2012 Archives Hot Tip of the Week

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Family Therapy for Children In Foster Care

December 31, 2012

MO HealthNet Division in collaboration with the Children’s Division recognizes there are circumstances within the Foster Care setting where a child may require additional Family Therapy services. If a Foster child requires Family Therapy sessions with both the foster parent and the biological parent/parents, the provider should obtain one Family Therapy PA for the child. The hours may be split between the two families. The provider must develop an integrated Treatment Plan for the Family Therapy with objectives and outcomes for therapy for both the foster and biological families.

Foster families that consist of several unrelated children should request one Family Therapy PA per family as stated in policy in section 13 of the Behavioral Health Services Manual. Rare circumstances may arise when a child in a foster family requires separate Family Therapy sessions with the foster parent. Requests for multiple Family therapy PAs per foster family will only be considered through the Clinical Exceptions process. Providers may contact the Behavioral Health Services Help Desk (866-771-3350) for additional information on requesting a Clinical Exception.

Hours required beyond the guidelines may be requested through the Clinical Exception process. Providers are required to adhere to the maximum daily and monthly unit limitations and all other program restrictions. Units billed over the daily, monthly, yearly limits represent a violation of MHD policy and are not reimbursed.

For more information related to Family Therapy for children in Foster Care, please refer to the Behavioral Health Services Manual and Archived Psychotherapy Bulletin Volume 30, Number 34 dated December 18, 2007.

Spend Down Eligibility

December 24, 2012

MO HealthNet participants may become Medicaid eligible through a “spend down” process. Spend down is a MO HealthNet process in which participants have an amount they must pay or be responsible to pay each month for medical services before having MO HealthNet coverage. It is similar to an insurance premium.

Participants have the option to pay-in their spend down amount or meet the amount with paid or incurred medical bills showing what he/she is responsible to pay. Bills must be presented to the Family Support Division (FSD) office.

The FSD recently developed a MO HealthNet Spend Down Provider form that providers may complete when medical bills is the method of meeting spend down and the provider is not able to generate a bill or a copy of the bill for the participant. The MO HealthNet Spend Down Provider form and the instructions are available on the Internet at http://dss.mo.gov/fsd/massist.htm. Once completed, the form should be given to the participant to forward to the FSD. This form does not replace the responsibility of the provider to bill the patient their customary charges.

Using the Timely Filing Tab to Correct Claims

December 17, 2012

The Timely Filing Tab found on the MO HealthNet billing Web site can be used to document timely filing when a claim has been submitted and denied within the MO HealthNet timely filing guidelines {within twelve (12) months from the date of service or six (6) months from the date on the Medicare provider's notice of the allowed claim} and is being corrected and resubmitted within two years of the date of service by following the instructions below.

  • Log onto the MHD Web billing portal
  • Click on Claim Management.
  • In the “Claim Search” Box, enter the participant DCN and the date of service and click on “Search”.
  • Click on the highlighted ICN number of the claim to be resubmitted.
  • Click on the Timely Filing tab. This will bring up the claim.
  • Make the appropriate corrections to the claim, save and resubmit the claim.

To replace a paid claim that is past one year from the date of service is a two step processing.

  • First you must void the paid claim.
  • Then go back into the original Internal Control Number (ICN) and click on the Timely Filing tab, make any applicable corrections and resubmit the claim.
Clarification of Hospital Observation Policy

December 10, 2012

“Observation care is a well defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge. Observation services are covered only when provided by the order of a physician or another individual authorized by State licensure law and hospital staff bylaws to admit patients to the hospital or to order outpatient services.

General standing orders for observation services following outpatient surgery are not recognized. Hospitals must not report as observation care, services that are part of another covered outpatient service, such as postoperative monitoring during a standard recovery period (e.g., 4-6 hours). Similarly, in the case of participants who undergo diagnostic testing in a hospital outpatient department, routine preparation services furnished prior to the testing and recovery afterwards are included in the payments for those diagnostic services. The participant must have been seen and/or received a service/procedure and had a complication arise or the participant is not recovering as quickly as expected, etc… and requires additional hospital care for observation until stabilized or formally admitted as an inpatient. Documentation in the participant’s medical record must record this complication or the need for the observation services.

Observation services should not be billed concurrently with diagnostic or therapeutic services for which active monitoring is a part of the procedure (e.g., colonoscopy, chemotherapy). In situations where such a procedure interrupts observation services, hospitals would record for each period of observation services the beginning and ending times during the hospital outpatient encounter and add the length of time for the periods of observation services together to reach the total number of units reported on the claim for the hourly observation services.”

More information on billing hospital observation can be found in the provider bulletin titled “Observation Care Bulletin” Vol.33 No. 33 dated March 28, 2011.

Inpatient Hospital Certification

December 3, 2012

Inpatient hospital admissions must be certified as medically necessary and appropriate as inpatient services before MO HealthNet reimburses the provider. All MO HealthNet enrolled hospitals in Missouri and bordering states are subject to this admission certification requirement.

Admissions covered by Medicare Part A; or MO HealthNet participants with both Medicare Part C and QMB coverage are exempt from admission certification. (The full list of exemptions can be found in section 13 of the hospital manual.)

MO HealthNet participants with Medicare Part B only, Medicare Part C non- QMB, or Commercial Insurance coverage require admission certification.

Additional information regarding inpatient hospital certification is covered in section 13 of the hospital manual.
To certify an inpatient stay, follow the hospital pre-certification instructions.

Reminders for Securing and Protecting Data

November 26, 2012

How well are you protecting and securing health information? Below are reminders regarding some of the more common issues for protecting health information.

  • Do not leave protected health information such as reports, claims, medical documentation, and other sensitive information in a parked car. While the car may be locked, that may not stop someone from looking in the car at exposed information or from breaking in. If protected health information must be left in a car, it is recommended that you store in the trunk.
  • Double-check phone numbers when you fax. Faxing is a secure way of sending information to another; however, that security is only good if you are sending the information to the right number. Pulling the wrong number from a list, or transposing numbers, are among the many things that may occur, so be certain to double-check the number you have entered before you hit send.
  • Use of flash drives. Flash drives are a quick and easy way to take large amounts of data with you, but they are not without security concerns of their own. For example, you can stick the drive loaded with PHI into your pocket or purse, and then accidentally lose it when reaching for your keys or wallet. If you maintain protected health information on a flash drive, it is critical to ensure the drive is encrypted to prevent unauthorized access should the drive be lost or stolen.
  • Shred versus Recycle. Many offices have both shred containers and recycle containers. Before you throw them away, double-check documents to be sure protected health information is going in the shred container.

Remember, taking an extra minute or two now to ensure you are protecting health information will make a big difference to your organization and the people you serve.

Groups/Clinics – Performing Provider

November 19, 2012

Reminder: If a claim is submitted using a group/clinic NPI, the individual provider NPI must be shown in the performing provider field; on the paper CMS-1500 form, this is field 24j and electronically, it is the performing provider identifier (NPI) field.

If the claim is filed using the group/clinic NPI and the performing provider field is blank or does not contain the individual performing provider NPI, the claim will deny with Remittance Remark Code N55 (Procedures for billing with group/referring/performing providers were not followed).

The claim adjustment reason codes and/or remark codes can be found by choosing HIPAA related Code Lists in the Featured Links box found on the MO HealthNet Providers page.

Use of Invalid Diagnosis Codes

November 13, 2012

An invalid diagnosis code submitted on a claim that requires a diagnosis will result in a claim denial. The claim adjustment reason codes and/or remark codes can be found by choosing HIPAA related Code Lists in the Featured Links box found on the MO HealthNet Providers page.

For those claims requiring diagnosis codes for billing, providers must utilize the codes from the International Classification of Diseases 9th Revision Clinical Modification (ICD-9-CM). When selecting the appropriate code from the ICD-9-CM, be sure to review all codes in a range and code to the highest level of specificity. Some diagnosis codes require a 4th and 5th digit. Most denials occur when providers do not include the appropriate digits. The ICD-9-CM clearly specifies when codes require a 4th or 5th digit.

Diagnosis codes are updated each year on October 1 with no grace period between the old codes and new codes. It is important for providers to have the updated ICD-9-CM edition in their offices. The ICD-9-CM can be obtained from any medical bookstore.

NOTE: When submitting claims on the MO HealthNet billing Web site, emomed.com, do not include the decimal point in the diagnosis field.

Concurrent Dates of Hospital Services

November 5, 2012

Due to recent findings in a federal audit, MO HealthNet was made aware of billing areas of concern for hospital outpatient services when a participant is in an inpatient status.

Section 13 of the Hospital Provider Manual discusses billing for outpatient/emergency room/observation services that occur on the same day that a participant is admitted for inpatient services but prior to the actual admission.

Any outpatient service performed after a participant has been admitted as an inpatient must be shown as ancillary charges on the inpatient claim. It is an improper billing procedure for a provider to submit an inpatient claim and the same or a different provider to submit an outpatient claim for concurrent dates of service for the same participant. Outpatient services provided on the day of admission, but prior to admission, or on the day of discharge, but following discharge, are not considered concurrent care for the purpose of this policy. Such outpatient services provided on the day of admission or the day of discharge are reimbursable as outpatient services.

As an example of concurrent dates of service that are not separately reimbursable, consider the following circumstance: A participant receives emergency room services on Monday and is then admitted that day. The participant is discharged on Friday and on Friday begins the first of a series of outpatient therapy services. The outpatient services received on Monday and Friday are reimbursable. Any services performed in the outpatient department on Tuesday, Wednesday or Thursday of that inpatient stay are considered concurrent dates of service that are not reimbursable as outpatient services.

When procedures or services, such as complex laboratory or radiology procedures are furnished by a provider outside the hospital, the services are to be billed as ancillaries on the inpatient claim. It is the responsibility of the inpatient hospital to make arrangements with the outside provider for payment of those services. Any claim submitted to the fiscal agent for outpatient services when there are concurrent inpatient services is denied. If an outpatient claim is paid before the inpatient claim is processed, the inpatient claim is paid and a recoupment of the outpatient claim is made.

Hospital Outpatient Facility Charges

October 29, 2012

Due to recent findings in a federal audit, MO HealthNet was made aware of billing areas of concern. This is a reminder on how to bill hospital outpatient facility charges.

It is important to remember when it is appropriate to bill MO HealthNet a hospital outpatient facility charge. Inappropriate billing of facility charges will result in recoupment of payments. The following information was obtained from the MO HealthNet hospital provider manual. Please refer to Sections 13 and 15 for more information regarding outpatient facility charges.

A facility charge should be shown on the outpatient claim if the patient sees a MO HealthNet enrolled physician, nurse practitioner or podiatrist for evaluation or treatment of the condition that caused the need for hospital services and the person is registered on the hospital records as being in an outpatient status. Services and supplies that may be included in the facility charges include:

  • IV Infusion Services, including but not limited to: chemotherapy; antibiotic therapy; hydration therapy; immune globulin therapy; IV rate change; pitocin
  • Services such as: venipuncture; specimen collection; taking and monitoring vitals; prepping; positioning; injecting; call-back services; stat charges; routine monitoring (e.g. fetal, cardiac, etc…); after-hours services; claim filing fees; education/instruction (e.g. colostomy care, cardiac care, etc.); handling charge for specimens referred to an independent laboratory; late discharge fee; preparation of special reports sent to insurance companies; psychiatric reports for court evaluation or juvenile court; standby equipment
  • The following operational cost elements: administrative costs; basic floor stock supplies; durable, reusable items or medical equipment; fixed building costs; furnishings; insurance; laundry; maintenance; nursing salaries; paramedical salaries; records maintenance; utilities

Services that are not to be added to the facility charge:

  • Services performed by hospital staff that are incidental to physician services; and
  • Services provided by a physician assistant (PA), including those provided in an outpatient hospital-owned clinic.

If the following services are the only services provided during a visit, without any physician services, a facility charge must not be shown: physical, occupational or speech therapy; renal dialysis; Injections/immunizations; laboratory/pathology; radiology; HCY/EPSDT services. These services can be billed by the hospital using the appropriate HCPCS Level I (CPT), Level II or Level III procedure code. The costs of diagnostic testing and treatment type equipment should be included in the charge for the specific service provided to the patient. The costs of hospital staff that are necessary to the performance of the specific service should be included in the charge for that service.

A facility charge code may not be billed by the hospital on the same date of service as cardiac rehabilitation unless a physician provided services on that day.

Only one facility code (0450, 0459, 0490, and 0510) may be shown 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 with a unit of “1”.

A charge for an observation service is not considered a facility charge. Therefore, as an example, a provider can show a surgery facility code and an observation code for the same date of service.

Adequate Documentation

October 22, 2012

If you were to be audited, would your medical records of MO HealthNet participants contain adequate documentation to support the codes and level of services billed?

The Code of State Regulations 13 CSR 70-3.030, Section (2) (A) defines ‘adequate documentation’ more specifically.

Adequate documentation means documentation from which services rendered and the amount of reimbursement received by a provider can be readily discerned and verified with reasonable certainty. Adequate medical records are records which are of the type and in a form from which symptoms, conditions, diagnosis, treatments, prognosis and the identity of the patient to which these things relate can be readily discerned and verified with reasonable certainty. All documentation must be made available at the same site at which the service was rendered. An adequate and complete patient record is a record which is legible, which is made contemporaneously with the delivery of the service, which addresses the patient/client specifics, which include, at a minimum, individualized statements that support the assessment or treatment encounter that includes specific information as stated in the regulation.

In addition to the State Regulation, providers can also reference Section 2.3.A of the MO HealthNet Provider Manuals.

Estate Notice Revised

October 15, 2012

Since August 28, 2007, any open estate may not be closed with respect to a decedent until a release of the Estate Recovery Claim by MO HealthNet is obtained.  In order to obtain a release either as a result of payment of an Estate Recovery claim or if the decedent was not enrolled in MO HealthNet, the MO HealthNet Estate Notice form should be completed.

The MO HealthNet Estate Notice form has been revised. The form can be completed online, printed out and either mailed or faxed to the address or fax number listed on the form.  An additional option is to email the completed form to the Cost Recovery Unit email address now included on the form.

If you have questions regarding the Estate Notice MO HealthNet report form, please contact the Division of Medical Services, Cost Recovery Unit at (573) 751-2005.

Insurance Resource Report form (TPL-4) Revised

October 9, 2012

A provider may learn of a change in third party insurance information for a MO HealthNet participant prior to MO HealthNet obtaining the information since the provider has immediate contact with their patients. If the provider learns of new insurance information or of a change in third party information, they may submit the information to the MO HealthNet agency to be verified and updated to the participant's eligibility file. The provider may report this new information to the MO HealthNet agency using the MO HealthNet Insurance Resource Report.

The MO HealthNet Insurance Resource Report (TPL-4) form has been revised. The revised form is available on the MO HealthNet Web site in the Featured Links box under MO HealthNet Forms. The forms are in alphabetical order.

The form can be completed online, printed out and mailed to the address on the form. An additional option is to email the completed form to the Cost Recovery Unit email address now included on the form. Instructions can be found on the bottom of the page.

The verified form will no longer be returned to the provider. Please allow 2-3 weeks for the information to be updated. Eligibility can be verified through the Interactive Voice Response (IVR) system at (573) 751-2896 or on the Web at emomed.com.

If you have questions regarding the MO HealthNet Insurance Resource Report form, please contact the Cost Recovery Unit at (573) 751-2005.

CMS Provider Toolkit No-Cost CME Credit

October 1, 2012

The Centers for Medicare and Medicaid Services and the Education Medicaid Integrity Contractor are disseminating new provider education material on medical identity theft.

“Safeguarding Your Medical Identity” provides continuing medical education (CME) credit at no cost. This material will provide recommendations to help providers protect their practice.

Participant Inquiries

September 24, 2012

Occasionally, providers may have MO HealthNet patients ask questions about specific benefits, non-covered services, administrative lock-in or other matters regarding the MO HealthNet program.

The MO HealthNet Division maintains a Participant Services Unit to which providers can direct participants for assistance with these questions and others regarding such things as MO HealthNet covered services, the denial or payment of claims filed with the MO HealthNet Program, and the location of participating providers in their area of the state. This unit can be helpful, for example, when a participant moves to a new area of the state and needs the names of all physicians who are active MO HealthNet providers in the new area.

Participants who have problems or questions concerning MO HealthNet should be directed to call (800) 392-2161 or to write:

MO HealthNet Division
Participant Services Unit
PO Box 3535
Jefferson City, MO 65102

Dental Billing Reminders

September 17, 2012

When it is necessary to submit a Dental claim form via paper to MO HealthNet for processing, please keep the following in mind:

  • the only form currently accepted is the 2002, 2004 American Dental Association version;
  • fields 12-17 should only be completed if the participant has a dental insurance policy primary to MO HealthNet;
  • the participant’s name as currently stated in the participant eligibility file is required in field 20;
  • the participant’s eight-digit MO HealthNet ID number is required in field 23 of the claim form;
  • the billing NPI is required in field 49; and
  • if billing as a clinic, the NPI of the treating dentist (performing provider) is required in field 54.

Unless the procedure code requires one, or the State Dental Consultant has requested one, x-rays are not to be routinely mailed with the claim form.

Dental claims are to be mailed to the following address:

Wipro Infocrossing Health Care Systems
PO Box 5300
Jefferson City, MO 65102

Physician Primary Care Rate Increase

September 10, 2012

For dates of service January 1, 2013 and beyond, primary care services provided by physicians with a specialty designation of family medicine, general internal medicine or pediatric medicine are eligible for increased payments for primary care Evaluation and Management (E/M) procedure codes 99201-99499 and services related to immunization administration for vaccines and toxoids. The fee increase applies to MO HealthNet providers enrolled in the fee-for-service and managed care programs.

To qualify, the provider must be board certified in a specialty designation of family medicine, general internal medicine or pediatric medicine; or if not board certified, at least sixty percent (60%) of services billed MO HealthNet by the physician for calendar year 2012 must be for primary care E/M codes 99201-99499. MO HealthNet claims data will be reviewed to ensure the 60% threshold is met. Claim volume for the 60% rule will be taken from both fee-for-service Medicaid and the managed care health plans. If a provider is enrolled in both fee-for-service Medicaid and a managed care health plan, the claim volume will be combined to get to the 60% threshold.

The rate increase applies to services of auxiliary personnel employed by the physician and working under the physician’s supervision such as nurses, technicians, therapists and physician assistants. The payment is made directly to the qualifying physician who bills for the services.

Eligible providers must complete the ‘Certification and Attestation for Primary Care Rate Increase’ available from the Missouri Medicaid Audit & Compliance forms page. The form must be submitted to the address or fax number listed.

For more information, please reference Provider Bulletin, Volume 35 Number 03, dated July 31, 2012.

Glossary of Definitions used in the Medicaid Integrity Program

September 4, 2012

Missouri Medicaid Audit and Compliance (MMAC) has available a Glossary of Definitions Used in the Medicaid Integrity Program. By utilizing this list of definitions, you will have a better understanding of the Missouri Medicaid Integrity Program and their goals.

Transportation for Hospital Discharge

August 27, 2012

Transportation for hospital discharges for eligible participants can be arranged by calling LogistiCare Solutions, L.L.C., 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 LogistiCare. 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.

Attestation of Medical Record Loss or Destruction

August 20, 2012

The Missouri Medicaid Audit and Compliance Unit requests that any provider who believes that documentation to support services provided to Missouri Medicaid participants is no longer available, due to extenuating circumstances or unforeseen events, utilize the Attestation of Medical Record Loss of Destruction Form which can be found on the Provider Enrollment Applications and Forms page of the MMAC website.

Speech-Language Pathologists

August 13, 2012

Missouri state law (RSMO 345.020) prohibits anyone from practicing speech-language pathology without a Missouri license.

RSMO 345.025.1(6) provides: The provisions of sections 345.010 to 345.080 do not apply to an individual who “holds a current valid certificate as a speech-language pathologist issued by the Missouri Department of Elementary and Secondary Education (DESE) and who is an employee of a public school while providing speech-language pathology services in such school system”.

There are three different ways to obtain a speech-language pathologist student services certificate from DESE:

  1. A certificate will be issued if the person holds a valid Missouri license from the Board of Healing Arts. This certificate is valid for as long as the license is current. If the license becomes inactive, the certificate is no longer valid.
  2. A certificate will be issued if the person completes a teacher preparation program with sufficient credits in speech pathology. This certificate is valid for 99 years.
  3. A certificate will be issued if the person has completed a teacher preparation program in another state and holds a valid teaching certificate in speech pathology or something comparable from another state. This certificate is valid for 99 years.

If a speech-language pathologist's certificate was issued based on holding a valid Missouri license and the Missouri license is no longer current, the certificate becomes invalid. As a result, the speech-language pathologist's enrollment in the Missouri Medicaid program will be terminated.

Adult Day Health Care

August 06, 2012

Do I have to have a nurse on-site at the Adult Day Health Care facility, full-time?

13 C.S.R. § 70-92.010(3)(F)(3)(D) provides:

D. Because of the type of participant(s) and the services offered by an adult day health care program, a registered or licensed nurse must be available to the adult day health care participants at all times and readily available in the event of an emergency during the adult day health care program’s operating hours. The registered or licensed nurse must be available by being a staff member of the adult day health care program or located in the same building provided that a formalized agreement is executed which outlines the responsibilities of the registered nurse (RN) or licensed practical nurse (LPN) to the adult day health care program. Part of each day must be committed by the RN or LPN to the adult day health care program. If the RN or LPN is employed by another party, that party must co-sign the agreement. In the event an adult day health care program does not have a registered nurse or licensed nurse as a staff member or available in the building, a certified medication technician may be employed as a full-time staff member provided that an RN or LPN consultant monitors patient charting, medication distribution and assists in medical planning.

There are three ways in which this standard may be met:

  1. The standard may be met “by [the qualifying nurse] being a staff member of the … program.” The fulfillment of the standard in this manner requires that the qualifying nurse be employed on a full-time basis by the program.
  2. The standard may be met “by [the qualifying nurse] being located in the same building provided that a formalized agreement is executed which outlines the responsibilities of the … nurse … to the … program.” Should the provider choose this compliance option, then “[p]art of each day must be committed by the [nurse] to the … program.” Also, if the provider chooses this option and “the [nurse] is employed by another party, that party must co-sign the agreement.”
  3. The standard may be met “in the event an adult day health care program does not have a registered nurse or licensed nurse as staff member or available in the building." In this case, “a certified medication technician may be employed as a full-time staff member provided that an RN or LPN consultant monitors patient charting, medication distribution and assists in medical planning.” (NOTE: State licensure requirements at 19 CSR 30-90.050 (8D) allow only a licensed nurse to receive, control and manage the medication and drug program. This includes administration of medication and treatments. Also note that the provider must be in compliance with the “Practice Act”, 335.081RSMO.)

    In addition to complying with one or more of the above, please note that a registered or licensed nurse must be readily available in the event of an emergency during the adult day health care program’s operating hours.

MMAC recognizes providers are assessed, reviewed, and audited by different entities. Other agencies may impose their own requirements. Providers are also required to comply with their state licensure requirements.

Requesting Provider Assistance

July 30, 2012

The Provider Education and Provider Communication Units within the MO HealthNet Division (MHD) provide education and assistance for the provider community. These units strive to provide accurate and timely responses to provider inquiries and concerns regarding MO HealthNet policies and procedures. On occasion, an issue is more complex in nature and may require further research by MHD staff which could delay the response time. If multiple requests are received from the same provider for the same issue, this could also further delay the response time. Therefore, providers are encouraged to direct all follow-up communication regarding the same issue to the same MHD staff member. This will allow for the most efficient and timely resolution of the issue.

Inquiries, concerns or questions regarding claim filing, claims resolution, and participant eligibility and verification should be directed to Provider Communications at 573/751-2896.

Provider Education can be contacted at 573/751-6683 to schedule training in claim filing and program policies.

Postoperative Care

July 23, 2012

Postoperative care includes 30 days of routine follow-up care for those surgical or diagnostic procedures having a MO HealthNet reimbursement amount of $75.00 or more. For counting purposes, the date of surgery is the first day.

This policy applies whether the procedure was performed in the hospital, an ambulatory surgical center or an office setting, and applies to subsequent physician visits in any setting (e.g., inpatient and outpatient hospital, office, home, nursing home, etc.).

Pain management is considered part of postoperative care. Visits for the purpose of postoperative pain control are not separately reimbursable. Physician (surgeon or physician other than the surgeon) services are audited against claims that have already been paid as well as against those claims currently in process.

Supplies necessary for providing the follow-up care in the office, such as splints, casts and surgical dressings in connection with covered surgical procedures that meet the postoperative care policy, may be billed under the appropriate supply code. Attach an invoice if applicable.

Sometimes providers fail to use the appropriate modifier when billing for surgical care only or post operative management only. Use modifier 54 with the surgical procedure code to indicate surgical care only. Use modifier 55 with the surgical procedure code to indicate postoperative management only.

For procedures subject to postoperative editing, please see Section 13.41.A of the Physician Manual.

For exceptions to the postoperative policy, please see Section 13.41.B of the Physician Manual.

Missouri Medicaid Audit and Compliance (MMAC) Provider Review Tips

July 16, 2012

In-Home Services and Consumer-Directed Services:

  • Follow the current care plan as closely as possible
  • Never serve more than approved units
  • Intermittent changes: If the services provided do not match the care plan, document why and attach the documentation to the time sheet.
  • Permanent changes: If the units need to be decreased or increased, contact Department of Health and Senior Services (DHSS) and the document date of that contact in the participant record. If a participant does not want a certain service on the care plan, call DHSS for a care plan change.

    Example: A participant tells an aide that he/she does not want the aide to bathe her because he/she has made other arrangements. DHSS should be contacted to reduce the care plan. Document the date of that contact in the participant’s record.

  • Listed below are the types of documentation MMAC Provider Review may request but are not limited to:
    • Time sheets/telephone records
    • Current care plan and LTACS/Web Tool
    • Nurses Notes
    • Training Records
    • Employee Records
    • Any other documents maintained by the provider that would support billings to MO HealthNet.

Residential Care Facilities:

  • Provide the services that are on the current care plan
  • Bill only for the days that services are provided. This will not always be 31 days.
  • Time sheets must be signed daily per regulation 13 CSR 70-91.010(4)(A)2.f.
  • Intermittent changes: If the services provided do not match the care plan, document why and attach the documentation to the time sheet.
  • Permanent changes: If the units need to be increased or decreased, contact DHSS and document the date of the contact in the participant’s record.
  • Listed below are the types of documentation MMAC Provider Review may request but are not limited to:
    • Service delivery logs
    • Written notes and observations
    • Daily nursing chart
    • Medication Administration Records (MAR) Census records
    • Current care plan and LTACS/Web Tool
    • Any other documents maintained by the provider that would support billings to MO HealthNet.
Incarcerated Participants

July 9, 2012

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.

Admittance as an inpatient in a hospital, nursing facility, juvenile psychiatric facility or intermediate care facility interrupts or terminates the inmate status. At that time, an application may be made for MO HealthNet benefits. The individual, a relative, an authorized representative, or penal institution designee may initiate the application. If approved, eligibility for MO HealthNet benefits 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.M, Section 1.5.M(1) and 1.5.M(2) of your MO HealthNet provider manual.

Dual Eligible Hospice Participants

July 2, 2012

Participants who are eligible for both Medicare and MO HealthNet at the time of election must simultaneously elect the hospice benefit for both programs. Hospice providers are not to wait until the participant enters a nursing home to elect MO HealthNet hospice. Concurrently electing both Medicare and MO HealthNet hospice benefits enables MO HealthNet to avoid duplication of payments for services covered under the Medicare hospice benefit.

Should a participant’s MO HealthNet eligibility begin, or the hospice becomes aware of the participant’s MO HealthNet eligibility after Medicare hospice benefits have been elected, providers are to complete the informational portion of the MO HealthNet Hospice Election Statement and attach a copy of the Medicare election form indicating the original election date. The signature(s) and dates on the Medicare election may be used as verification of the participant’s election date and consent to use hospice benefits when attached to the MO HealthNet Hospice Election Statement. The hospice must submit these forms to MHD as soon as possible.

Re-Pricing Medicare Inpatient Hospital Claims

June 25, 2012

Since July 1, 1991, the MO HealthNet Division (MHD) has been re-pricing Medicare Part A inpatient hospital crossover claims for the possible payment of Medicare deductible and co-insurance amounts. This Hot Tip is a reminder that the re-pricing policy also applies to Medicare Part C/Advantage plans for inpatient hospital services for deductible, co-insurance and co-pay amounts for participants who are QMB eligible. The following information is taken from Section 12.5.A of the Hospital Provider Manual.

MO HealthNet is responsible for deductible and coinsurance amounts for Medicare Part A crossover claims only when the MO HealthNet applicable payment schedule exceeds the amount paid by Medicare. In those situations where MO HealthNet has an obligation to pay a crossover claim, the amount of MO HealthNet’s payment is limited to the lower of the actual crossover amount or the amount the MO HealthNet fee exceeds the Medicare payment. The hospital’s remittance advice will show the amount to be paid for each re-priced Part A/Part C crossover claim. Please refer to your provider manual for additional program and provider information for those claims where Medicare has paid more than MO HealthNet would.

Amounts not reimbursed by MO HealthNet for allowable crossover claims may not be billed to the MO HealthNet participant.

The Part A Medicare deductible for inpatient services is always applied to the day of admission or the first day in the hospital stay that the individual becomes Medicare eligible. If the patient is not MO HealthNet eligible on the day the deductible is applied, MO HealthNet does not pay the deductible and it becomes the responsibility of the patient to pay for the deductible.

Provider Audio/Visual Presentations

June 18, 2012

A provider training feature, audio/visual presentations, was recently updated on the MO HealthNet Web site adding instructions on manually filing crossover claims and Eligibility Determination. Providers and others can view and listen to these and other short audio/visual billing tips and presentations at their own pace. The trainings are PowerPoint presentations with a voice to explain each slide. All you need is a computer with Internet access, PowerPoint or PowerPoint Viewer and a sound card.

Claim Processing Schedule FY 2013

June 11, 2012

The provider claim processing schedule has been updated for state fiscal year 2013 which begins July 1, 2012. The schedule lists the dates the cycles are run and their corresponding check dates.

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

Participant Copayment

June 4, 2012

Since September 1, 2005, participants receiving services under certain programs are required to pay a small portion of the costs of the services. The copayment ranges from fifty cents ($.50) to three dollars ($3.00) depending on the service received, except for inpatient hospital copayment, which is ten dollars ($10.00). Copayments apply to the following hospital and physician related services and is applied to the billing provider type:

Type of Provider Copay Amount

Inpatient Hospital

Copayment will be applied to the first date of admission, except for emergency or transfer inpatient hospital admissions

$10.00
Outpatient Hospital $3.00
Case Management $1.00
Physician, M.D. $1.00
Physician, D.O. $1.00
Nurse Midwife $1.00
Nurse Practitioner $1.00
Psychologist $2.00
Independent Clinic/FQHC $2.00
Independent Clinic $0.50
Public Health Dept Clinic $0.50
Teaching Institution Department $0.50
Teaching Institution $0.50
Rural Health Clinic $2.00
Independent Laboratory $1.00
Independent X-ray Service $1.00
CRNA $0.50

For dental, optical and podiatry services, copayment is based on the amount MO HealthNet pays per date of service or item as shown below:

MO HealthNet Amount Copay Amount
$10.00 or less $ .50
$10.01 to $25.00 $1.00
$25.01 to $50.00 $2.00
$50.01 or more $3.00

The following participant groups or services are exempt from copayment:

  • Participants under 19 years of age;
  • Managed Care enrollees
  • Persons receiving MO HealthNet under a category of assistance for pregnant women or the blind;
  • Services to residents of a skilled nursing facility; intermediate care nursing home; residential care home; adult boarding home or psychiatric hospital;
  • Services to participants who have both Medicare and MO HealthNet;
  • Emergency or transfer inpatient hospital admissions;
  • Emergency services provided in a hospital outpatient clinic or emergency room to treat a life threatening condition;
  • Certain therapy services (physical therapy; chemotherapy; radiation therapy; chronic renal dialysis) except when provided as an inpatient hospital service;
  • Family planning services;
  • Services provided to pregnant women, directly related to the pregnancy or complications of the pregnancy.
  • Foster care participants;
  • In-home/personal care services;
  • Hospice services;
  • Medically necessary services identified through an Early Periodic Screening, Diagnosis and Treatment screen (EPSDT);
  • Department of Mental Health services;
  • Medicaid waiver services

Providers of services subject to a copayment may not deny or reduce services based on the participant’s inability to pay when charged. A participant’s inability to pay a required copayment when charged does not extinguish the participant’s liability to pay the due amount or prevent a provider from attempting to collect a copayment.

If a provider has uncollected copayment debt and it is the routine business practice to discontinue future services to an individual with uncollected debt, the provider may include uncollected copayment under this practice. The provider must however, give the participant reasonable opportunity to pay and advance notice to arrange care with a different provider before services can be discontinued.

For detailed information regarding MO HealthNet copayments, please reference the ‘Missouri Medicaid Program Changes’ bulletin dated July 12, 2005.

MO HealthNet Mailing Addresses

May 29, 2012

Sometimes it is necessary to file a paper claim and/or attachments to collect MO HealthNet reimbursement for services provided. It may also be necessary to send a claim or other inquiry through the mail. Please use the addresses below when mailing:

Wipro Infocrossing Health Care Systems,

PO Box (select the appropriate PO Box from the following list)

Jefferson City, MO 65102

PO Box Claim Type
PO Box 5200 Inpatient hospital claims
PO Box 5200 Outpatient hospital, rural health clinic, hospice and home health claims
PO Box 5300 Dental claims
PO Box 5500 Provider Communications (for claim inquiries only)
PO Box 5600 Medical, mental health, optical, durable medical equipment, therapy (speech, occupational and physical), private duty nursing, personal care, adult day care, hearing aid, homemaker/chore and ambulance claims
PO Box 5700 Prior Authorization requests
PO Box 5900 Attachments (Sterilization Consent form, Acknowledgement of Hysterectomy Information form, Program Integrity 118 Lock-in Referral form, Oxygen and Respiratory Equipment Medical Justification and Certificate of Medical Necessity form (DME program only).

The street address for Wipro Infocrossing Health Care Systems is: 905 Weathered Rock Road, Jefferson City, MO 65101

The MO HealthNet Division mailing address is: MO HealthNet Division, PO Box 6500, Jefferson City, MO 65102

Billing Nursing Home Therapy Crossover Claims

May 21, 2012

MO HealthNet reimburses coinsurance and/or deductible amounts for therapy provided in the nursing home under the following circumstances:

  • Resident has traditional Medicare Part B; or
  • Resident has Medicare Part C with QMB (Qualified Medicare Beneficiary).

The majority of Medicare/Medicaid claims for residents with traditional Medicare Part B will automatically cross from Medicare to MO HealthNet. Medicare Part C claims are not electronically forwarded to MO HealthNet. The following is clarification for submission of therapy services on the Medicare UB-04 Part B and/or Part C Professional claim formats on the MO HealthNet billing Web portal.

  • Service line detail information should be entered online as it was submitted to Medicare.
  • Procedure codes, as well as modifiers, are to be entered by line item, by date of service (DOS).
  • Like therapy disciplines cannot be bundled together as a single line item or date spanned.
  • Revenue codes are not required for Part B claims.

Medicare Part B claims crossed from Medicare to MO HealthNet in excess of 28 line items will “split” and process as multiple claims however the claims processing system can only process 25 edits or less on one claim. Providers are encouraged to reference MO HealthNet Bulletin Crossover Claim Editing, dated August 21, 2006, Volume 29, Number 8 . If services are bundled or the same therapy was provided on the same DOS but with different modifiers, services would deny as duplicates if resubmitted. As an example, the resident received four units of 97530 GO during the month of April and ten units of 97530 GP; it is incorrect to bill 15 units of 97530 with a date span of April 1st -30th. Should it be determined a unit of 97530 GP was overlooked during the month of April and submitted after the initial 15 units paid, the single unit of 97530 would deny as a suspect duplicate as the DOS fell sometime between April 1st and April 30th.

Webinars for Nursing Home Medicare Institutional and Professional Crossover Claim Filing are available from the MO HealthNet Provider Education Unit. See schedule and registration information.

Filing a Secondary (TPL) Claim to MO HealthNet

May 14, 2012

You have a patient who has private commercial insurance in addition to MO HealthNet. The commercial insurance company has processed and either paid or denied your claim. Now you need to submit your claim to the MO HealthNet Program to determine if any of the balance will be paid by the program. How do I file this claim to MO HealthNet?

Note–if the commercial insurance has paid the provider more than the MO HealthNet allowable for the service(s), no additional payment will be made when the claim is submitted.

The claim should be billed through the MO HealthNet Web portal, emomed.com using the following guidelines:

  • Log on to the Web site and choose ‘Claim Management’. Be sure the correct NPI is displayed.
  • Select the appropriate claim type under ‘New Claim’ and complete the required fields in the Claim Header Information section. Be sure to click on ‘Save Claim Header’ to save the data to the claim.
  • Complete all the newly opened and required detail line fields. Make sure you save each detail line to the claim.
  • After you have entered all the information and saved, scroll to the first orange divider line titled ‘Other Payers’ and click on the title. Complete the Header Summary fields and then click on ‘Save Other Payer Data and Manage Codes’. This opens the ‘Other Payer Detail Summary’ fields.
  • Under ‘Associated Line Items’, click on the appropriate numbered box for the line of the claim that you are entering information. From the information on the commercial EOB, select the correct ‘Claim Group Code’ (such as PR-Patient Responsibility and/or CO-Contractual Obligation) from the drop down box, enter the appropriate Claim Adjustment Reason Code (such as 1-deductible, 2-co-insurance, 3-copayment and/or 45 for the contractual) and the Adjustment Amount ( amount of patient responsibility and/or contractual). Once the information has been entered for this line of the claim, click on ‘Save Codes to Other Payer‘. If appropriate, complete any additional detail lines.
  • After completing information for each detail line of the claim, click on ‘Save Other Payer to Claim’.
  • Finally, click on the ‘Submit’ button at the bottom of the page for submission of your completed claim.
Insurance Fields on a Paper CMS-1500 Claim Form

May 7, 2012

Sometimes it is necessary to file a paper CMS-1500 claim form, such as when there are multiple surgeries or when submission of other claim documentation is necessary to receive reimbursement.

When you do file a claim by paper, and the patient has no third party resource for payment, remember to leave fields 4, 7, 9-9d, 11-11d, and 29 blank. When information is entered in these fields, the claim will deny asking you to bill the third party resource before submitting the claim to MO HealthNet. Many providers are entering Medicaid information in these fields which results in claim denial.

Field-by-field claim filing instructions can be referenced in Section 15 of the provider manuals

CMS Hosting Provider Education Webinar/Conference Calls

April 30, 2012

The Centers for Medicare & Medicaid Services (CMS) is hosting six Payment Error Rate Measurement (PERM) program provider education Webinar/conferences calls during PERM Cycle 1 (2012) of which Missouri is included. The purpose is to provide an opportunity for the providers of the Medicaid and Children's Health Insurance Program (CHIP) communities to enhance your understanding of specific provider responsibilities during PERM.

The PERM program is designed to measure improper payments in the Medicaid and CHIP programs as required by the Improper Payments Information Act (IPIA) of 2002 (amended in 2010 by the Improper Payments Elimination and Recovery Act (IPERA).

Webinar/Conference call participants will learn from presentations that feature:

  • The PERM process and provider responsibilities during a PERM review
  • Frequent mistakes and best practices
  • The Electronic Submission of Medical Documentation (esMD) program

Participant call in information will be posted on the Provider Education Calls page, approximately 10 days prior to the calls. The PERM Cycle 1 (2012) Provider Education Webinar/Conference calls Webinar are being presented on a Connect Pro platform.

Prior to attending a webinar, a Adobe Acrobat Connect Pro Connection Test is recommended. This test will verify that your computer meets the minimum system requirements needed to attend this meeting and suggest actions to take if it does not. The test will also ensure that your system is configured to provide you with the best Connect meeting experience.

The webinar dates are:
Date Time Join the webinar
May 23, 2012 1:00 to 2:00 PERM Cycle 1-2012-Web1
June 21, 2012 1:00 to 2:00 PERM Cycle 1-2012-Web2
July 24, 2012 1:00 to 2:00 PERM Cycle 1-2012-Web3
August 23, 2012 1:00 to 2:00 PERM Cycle 1-2012-Web4
September 25, 2012 1:00 to 2:00 PERM Cycle 1-2012-Web5
October 24, 2012 1:00 to 2:00 PERM Cycle 1-2012-Web6 

There will be time available for questions and answers at the end of the presentations however; CMS encourages all participants to submit questions in advance to PERMProviders@cms.hhs.gov or you may also contact your State PERM representative, Carissa Duewell at MMAC, Carissa.duewell@dss.mo.gov or 573/751-3399 with any questions and for education and training in your state.

Please check the CMS website and PERM Provider's page regularly for helpful education materials, FAQS, and updates.

Time Limit to File Adjusted Crossover Claims

April 23, 2012

Adjustments to MO HealthNet payments are only accepted if filed within 24 months from the date of the Remittance Advice (RA) on which payment was made OR within 6 months from the date of the Medicare reprocessing date. Only the adjustments that are the results of lawsuits or settlements are accepted beyond 24 months.

If the above guidelines are met and processing of an adjustment necessitates filing a new claim, the timely limits for resubmitting the corrected claim is limited to 90 days from the date of the MO HealthNet RA indicating recoupment, 12 months from the date of service, or 6 months from the Medicare reprocessing paid date, whichever is longer.

If the above guidelines are NOT met and higher reimbursement is being sought, DO NOT adjust the claim as there will be no additional reimbursement above the original payment.

If the above guidelines are NOT met and a lower reimbursement amount is due, providers should not void the claims; instead submit the Provider Initiated Self Disclosure Report Form (PISDR) or submit a spread sheet as long as the spread sheet includes all the information that is required on the PISDR form. The provider should include:

  • The date MO HealthNet made payment on the claim(s) that Medicare adjusted.
  • A letter explaining why the claim(s) were adjusted.
  • A check in the amount to be refunded.

The provider should send all documentation to the address indicated on the form.

Please reference Hot Tip "Sending Claims for Special Handling" dated July 5, 2011, which explains the guidelines to follow when submitting paper crossover claims that require special handling.

Injections and Immunizations Given in a Rural Health Clinic

April 9, 2012

Provider-based Rural Health Clinics (RHCs) may not bill for administration fees for injections or Vaccine of Children (VFC) immunizations. Provider-based RHCs may bill an appropriate level Evaluation and Management (E & M) code if a medically necessary E&M service is provided in addition to an injection or VFC immunization. If an injection or non-VFC immunization is given, the provider must bill using the National Drug Code (NDC) on a pharmacy claim form. Injections or non-VFC immunizations for MO HealthNet managed care participants must be billed to MO HealthNet through the fee-for-service program as pharmacy is carved-out of managed care.

Independent RHCs may not bill an administration fee for injections or VFC immunizations. The administration fee is included in the all-inclusive encounter rate for the visit. If the injection or immunization is the only service provided then an encounter may not be billed. The costs associated with the injection or non-VFC immunization would be included on the RHC cost report.

Note: MO HealthNet requires providers who administer immunizations to qualified MO HealthNet eligible children to enroll in the Vaccines for Children (VFC) Program through the MO Department of Health and Senior Services. Details are given in Section 13.4 of the Rural Health Clinic Manuals.

Hospitalization at the Time of Managed Care Enrollment or Disenrollment

April 2, 2012

If a MO HealthNet participant is in the MO HealthNet fee-for-service program at the time of acute inpatient hospitalization on the effective date they are to enter a MO HealthNet managed care health plan, the participant shall remain in the fee-for-service program until an appropriate acute inpatient hospital discharge.

Participants, including newborns, who are in a managed care health plan at the time of acute inpatient hospitalization on the effective date of entering a different health plan, shall remain with that health plan until an appropriate acute inpatient hospital discharge.

Participants, including newborns, who are hospitalized in an acute setting, shall not be disenrolled from a health plan until an appropriate acute inpatient hospital discharge, unless the member is no longer MO HealthNet fee-for-service or MO HealthNet Managed Care eligible or opts out.

Providers should notify the Provider Communications Unit at 573/751-2896 when any of the above situations occur so changes can be made to the participant’s file and the provider is reimbursed from the proper payor.

How to Submit Claims When MO HealthNet is Tertiary Payer

March 26, 2012

There are times when you must file a Medicare Crossover claim for a participant that has a supplemental insurance policy. To enter your claim, do the following:

  • Log onto the MO HealthNet Web Portal at emomed.com and enter your user ID and Password.
  • Choose the appropriate crossover claim form.
  • Complete the claim header Information and save claim header.
  • Complete each line detail saving after each entry.
  • Complete the other payers header summary using the information on the Medicare EOMB and "save other payer data and manage codes".
  • Complete the associated line items fields based on the information on the Medicare EOMB (show PR-Patient Responsibility and CO-Contractual Obligation) and “save codes to other payers” after completing the required fields for each line on the claim.
  • Save other payer to claim.
  • Complete the other payers header summary for the supplement policy and "save other payer data and manage codes".
  • Complete the associated line items fields. Under claim group code, you must choose OA-Other Adjustments. The claim adjustment reason code is 023 (payment and/or adjustments from other payer). The adjustment amount is the amount Medicare paid on the line. In the next claim group code field, you must choose PR-Patient Responsibility. The claim adjustment reason code is 001-Deductible or 002-Co-insurance. The adjustment amount is the amount of deductible/co-insurance due minus what the supplemental policy paid on the line. In the next claim group code field, you should choose CO-Contractual Obligation. The claim adjustment reason code is typically 045. The adjustment amount is the amount of the contractual or write-off on the line. You must complete an associated line item for each line on the claim.

Note: If billing for inpatient services on the MedicareUB-04 Part A Institutional Crossover Claim, complete your claim header information and enter each revenue code and days/units billed to Medicare. Be sure to save after each entry. Then you must complete the other payer header summary for both Medicare and the supplemental insurance policy. Part A claims are processed at the header. Therefore, the Payer at Header Level box must be checked.

Delivery and Placement Dates Versus Date of Service

March 19, 2012

Reminder — The date of service for items such as dentures, hearing aids, eyeglasses or durable medical equipment, should be the date of delivery or placement of the device or item. The date of service is not the date the device or item is ordered or fabricated. Providers should reference Missouri State Regulation 13 CSR 70-3.100(7)(D)(7).

5010 Compliant?

March 12, 2012

By now, most of you may be aware that if you are not 5010 compliant by April 1, 2012, you cannot be reimbursed by MO HealthNet for service claims you submit for MO HealthNet participants.

What we are referring to is being compliant with the Accredited Standards Committee (ASC) X12 version 5010 and NCPDP Telecom D.0 standards for electronic health care transactions under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

If you continue to submit claims through v4010 or v5.1transactions, they will be rejected and you will have a disruption in payment.

Please reference Provider Bulletin dated December 12, 2011 for complete information.

Participant Administrative Lock–In

March 5, 2012

Some MO HealthNet participants are restricted (or locked-in) to a provider or providers, such as a certain physician, hospital and pharmacy where they can receive treatment or services. This is to help the participant use the MO HealthNet program properly. A provider checking patient eligibility is given the names and phone numbers of the lock-in providers. Payment of services for a locked-in participant cannot be made to other providers except for emergency services or authorized referral services.

Claims for emergency services must be submitted on a paper claim form with an attached Certificate of Medical Necessity and/or medical records documenting the emergency circumstances.

When a physician is the designated/authorized provider, they are responsible for the participant's primary care and for making necessary referrals to other providers as medically indicated. When a referral is necessary to other providers, the lock-in provider must complete a Medical Referral Form of Restricted Recipient (PI-118) and send it to each provider to whom the participant is referred.

The referral form must contain the NPI (and taxonomy code if appropriate) for the provider to whom the patient was restricted on the date of service. For example, if the participant is locked into a clinic, you must use the clinic's NPI (and taxonomy code if appropriate) on either the paper form or the electronic form. Do not put the physician's individual NPI on the referral form as the information will not match the MO HealthNet lock-in file. The NPI on the claim from the provider who received the referral must match the NPI on the referral form.

The information from the form can then be submitted by the treating provider(s) via the Internet at emomed.com or the form can be mailed to Wipro Infocrossing Healthcare Services, PO Box 5900, Jefferson City, MO 65102.

The referral form is good for 30 days from the date of service or appointment. A new referral form must be submitted if additional care is required after the 30 days.

We Need Your Suggestions!

February 27, 2012

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 when MHD observations and reports 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.

Denture Coverage Reminders

February 21, 2012

Dentures are a covered benefit for the following MO HealthNet participants:

  • members eligible in one of the assistance categories for pregnant women, ME (Medical Eligibility) codes 18, 43, 44, 45 and 61 (the MO HealthNet Managed Care health plans are responsible for coverage of dentures for pregnant members with these same ME codes);
  • individuals eligible through one of the assistance categories for the blind, ME codes 02, 03, 12 and 15;
  • individuals residing in a nursing home regardless of their ME code – verification of vendor care/nursing home eligibility is determined by checking for “Nursing Home Information” when verifying participant eligibility; and
  • participants under the age of 21.

Dentures are not covered for MO HealthNet participants with a limited benefit package. For those participants receiving dental care meeting the criteria established for individuals with a limited benefit package even when that care may include full mouth extractions, dentures are still a non-covered service. A complete list of ME codes for participants receiving limited benefits can be found in the MO HealthNet Guide–Puzzled by the Terminology.

>When submitting claims for dentures to MO HealthNet, the date of service is the date of placement. Dentures, full or partial, do not require prior authorization.

History and Physical Prior to Outpatient Surgery

February 14, 2012

As a reminder, Procedure code 99218, 99219 or 99220 may be used in the outpatient setting (POS 22) for the initial history and physical workup prior to outpatient surgery.

NOTE: These procedure codes are not to be used for any other service provided in the outpatient setting.

Information regarding billing a history and physical prior to outpatient surgery can be found in Section 13.21.B of the MO HealthNet Physician Manual.

Split Claims

February 6, 2012

Claims submitted to MO HealthNet may, due to the adjudication system requirements, have service lines separated from the original claim. This is commonly referred to as a split claim. Each portion of a claim that has been split is assigned a separate internal control number and the sum of the service line(s) charge submitted on each split claim becomes the split claim total charge. Currently, a maximum of 28 service lines per claim are processed. All detail lines that exceed the size allowed are split into a separate claim. If a claim denies for more than 25 edits, the claim must be split into multiple claims.

Timely filing, duplicate claim submission, third party liability and spend down all post an edit for each line and can cause a claim to deny for more edits than the system can process. Providers can avoid this type of claim denial by submitting smaller claims with fewer line details.

MO HealthNet applies editing to Medicare/MO HealthNet crossover claims very similar to that used to process MO HealthNet only claims. The system can only process 25 edits or less on one claim. If the claim denies for more than 25 edits, the crossover claim must be split into multiple claims. When splitting the claim into multiple claims, the claim header charge will be different than the one sent to Medicare because the claim header charge must reflect the total charge of the service lines on the smaller split claim.

Providers can also bill smaller claims to Medicare so that the claim can crossover correctly without being manually split to address more than 25 edits.

Additional information regarding split claims can be found in Section 17.6 of the provider manual. Information regarding Medicare/MO HealthNet crossover claims can be found in the Crossover Claim Editing Bulletin, Volume 29, Number 8 dated August 21, 2006.

Temporary MO HealthNet During Pregnancy (TEMP)

January 30, 2012

As a reminder, TEMP services for pregnant women (Medical Eligibility codes 58 or 59) are limited to ambulatory prenatal services. Services other than ambulatory prenatal may be reimbursed if a Certificate of Medical Necessity is submitted with the claim and it affirms that the pregnancy would have been adversely affected without the service.

The diagnosis on the claim form must be a pregnancy/prenatal diagnosis (V22.0 through V23.9 or V28 through V28.9). Nurse midwives must use diagnosis codes V22.0 through V22.2 or V28 through V28.9.

If the TEMP participant is provided illness care, the illness diagnosis code must appear as the primary diagnosis code on the claim. However, a pregnancy/prenatal diagnosis code must also appear on the claim form.

Inpatient hospital services and deliveries performed either inpatient or outpatient are not covered under the TEMP program. Other non-covered services include: postpartum care; contraceptive management; D & C; treatment of spontaneous, missed abortions or other abortions.

Infants born to mothers who are eligible under the TEMP Program are not automatically MO HealthNet eligible under the TEMP program.

For more information on the TEMP Program, please reference Section 13.3 of the MO HealthNet Physician Manual.

Timely Filing Guidelines

January 23, 2012

MO HealthNet timely filing guidelines for claims and adjustments can be found in Section 4 of Provider Manuals and are outlined below:

  • Original claims must be filed by the provider and received by the state agency within twelve (12) months from the date of service. Any claims that originally were submitted and received within twelve (12) months from the date of service, but were denied or returned to the provider, must be resubmitted and received within twenty-four (24) months of the date of service.
  • Medicare/MO HealthNet crossover claims that have been filed within the Medicare timely filing requirement must be received by the state agency within twelve (12) months from the date of service or six (6) months from the date on the Medicare provider's notice of the allowed claim. Claims denied by Medicare must be filed by the provider and received by the state agency within twelve (12) months from the date of service.

    NOTE: A non-QMB Medicare Part C claim must be filed by the provider and received by the state agency within twelve (12) months from the date of service. Any claims that originally were submitted and received within twelve (12) months from the date of service, but were denied or returned to the provider, must be resubmitted and received within twenty-four (24) months of the date of service.

  • MO HealthNet claims with third party liability must first be submitted to the insurance company in most instances. However, the claim to MO HealthNet must still meet the timely filing guidelines outlined above. Claim disposition by the insurance company after one (1) year from the date of service does not serve to extend the filing requirement. However, the twelve (12) month filing rule may be extended if a third-party payer, later reverses the payment determination sometime after twelve (12) months from the date of service has elapsed and requests the provider return the payment. In this case, the provider may file a claim with MO HealthNet later than twelve (12) months from the date of service by submitting the claim to the Third Party Liability Unit, PO Box 6500, Jefferson City, MO 65102 for special handling.
  • Adjustments to a paid claim must be filed within twenty-four (24) months from the date of the remittance advice on which payment was made. If the processing of an adjustment necessitates filing a new claim, the time limit for resubmitting the new, corrected claim is ninety (90) days from the date of the remittance advice indicating recoupment or twelve (12) months from the date of service, whichever is longer.

MO HealthNet provider manuals can be referenced through the following link: http://manuals.momed.com/manuals/.

Consultations

January 17, 2012

As a reminder, MO HealthNet still recognizes the consultation codes, 99241-99245 and 99251-99255. While many payors have changed the way consultations are billed, MO HealthNet still requires the use of the codes shown above for reimbursement.

If you have billed consultations incorrectly, please file an online adjustment to correct.

Please reference the Physician Manual, Section 13.28 for the guidelines to bill consultations.

Nursing Home Room & Board Claim Filing Reminders

January 9, 2012

The following are claim filing reminders for nursing homes when submitting claims for their room and board charges:

  • The FA–465 is the facility’s authorization to submit claims to MO HealthNet;
  • With the exception of days a resident is locked in to a hospice, all days are to be billed to MO HealthNet with the appropriate revenue codes;
  • Each month should be billed chronologically. For example, if a resident had an inpatient hospital stay 11/29/11 – 12/02/11,
    was discharged 12/03/11 and in a Medicaid only bed for the remainder of the month,
    the inpatient hospital days for 12/01/11 – 12/02/11 must be billed before the Medicaid only days;
  • Facilities are not restricted to once monthly billing, room and board charges may be submitted at anytime during the month.

For more information on MO HealthNet’s nursing home program, providers can reference Section 13 of the MO HealthNet nursing home manual.

Contacting Provider Education

January 3, 2012

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. It is not possible to list all the MO HealthNet programs below, but by providing the pertinent information above, your request for assistance can easily be directed to the appropriate staff.

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

Becky – personal care/homemaker-chore, home health, private duty nursing, psychology/counseling, speech/occupational/physical therapy, including these providers within a group or clinic;

Dawn – durable medical equipment, ambulance, adult day health care, nursing homes, dental, hospice, optical (optometrists), including these providers within a group or clinic;

Renee – 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 including Columbia.

Carol – 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 including Jefferson City.

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 only for program training or questions regarding policy clarification.