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• Deborah E. Scott, Director

Verifying Participant Eligibility

June 30, 2008

The MO HealthNet Division (MHD) wants providers to be reimbursed for their services the first time their claim is submitted. By far, the top claim denials result from providers failing to check participant eligibility. These denials are:

• 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 them.
• 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 573-635-8908 or through the Internet at www.emomed.com.

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