Exceptions Process

Is there a special form for the Exception Process?

Yes, the Exception Request form is located on the MO HealthNet Forms page.

How do I contact the Exception Process?

Completed request forms may be faxed to the Exception Process at 573-522-3061. The telephone number for provider calls is 800-392-8030. Participants with questions about the Exception Process may contact the Participant Services Agent at 800-392-2161.

What are the program business hours of operation?

Hours are 8 a.m. to 5 p.m. Monday through Friday, excluding state and federal holidays.

How long will the review process take?

Reviews are completed within 15 working days of receipt.

What if the request is an emergency and the prescriber determines the participant cannot wait 15 working days?

Requests for life-threatening emergencies should be telephoned by the authorized prescriber to 800-392-8030 option 2. If the request meets the criteria of life-threatening, the review will be completed within 24 hours.

If I have the prescriber complete the Exception Request form and have faxed it in, can I call to get it reviewed as an emergency?

Requests submitted by fax will be processed as non-emergency requests within 15 working days.

Who will receive the notice of the review decision?

In the case of an approval, those who will receive notification include the prescriber, the participant, and the service provider for the approved item. In the case of a denial, only the prescriber and the participant will receive a notification letter.

What if I receive a denial and my prescriber wants additional information to be considered?

Any information submitted in writing by the prescriber will be reviewed.

The prescriber has questions about the denial. Is there someone they may call to discuss the denial or ask questions?

While phone calls for clarification purposes are permissible, any additional information for review reconsideration must be submitted by the prescriber in writing.

Where do I locate the codes required on the request form?

For requested durable medical equipment (DME) and supplies, the current version of the Health Care Procedure Coding System (HCPCS) must be utilized. For professional services, coding must be consistent with the Current Procedural Terminology (CPT) coding system. These codes should be available by contacting the supplier who will provide the service or you can purchase the coding book.

I'm not sure how to complete some fields on the form. Will the review be completed if I submit the incomplete form?

If the form is not completed, a review may not be performed. The form will be returned to the prescriber with a request to supply all necessary information.

I am a DME supplier and I called the hotline number to check the status of a request and was told that the request was returned to the prescriber or was denied. Since I sent the request for the prescriber, why don't I receive the notice when the request is returned or denied? Why is the notice sent to the prescriber and not the supplier?

Until an exception approval has been given and agreement notification to cover the item has been mailed to the supplier, requests for additional information are sent to the prescriber because they are considered to be the care coordinator. There is often a need for additional clinical information and/or clarification. As care coordinator, the prescriber has all medical record documentation to justify the need for the requested item.