MO HealthNet Provider Hot Tips
The MO HealthNet Division provides hot tips to providers to assist them in receiving timely reimbursement for services provided. Please share these hot tips with your billing staff.
2017 Provider Tips
Managed Care Goes Statewide on May 1, 2017
Effective May 1, 2017, the MO HealthNet Managed Care program is offered statewide to all 114 counties and the City of St. Louis. Approximately 240,000 participants, who previously were enrolled in the MO HealthNet Fee-For-Service (FFS) program, are transitioned to a Managed Care health plan. These new Managed Care participants join about 500,000 existing Managed Care participants, amounting to an estimated 740,000 Missourians in the Managed Care program. Participants have received welcome packages from their health plans and will receive services through their health plan’s network of providers.
Missourians who are aged, blind or disabled will remain in the MO HealthNet FFS program. MO HealthNet FFS and Managed Care program participants will not lose eligibility or coverage as a result of the transition to statewide Managed Care; health care benefits will remain the same.
Providers currently enrolled with MO HealthNet’s FFS program in the counties impacted by the Managed Care geographic extension are encouraged to contract with the three newly awarded MO HealthNet Managed Care health plans and to maintain their enrollment with MO HealthNet. To contract with the MO HealthNet Managed Care health plans, contact them directly.
Open enrollment for participants to choose a Managed Care health plan ended April 3, 2017. Participants who did not enroll by April 3, 2017, have been auto-assigned to a health plan. Participants have 90 days from the date coverage starts to change health plans for any reason. For example, a participant may change health plans if their provider is not contracted with the same health plan. After the 90 day period has passed, participants may change health plans if they have “just cause.” For more information, refer to the Participant Resource on “just cause” http://dss.mo.gov/mhd/participants/mc/files/changing-managed-care-health-plans.pdf.Please note: While the Managed Care program is based on the MO HealthNet FFS program, the two programs have differences. The Managed Care health plans are not required to follow the FFS program’s prior authorization or timely filing rules; in certain circumstances, the Managed Care health plans may establish rates of reimbursement different than the FFS program. Providers are encouraged to work with the Managed Care contracting teams to define and understand those differences and negotiate a mutually satisfactory agreement.
Aetna Inpatient Care
Consistent with the Managed Care health plan contract, all participants enrolled with Aetna Better Health of Missouri (Aetna) will be transitioned to a new Managed Care health plan effective May 1, 2017. However, for Aetna participants in an inpatient hospital setting that will extend beyond April 30, 2017 coverage will continue under Aetna until discharged. The MO HealthNet Division is asking that providers, participants or the Managed Care health plans contact the following with the admission date and/or the discharge date:
- Providers call the MO HealthNet Provider Communications Unit at 1-573-751-2896
- Participants call the MO HealthNet Participant Services Unit at 1-800-392-2161
- Managed Care Health Plans e-mail [email protected]
The MO HealthNet Division will update the participant’s enrollment end date to remain enrolled with Aetna until the date of discharge. The effective date of the health plan enrollment will depend on the participant’s inpatient hospital discharge date.
Verifying Participant Eligibility
April 24, 2017
MO HealthNet Division (MHD) still uses day specific eligibility.
The MHD recently informed providers of the new Emomed functionality allowing them to view participant information and Managed Care enrollment up to 31 days in the future.
The recent change to Emomed was “technical only” and does not reflect a change in eligibility policy.
Participant eligibility must be checked on each date of service. Eligibility can change for MHD participants daily.
For additional information, please reference the document titled “Verifying Participant Eligibility”, located on the Provider Participation page at http://dss.mo.gov/mhd/providers/, under the General Information section.
If you have questions regarding this change, please contact the Provider Communications Unit at (573) 751-2896.Refer to section 1.2.B of any provider manual to see information regarding verifying eligibility.
Outpatient Hospital Facility Charges
April 13, 2017
It is important to remember when it is appropriate to bill MO HealthNet an outpatient hospital facility charge. Inappropriate billing of facility charges will result in recoupment of payments. The following information can be found in the MO HealthNet hospital provider manual which is available at http://manuals.momed.com/manuals/. Please refer to sections 13.38, 15.20, 15.21 and 15.23 for more information regarding outpatient facility charges.
An outpatient facility charge should be shown on the 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 who is registered on the hospital records 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 and pitocin. Infusion therapy by nurses in an outpatient setting may be added to the outpatient facility charge.
- 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 and 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 and 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 who 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 may be shown per date of service. If several physicians or clinics are seen, the charges must be combined into one facility code.
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.
2017 MO HealthNet Managed Care Webinar Training
February 17, 2017
The MO HealthNet Division (MHD) Provider Education staff will be conducting additional webinar trainings regarding the expansion of state-wide Managed Care, effective May 1, 2017. Currently, there are four webinars scheduled for February 22 and 28, 2017, and March 9 and 30, 2017, from 9:00 AM to 11:00 AM.
All MO HealthNet Provider Training schedules can be found on the Provider Page under the Education heading. Then click on Training Information. Scheduled trainings and enrollment information is posted on this page.
Please contact Provider Education staff at [email protected] (preferred method) or (573) 751-6963 with any questions or training needs.
Hot Tips will be published notifying providers of future trainings.
Providers should continue to view this page for updates.
Updated 1st Quarter Webinar Trainings
February 14, 2017
The MO HealthNet Webinar Training Conference schedule for the 1st Quarter has been updated. We will not offer training for the following programs during the 1st quarter: Local Public Health Agency, Outpatient Hospital, Medical Clinics and Physicians, Inpatient Hospital, Rural Health Clinic Independent, and Rural Health Clinic Provider-Based. The above programs will be included in the 2nd quarter webinar schedule that will be posted in early March 2017.
Please access the 1st Quarter 2017 Webinar Trainings to register.
Please contact the Provider Education Unit at [email protected] (preferred method) or (573)751-6963 with any questions or training needs.
2017 MO HealthNet Training Workshops
February 14, 2017
The MO HealthNet Division (MHD) Provider Education staff conducts yearly general program workshops. Instructions on how to register are outlined on the workshop schedule.
If a provider has registered for a workshop and cannot attend for any reason, contact MHD Provider Education Unit to cancel the registration. The Provider Education staff may be contacted by phone at (573)-751-6963, or by email at [email protected].
Dental Billing — Adult Dental Codes
- D0120 – Periodic Oral Evaluation
- Not included in the Adult Dental Limited Package
- Would require a letter of medical necessity from the patient’s primary care provider The medical necessity must meet MO HealthNet policy in Section 13 of the Dental Manual.
- D0140 – Limited Oral Evaluation Problem Focused
- Code could be used with appropriate documentation of the problem.
- D0150 - Comprehensive Oral Evaluation - new or established patient.
- This is generally billed once per patient per provider.
- Per the ADA CDT Coding book: “Applies to new patients; established patients that have had a significant change in health conditions or other unusual circumstances by report or established patients that have been absent from active treatment for 3 or more years”. This examination includes periodontal charting.
- D0210 – Intraoral-complete series of radiographic images
- Not included in the Adult Dental Limited Package
The following codes are covered for adults:
- D0330- Panoramic Radiographic Image
- D0220- Intraoral-Periapical first radiographic image
- D0230- Intraoral-Periapical each additional radiographic image
- Limit of 4 per Date of Service
- Only 1 Sedation code approved for Limited Adult Dental Program
- D9423 - Intravenous Moderate (conscious) Sedation
Note: May use Propofol, but only at the Moderate level of sedation.
Adults: Medical Necessity Patients
- Patients are still able to access other Medically Necessary Dental Services as outlined in Section 13 of the Dental Manual.
Note: You must have adequate documentation of the patient’s Medical Necessity and have a physician’s referral in the participant’s file.
- D0240- Intraoral-Occlusal radiographic image x-ray
Note: Only 1 allowed per Date of Service
- D9223 (not covered for adults) and D9423 Sedation codes
- Preoperative assessment time and post-operative recovery time are not covered under this code.
- “Anesthesia time begins when the doctor administering the anesthetic agent initiates the appropriate anesthesia and non-invasive monitoring protocol and remains in continuous attendance of the patient. Anesthesia services are considered completed when the patient may be safely left under the observation of trained personnel and the doctor may safely leave the room to attend to other patients or duties” (Per the 2016 CDT Code Book)
- These codes have a limit of 3 per date of service. Additional units will require justifying documentation to be submitted.
Adults and Patients 0-21 years
- D4341- Periodontal Scaling and Root Planning- four or more teeth per quadrant
- D4342- Periodontal Scaling and Root Planning- one to three teeth per quadrant
Note: Please submit periodontal charting for the above codes or any periodontal procedure codes
Important Billing Reminders
- Only bill for services you have documented proof of providing.
Section 2.3.A of the Dental Provider Manual
13 CSR 70-3.030, Section (2)(A) defines “adequate documentation” and “adequate medical records” as follows:
- Documentation of rendered services
- Some procedure codes require certain services to be performed. Document what services were provided.
- Be sure they match the code being billed.
- Ensure that reimbursement can be readily justified by documentation of key information, such as symptoms, conditions, diagnoses, treatments, and prognosis.
- Identify the patient who was treated.