personally rendered by the individually enrolled provider, except for services rendered under provisions specified in the MO HealthNet dental, physician, or nurse midwife programs. In accordance with these provisions, such claims may be submitted only if the individually enrolled provider directly supervised the person who actually performed the service and the person was employed by the enrolled provider at the time the service was rendered. Information regarding Conditions of Provider Participation, Reimbursement and Procedure of General Accountability can be found in the Missouri Code of State Regulations, Section 13 CSR 70-3.030.

If the locum tenen is already a currently enrolled MHD provider or enrolls as an MHD provider, then the services can be billed to MHD using the locum tenens’ NPI.

Instructions for Submitting Provider Enrollment Documentation

April 8, 2013

To better process the information submitted to the Missouri Medicaid Audit and Compliance (MMAC) Provider Enrollment Unit, it is important that the information be submitted via the appropriate method.

For new enrollment applications and re-enrollments completed through the website, please fax all documentation to 573-634-3105. This documentation may include the “signature page,” tax documents, Medicare enrollment verification, Board of Healing Art licensure, or other verification documentation needed for enrollment. The application “signature page” (page 4 of the Provider Enrollment Application) MUST be printed, signed and faxed to 573-634-3105. Remember, the application cannot be processed until the signed signature page is received by Provider Enrollment.

For new paper enrollment applications, and paper re-enrollments (not completed through the web site), please fax all documentation to 573-751-5065 or scan and e-mail to mmac.providerenrollment@dss.mo.gov.

To update a currently enrolled provider’s information, a Provider update form, must be completed and submitted via fax to 573-751-5065 or scanned and e-mailed to mmac.providerenrollment@dss.mo.gov. The Provider Enrollment e-mail account has an auto-responder that will confirm the receipt of your e-mail.

For additional information, visit the MMAC web site.

Suggestions for On-line Training Conferences

April 1, 2013

The Provider Education Unit of the MO HealthNet Division (MHD) provides interactive training to providers at their office location using the Internet and telephone conference lines. The presentations are relatively short and are usually limited to 60 to 90 minutes in length. New training dates are scheduled each quarter and can be found on the MHD Provider page under Webinar Training.

Provider Education encourages and welcomes your input to the topics you would like to see included for on-line training. If you have suggestions regarding on-line trainings, please send them by E-mail to: MHD.provtrain@dss.mo.gov.

Proper Paper Alignment—UB-04 and CMS 1500

March 25, 2013

Most claims can and should be submitted to MO HealthNet electronically. However, if it is necessary to submit paper claim forms (UB-04 or CMS-1500) because of special circumstances, make sure your paper is properly aligned with the printed information on the claim forms. Improper alignment may cause information to appear in the wrong fields and cause claims to process incorrectly or deny. Please contact your software vendor for information on how to properly align the claim forms.

Reminders for Securing and Protecting Data—Emails

March 18, 2013

Direct communication between the State and providers is an important part of how we manage the care of MO HealthNet participants, review claims and payment of claims, and operate our respective agencies and organizations.

Communicating through emails is one of the ways we work together. Email is not a secure (encrypted) method of transmitting information. When transmitting information of a confidential or sensitive nature via email it is important to remember the following:

  • Always encrypt emails containing sensitive or protected health information (PHI). Most entities have some sort of encryption available to use when sending emails that require protection. If you do not have encryption available, you should refrain from sending the information via email and look for a more secure method such as faxing or sending through standard mail. You may also use the DSS secure email encryption method and follow Instruction #3: How DSS clients, business partners and end-users can send an encrypted email to DSS.
  • Never put identifying information in the Subject Line. While the body of an email may be encrypted, the subject line is not. Names, departmental client numbers (DCN's), patient account numbers, Social Security Numbers, and other identifiers should be removed from the Subject Line.
  • If you prefer to email, remove identifying information. If you would rather send an email and do not have encryption available, remove identifying information and simply request a return call from the agency.

Furthermore, the use of encrypted email may also be required if you have a contract with the State, thus providing you additional incentive to ensure its regular use when transmitting sensitive information via email.

Under recent amendments to the Health Insurance Portability and Accountability Act (HIPAA), Business Associates of covered entities are now directly responsible for complying with the requirements of HIPAA, which includes protections under both the Privacy and Security Rules.

Communicating by email within an agency or organization is generally secure and requires no additional security measures to send PHI. Because emailing is second-nature for most of us, it is may be easy to forget to protect an email when sending outside of the organization. Remember these tips when communicating with any outside agency or organization.

Encrypted E-mail

March 11, 2013

E-mail is not a secure method of transmitting information. Transmitting information of a confidential or sensitive nature, such as protected health information or participant Departmental Client Number (DCN), via e-mail to entities is only permitted if the e-mail is encrypted.

When an e–mail is sent encrypted by the Department of Social Services (DSS), MO HealthNet Division, it will require decryption by the recipient of the e-mail. The process of decrypting e-mails is simple. Upon receiving and opening a DSS encrypted e-mail; you will be instructed to open the attachment called "SecureMessageAtt.html". When the attachment is opened, you will be instructed to click a button to read the message. You will also be prompted to register in the Proofpoint e-mail encryption system the first time you open an encrypted message. This is a one-time registration process and is required in order to view the encrypted message.

Detailed instructions outlining how to send, open and register to receive encrypted emails can be found on this site. Secure e-mails may also be sent to a state recipient by following "Instruction #3: How DSS clients, business partners and end-users can send an encrypted email to DSS" in the above link.

March 4, 2013

Through the Vaccine for Children (VFC) Program, federally provided vaccines are available at no cost to public and private providers for eligible children ages 0 through 18 years of age. Children who meet at least one of the following criteria are eligible for a VFC vaccine:

  • MO HEALTHNET ENROLLED—means a child enrolled in the MO HealthNet Program
  • UNINSURED—means a child has no health insurance coverage
  • NATIVE AMERICAN/ALASKAN NATIVE—means those children as defined in the Indian Health Services Act
  • UNDERINSURED—means the child has some type of health insurance, but the benefit plan does not include vaccinations. The child must be vaccinated in a Federally Qualified Health Center (FQHC) or a Rural Health Clinic (RHC).

MO HealthNet enrolled providers must participate in the VFC Program administered by the Missouri Department of Health and Senior Services and must use the free vaccine when administering a vaccine to qualified MO HealthNet eligible children. Providers may bill for the administration of the free vaccine by using the appropriate procedure code(s) found in VFC Administration Codes.
Providers must not use any additional administration procedure code.

The MO HealthNet reimbursement for the administration is $5.00 per component. The administration fee(s) may be billed in addition to a Healthy Children and Youth (HCY) screen, a preventive medicine service, or in addition to an office visit if a service other than administration of a vaccine was provided to the child.

Providers enrolled as Rural Health Clinics (RHCs) or Federally Qualified Health Centers (FQHCs) must not bill an additional administration fee for any vaccine.

Choosing the Correct Claim Form

February 25, 2013

Confusion exists among providers in determining which MO HealthNet Division (MHD) claim form to complete for reimbursement of co-insurance and deductible amounts for those Medicare/MO HealthNet participants with Medicare Part C coverage. Claims for participants with Medicare Part C coverage do not cross over automatically from the Medicare Advantage/Part C Plans. As a result, providers must file claims through the MO HealthNet web portal. Providers should choose from the appropriate claim options shown below.

If the participant is enrolled in a Medicare Advantage/Part C Plan and is a Qualified Medicare Beneficiary (QMB) eligible, use one of the following:

  • The Medicare UB-04 Part C Institutional Crossover to file for inpatient room and board. The header screen must be completed. Choose filing indicator '16' (Medicare Part C Institutional); or
  • The Medicare UB-04 Part C Professional Crossover to file for outpatient professional services. The header screen and line detail screens must be completed. Choose filing indicator '16' (Medicare Part C Professional) on the header screen; or
  • The Medicare CMS-1500 Part C Professional Crossover to file for professional services. The header and line detail screens must be completed. Choose filing indicator '16' (Medicare Part C Professional) on the header screen.

If the participant is enrolled in a Medicare Advantage/Part C Plan and is not QMB eligible, you must submit your claim on one of the following:

  • The Inpatient UB-04 for room and board. You must show the Part C information on the header screen. Choose filing indicator '16' (Health Maint Org Medicare Risk). Inpatient claims require pre-certification through ACS; or
  • The Outpatient UB-04 for outpatient professional services. Show the Part C information on the header and line detail screens. Choose filing indicator '16' (Health Maint Org Medicare Risk); or
  • The Medical (CMS-1500) claim form for professional services. Show the Part C information on the header and line detail. Choose filing indicator '16' (Health Maint Org Medicare Risk).

Reminder - For non QMB participants enrolled in a Medicare Advantage/Part C Plan, MHD will process claims in accordance with the established MHD coordination of benefits policy. The policy can be viewed in Section 5.1.A of the MHD provider manuals. In accordance with this policy, the amount paid by MHD is the difference between the MHD allowable amount and the amount paid by the third party resource.

MHD guidelines and policies regarding attachments and prior authorization must be followed for all MO HealthNet participants, including Medicare Part C non-QMB participants. If the procedure billed requires an attachment (Certificate of Medical Necessity, Second Surgical Opinion, Sterilization Consent, etc.), you must have a completed, approved form on file. If the procedure requires prior authorization, you must have an approved prior authorization from MHD on file.

Invasive Ventilators, E0450, E0463

February 19, 2013

Physicians and Durable Medical Equipment providers are reminded procedure codes E0450 and E0463 are to be billed only for those ventilators that have an invasive interface. With an invasive ventilator, delivery is through an artificial airway which is normally a tracheostomy but could also be an endotracheal tube.

Procedure codes E0450 and E0463 require precertification through the CyberAccess tool or by calling 1-800-392-8030. Providers not currently CyberAccess users are encouraged to sign up for the MO HealthNet Web-based tool by contacting Xerox Care and Quality Solutions help desk at 888-581-9797 or 573-632-9797 or send an e-mail to CyberAccessHelpdesk@xerox.com. To be approved, requests for precertification must meet the MO HealthNet Division medical criteria.

Suspended Claims

February 11, 2013

A suspended MO HealthNet Claim is a claim that, although being in the fiscal agent's system, is in suspense and has not processed to pay or deny during the current payment cycle.

A claim can be suspended for various reasons. Examples include the following:

  • The claim is attempting to link to an approved attachment such as a Sterilization Consent form, an Acknowledgment of Hysterectomy Information form or a Medical Referral of Restricted Participant (Lock-in) form.
  • Records, such as an operative report, were sent with the claim and are being reviewed.
  • The claim is being reviewed as a possible duplicate.
  • The claim is being processed for participant spend down.
  • The claim is being reviewed because it is for an office visit possibly related to a surgical procedure done within the previous 30 days.

If the provider refiles the same claim while there is a corresponding suspended claim, the refiled claim will deny as a duplicate because the suspended claim has not been finalized. Providers should always check the status of a suspended claim before refiling using the MO HealthNet billing web portal. Claims that are suspended are indicated on the emomed status screen with a C-suspended.

Questions regarding a suspended claim should be directed to the Provider Communications Unit at 573/751-2896. Providers can also submit E-mail claim inquiries through the MO HealthNet billing web portal.

Reminder—Filing Medicare Denied Claims

February 4, 2013

Medicare denied services for Medicare/MO HealthNet participants may be considered for payment by MO HealthNet if the service is a MO HealthNet covered service.

When providers receive a Medicare Remittance Advice that has a denied non-covered service, the provider may submit a claim to MO HealthNet for payment consideration using the appropriate claim type (i.e., CMS-1500, UB-04). Providers are encouraged to submit MO HealthNet claims electronically.

To bill through the MO HealthNet billing Web portal for a non-covered Medicare service, go to emomed.com. After logging on, follow these steps:

  1. Choose the ‘Claim Management’ option;
  2. Select the appropriate claim form (CMS-1500, UB-04, Nursing Home, etc.) under the ‘New Claim’ option. Do not select the Medicare Crossover claim form.
  3. Complete all the required fields on the claim form;
  4. Then, choose ‘Other Payers’. This brings up the Header Summary.
  5. Complete the required fields.
  6. Under ‘Associated Line Items’, choose Claim Group Code ‘PR-Patient Responsibility’.
  7. Enter the reason code exactly as shown on the Medicare Remittance Advice.
  8. The ‘Adjustment Amount’ is the billed amount for the line item and/or claim.
  9. Click on ‘Save Codes to Other Payer’.
  10. Click on ‘Save Other Payer to Claim’.
  11. Click on ‘Submit Claim’.

For further assistance when filing electronically, billers may also select the question mark (?) option on the right-hand portion of the screen for field-by-field directions.

Adult Dental Criteria

January 28, 2013

Pre-existing Medical Condition

MO HealthNet will only consider payment for dental services for adults (except individuals under a category of assistance for pregnant women or the blind or nursing facility residents) when a written referral from the participant’s physician states the absence of dental treatment would adversely affect the stated pre-existing medical condition. The referral must be maintained in the participant’s record and made available to the MO HealthNet Division, the Missouri Medicaid Audit and Compliance Unit or it’s agent upon request. The referral must include the referring physician name and provider identifier, type of dental services needed and the medical condition that would be adversely affected without the dental care. Pre-existing medical conditions may include but are not limited to:

  • Transplants
  • Chemo/radiation therapy
  • Any other medical condition where if the dental condition is left untreated, the dental problems would adversely affect the health of the participant resulting in a higher level of care
  • Heart Valves
  • Diabetes
  • AIDS
  • Seizure Disorder treated with Dilantin

NOTE: Submitting a prior authorization request does not take the place of a written referral from the participant’s physician.

Trauma Criteria

Also, dental services may be provided for adults if dental care is related to traumatic injury to the jaw, mouth, teeth or other contiguous (adjoining) sites (above the neck), including but not limited to:

  • Motor vehicle accident; or
  • Fracture of the jaw or any facial bone.

Individuals under a category of assistance for pregnant women, the blind or vendor nursing facility residents are exempt from the above criteria and receive a comprehensive benefit package unless restricted by procedure code. General Section 1 of the MO HealthNet provider manuals provides an overview of benefit guidelines for MO HealthNet participants as well as restrictions for specific categories of assistance.

Dentures

Dentures (full and partial) are not covered under the above noted pre-existing medical condition or trauma criteria. Dentures do not require prior authorization and are only covered for individuals under the age of 21 years or those individuals under a category of assistance for pregnant women, the blind or reside in a nursing facility.

Updating Provider Enrollment Information

January 21, 2013

Providers are responsible for notifying Missouri Medicaid Audit and Compliance (MMAC) Unit of update practice information when changes occur. Providers should notify MMAC of changes by completing the “Provider Update Request” form.

This will ensure MMAC is receiving all the required information and that the appropriate provider NPI records are being updated.

ICD-10

January 15, 2013

The Centers for Medicare and Medicaid Services recently posted the following information regarding ICD-10:

Where to Find ICD-10 Information

To keep on track with planning and preparation for tasks that need to be completed by the transition deadline—October 1, 2014—take advantage of ICD-10 educational events, like online webinars and presentations in your area.

CMS – Official ICD-10 Resources

As the source for official ICD-10 information, CMS regularly updates a dedicated ICD-10 Web page. The ICD-10 Web page offers:

To provide practical transition tips, CMS recently partnered with Medscape to develop ICD-10 continuing medical education modules.

Check with Other Practices, Payers, and Vendors for Resources

To help you with your planning, you may want to work with other health care providers in your area to share resources. By working together you can reduce time spent gathering information as well as identify best practices for making the ICD-10 transition. For in-person events, suggest taking turns attending presentations or rotate sending staff to events. Arrange to share a recap and updates with each other after each event.

Also check with your payers and vendors for ICD-10 resources that can help you with your transition.

Keep Up to Date on ICD-10

Visit the CMS ICD-10 Web site for the latest news and resources to help you prepare.

Provider Update Meetings

January 7, 2013

The Missouri Medicaid Audit and Compliance (MMAC) did not schedule a provider update meeting for the second half of calendar year 2012 for Home and Community Based Services (HCBS) providers. HCBS providers include: In-Home Service (IHS) providers, Consumer Directed Services (CDS) vendors, Residential Care Facility (RCF)/Assisted Living Facility (ALF) Personal Care (PC) providers and Adult Day Health Care (ADHC) providers.

In accordance with the 19 CSR 15-7.021(14)(D), In-Home Service Standards, each IHS provider is to “ensure the designated managers annually attend division-sponsored training designed to update certified managers”. Certified managers will not be penalized for not completing the annual training requirements for calendar year 2012. A copy of this letter should be maintained as proof that the training requirement was waived for 2012.