2014 Archived 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.

Give Us Your Suggestions!

December 29, 2014

The MO HealthNet Division (MHD) provides weekly Hot Tips to providers to assist them in receiving timely reimbursement. Please share these weekly hot tips with billing staff.

If there is a topic that you would like to see covered, please send them by e-mail to: MHD.provtrain@dss.mo.gov.

Participant Eligibility Training Tool

December 22, 2014

Eligibility verification is essential to processing a claim for reimbursement. Providers shall check participant eligibility on the date of service (DOS) to verify the participant’s eligibility status and covered services.

There are many reasons to check eligibility, such as name and MO HealthNet identification number match, eligibility verification on DOS, reference to medical eligibility (ME) plan code, benefits and limitations, additional payer information, administrative lock-in provider information, spenddown amount and Qualified Medicare Beneficiary (QMB) versus non-QMB identifiers.

MO HealthNet has created an audio/visual training PowerPoint presentation titled Determining Eligibility. Providers can utilize this tool as a guideline for staff to better understand the online eMOMED participant eligibility screens. This audio/visual tool is available electronically from the Provider Participation page.

In addition to checking MO HealthNet participant eligibility through eMOMED, providers may also verify eligibility by contacting Provider Communications at 573-751-2896.

Non-Emergency Medical Transportation

December 15, 2014

The Non-Emergency Medical Transportation (NEMT) program may be utilized by participants to receive transportation to their MO HealthNet covered medical appointment. The NEMT broker is LogistiCare Solutions, LLC.

An enrolled MO HealthNet provider may call 1-866-269-5927 to arrange transportation, Monday through Friday 8:00 AM to 5:00 PM at least 5 calendar days before an appointment to assist a patient. Urgent appointments and hospital discharges may be called in 24 hours a day, 7 days a week.

If a ride is more than 15 minutes late or there is a complaint, call the “Where’s My Ride?” line at 1-866-269-5944.

Diabetes Self-Management Training

December 8, 2014

Per the Physician Manual, Section 13.60, diabetes self-management training services are used in the management and treatment of type 1, type 2 and gestational diabetes. These services are covered, when prescribed by a physician or a health care professional with prescribing authority and may be provided by a Certified Diabetes Educator (CDE), Registered Dietician (RD) or Registered Pharmacist (RPh).

Diabetes self-management training services are not available to adults receiving a limited benefit package. To provide and bill for diabetes self-management training, a provider must be approved and enrolled as a diabetes self-management provider with MO HealthNet.

Refer to Physician Manual, Section 13.60.A, for further information on the requirements to enroll as a provider under the Diabetes Self Management Training program.

Billing for Physician Services After Hours and Holiday Hours

December 1, 2014

Procedure code 99050, "Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed," may be billed in addition to the appropriate procedure code for the service, for those services provided before or after the physician's designated office hours. "Designated office hours" are defined as those hours known and understood by the public as times the office is regularly open for business. "After hours" designation may only be applied to those unusual circumstances occurring outside the regular/designated office hours as represented to the public, and during which the physician is not normally on-site

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

The following holidays are recognized:

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

Information regarding physician services after hours and holiday hours may be found in Section 13.21 A and 13.21  of the Physician Manual.

Ultrasound Exams in Pregnancy

November 24, 2014

Per Physician Manual, Section 13.57.B, routine ultrasounds are not indicated in normal pregnancies. However, MO HealthNet reimbursement is available for up to three ultrasound procedures during any one rolling year, when reasonable and necessary based on medical indication(s).

Ultrasounds provided in excess of three, during any one rolling year, must be medically necessary. All services must be adequately recorded in the patient's record and must demonstrate appropriateness of use in proper diagnosis, management and treatment of pregnancy-complicating or potentially complicating conditions.

Refer to Physician Manual, Sections 13.57.B(1) and 13.57.B(2) for an ultrasound indication checklist and non-covered ultrasound services.

Reimbursements for Circumcisions

November 17, 2014

As announced in the June 12, 2014, Volume 36, No. 31, Physician Bulletin, effective June 15, 2014, MO HealthNet will pay for elective circumcisions for all newborn infants less than 28 days old using Current Procedural Terminology (CPT) codes 54150 and 54160.

MHD policy previously required documentation in which two physicians had documented in writing that a disease, pathology or other abnormality exists that requires a medically therapeutic circumcision.  This policy has been rescinded effective immediately.
  
See bulletin for further information regarding these changes and the continuation of policy for CPT codes 54161, 54162, 54163, and 54164 that require a Prior Authorization.

Resources to Verify MO HealthNet Eligibility

November 10, 2014

Providers have several resources that make checking participant eligibility convenient.  The following resources are located at the Provider Participant Page:

• Provider Communications Unit at (573) 751-2896 for inquiries about participant eligibility status, or speak with a phone specialist;
• Email correspondence to Provider Communications Unit to inquire participant’s eligibility status, at eMOMED;
• Check the MO HealthNet Provider Manuals, Section 1.1.A, Description of

Eligibility Categories;

The following links are available from the Provider Participant Page:

• Puzzled by the Terminology? A Guide for providers that describes additional information of the MO HealthNet Medicaid Program.
• The Benefit Matrix A guide for providers to view if a service is covered or restricted based on the participants Medicaid Eligibility Code (ME) Plan.

Non-Covered vs. Non-Allowable Services

November 3, 2014

Providers commonly are confused between “non-covered” and “non-allowable” services.  The various provider manuals contain sections, which describe these services.

Generally, non-covered services are those that are not covered by MO HealthNet program, regardless of the participant’s medical eligibility (ME) code.  Or the services are not a covered benefit based on the participant’s eligibility and ME code.  There may be instances where a service or claim is denied stating that the service is not covered because the claim was incorrectly filed.  In these instances, the provider must correct and resubmit the claim.

Non-allowable services are those MO HealthNet considers to be included in the provider’s reimbursement for another procedure/surgery and are not separately allowable, not billable to the participant nor are reimbursable by the MO HealthNet program in any other manner.

Please review the appropriate section in your Provider Manual for this important information.  Questions regarding whether a service/procedure might be non-covered or non-allowable should be directed to the Provider Communications Unit at (573) 751-2896.

WebEx Meetings Conducted by Provider Education and Training Unit

October 27, 2014
Provider Education Unit would like to advise provider’s that Webinar’s are now scheduled and conducted with WebEx Meeting.  This new feature will assure that providers are still given full directions and allotted scheduled time for questions. 

The process to sign-up for a scheduled Webinar has not changed.  Please contact Provider Education and Training Unit by phone: (573) 751-6683, or by email at:  mhd.provtrain@dss.mo.gov.

Scheduled Webinars for Listed Claim Types

October 20, 2014

MO HealthNet Division (MHD) Provider Education Unit provides Webinar based trainings to enrolled providers.  Please access the Webinar Training schedule to attend any training that pertains to the provider’s specific training needs. 

Please limit questions to that specific Webinar, due to the time allotted for training sessions.  Please email the Provider Education Unit or call (573) 751-6683 with additional training questions that were not addressed during the scheduled Webinar.  

Providers, who are registered for a Webinar and unable to join the scheduled listed date and time, may cancel their attendance by emailing the Provider Education Unit, or calling at (573) 751-6683, to cancel the registration. 

Providers needing immediate assistance with submitted claims, may contact the Provider Communication call center at (573) 751-2896, or submit questions by email to Provider Communications through emomed.

Non-QMB, Medicare Part C Plan

October 14, 2014

MO HealthNet Division (MHD) will process claims in accordance with the established MHD coordination of benefits policy for Non-Qualified Medicare Beneficiary (Non-QMB) participants enrolled in a Medicare Advantage/Part C plan.  Please refer to the policy in the MHD provider manuals, General Section 5 - Third Party Liability.

In accordance with this policy, the amount paid by MHD is the difference between the MHD allowable amount and the amount paid by the third party resource.  The provider may not bill the participant for any unpaid balance of the total MHD covered charge, when the other resource represents all or a portion of the MHD maximum allowable amount. The provider is not entitled to any recovery from the participant except for services or items which are not covered by the MHD program, or services/items established by a written agreement between the participant and provider indicating that MHD is not the intended payer for the specific service/item. In this case, the participant accepts the status and liability of a private pay patient.

Missouri regulation 13 CSR 70-4.030 allows the provider to bill participants for MO HealthNet covered services if, due to the participant's action or inaction, the provider is not reimbursed by the MHD Program.

Participant Lock-In

October 6, 2014

Some MO HealthNet participants are restricted or locked-in to authorized MO HealthNet providers of certain services to help the participant use the MO HealthNet program properly.  When the participant has an administrative lock-in provider, the provider’s name and telephone number are identified on electronic billing website emomed or the IVR (Interactive Voice Response) system accessed from 573-751-2896, when verifying eligibility.

Participants, who are locked-in to a specific provider, clinic, pharmacy or a combination, are limited to obtain services from that provider.  Please refer to the Provider Manuals Section 1.5.B for additional information concerning lock-in.

Providers who wish to refer a participant to another provider must submit the Medical Referral Form of Restricted Participants (PI-118)  and the form must be signed by that referring provider.

Reconstructive Breast Surgery

September 29, 2014

Reconstructive breast surgery is considered a MO HealthNet covered service, if necessary to restore symmetry as recommended by the oncologist or primary care physician for the patient incident to mastectomy, as well as other documented medical necessity deemed appropriate via MO HealthNet physician consultant review.

Reconstructive breast surgery is not a covered service when performed for solely cosmetic purposes. The Prior Authorization Request form must be submitted and approved prior to rendering this service.

Electronic Claim Submission

September 22, 2014

A provider wishing to submit claims or attachments electronically or access the Internet website on emomed must be enrolled as an electronic billing provider.

Providers wishing to enroll as an electronic billing provider may register online on emomed or contact the Wipro Infocrossing Help Desk at (573) 635-3559.

Providers are unable to access emomed without proper authorization. An authorization is required for each individual user.

Third Party Resources

September 15, 2014

MO HealthNet funds are used after all other potential resources available to pay for the medical service have been exhausted. Please refer to the provider manual General Section 5 – Third Party Liability (TPL). The intent of requiring MO HealthNet to be payer of last resort is to ensure that tax dollars are not expended unnecessarily when another liable party is responsible for all or a portion of the medical service charge. It is to the provider’s benefit to bill the liable third party resource before billing MO HealthNet because some liable parties may pay in excess of the maximum MO HealthNet allowable.

Credit balances may occur when a provider receives payments from MO HealthNet and another third party payer for the same services. Providers should reconcile invoice records with credit balances to include a review of all charges and payment records, and, if the reconciliation identifies a MO HealthNet overpayment, the provider should report the overpayment to the State.

If the provider receives payment from a liable party after receiving MO HealthNet reimbursement for the covered service, the provider must promptly submit an Individual Adjustment Request form to MO HealthNet for the partial or full recovery of the MO HealthNet payment. The amount to be refunded must be the full amount of the other resource payment, not to exceed the amount of the MO HealthNet payment. Please refer to the provider manual, Section 6 for information regarding adjustments.

Women’s Health Services

September 8, 2014

The Women’s Health Services program, Medicaid Eligibility (ME) code 80 and 89, is a limited benefit program. Please refer to the Provider Bulletin, Women’s Health Services, which shows that services and supplies are only covered for the primary purpose of family planning or when a family-related problem was identified and/or diagnosed during a routine family planning visit. This bulletin provides a complete list of covered services for the Women’s Health Services Program.

All services under the Women’s Health Services Program must be billed with a primary diagnosis code within the range of V25 through V25.9. The limited benefit plan is outlined in the Provider Manuals, General Section 10 - Family Planning.

MO HealthNet Spenddown Provider Form

September 2, 2014

Spenddown refers to the amount of medical expenses that are a participant’s financial responsibility, which is similar to an insurance deductible. Participants may choose to have the providers submit incurred medical expenses to the spenddown unit on behalf of the participant.

Providers may utilize the MO HealthNet Spenddown Provider form located on the MO HealthNet for the Aged, Blind and Disabled page, under quick links and spenddown. Providers may scan and email the form to sesd@ip.sp.mo.gov and include receipts, bills, and information related to the spenddown.

Please email any questions or problems to the following address: SpendDown.Unit@dss.mo.gov, or fax the form to the numbers shown below.

Fax # for Spenddown ONLY information:

417-967-1043
417-967-0259
417-967-0372

Please do not email or fax duplicate forms, when a spenddown form was previously submitted. Please contact the spenddown unit with questions or issues.

Office Phone: 417-967-4551 Extensions for Manager, then supervisors listed below:

#250
#246
#227
#229
#270

CMS Hosts ICD-10 Webcast Series

August 25, 2014

The Centers for Medicare & Medicaid Services (CMS) recently announced the official compliance date of October 1, 2015, for implementation of the International Classification of Diseases, Tenth Edition (ICD-10). ICD-10 will have an effect on all medical and hospital claims that contain a diagnosis, and will be required for all providers covered by the Health Insurance Portability Accountability Act of 1996 (HIPAA). All healthcare professionals and facilities must be aggressively involved and develop a plan of action in order to be successful. The goal is for providers to identify resources and training needs in order to build a training plan. Preparation and planning will help reduce the risk of nonpayment for services provided on or after the ICD-10 implementation date of October 1, 2015.

CMS, in collaboration with physicians, has organized an ICD-10 webcast series to benefit providers during this time of transition to the new code set. The “Road to 10” tool is accessible through the CMS website and covers the history of the International Classification of Diseases (ICD), the benefits of ICD-10, clinical documentation tips, coding concepts, clinical scenarios, as well as a training calendar.

Visit the CMS ICD-10 website for further information on ICD-10 preparedness and to sign up for the “Road to 10” webcast series today.

Behavioral Health Telehealth Services

August 19, 2014

The Missouri Code of State Regulations 13 CSR 70-3.190 Telehealth Services, established coverage for Telehealth Services through the MO HealthNet Division (MHD) program and specifies that Telehealth providers must be Missouri licensed. The provider can be located in a state that borders Missouri, but must be Missouri licensed and enrolled as a MHD provider.

Telehealth Services are health care services provided through advanced telecommunications technology from one location to another. Medical information is exchanged in real-time communication from an Originating Site, where the participant is located, to a Distant Site, where the provider is located, allowing them to interact as if they are having a face-to-face, “hands-on” session.

A Telehealth service requires the use of a two (2)-way interactive video technology. Asynchronous telecommunication systems or store-and-forward systems are not covered technologies. Telehealth is not a telephone conversation, email, or faxed transmission between a healthcare provider and a participant, or a consultation between two healthcare providers. The participant must be able to see and interact with the off-site provider at the time services are provided, via Telehealth. Services provided via videophone or webcam are not covered.

MHD provides useful information for Telehealth in the Behavioral Health Manual Section 13.27. Additionally, MHD Bulletins relating to Telehealth include:

• Telehealth Bulletin,
• Rural Health Clinics and Federally Qualified Health Centers, and
• Physicians and Advance Registered Nurse Practitioners.

Billing for Multiple Surgical Procedures

August 4, 2014

MO HealthNet Division (MHD) receives inquires regarding MHD policy for claim denials concerning multiple surgical procedures on the same patient on the same date of service.  Please refer to Section 13.33.F of the Physician Provider Manual for additional information on billing for multiple surgical procedures.

When multiple surgical procedures are performed for the same body system through the same incision, the major procedure is considered for payment at 100% of the Medicaid allowable fee for the procedure (No reimbursement is made for incidental procedures).

Multiple surgical procedures performed on the same recipient, on the same date of service, by the same provider, for the same or separate body systems through separate incisions must be billed in accordance with the following guidelines:

• The major, secondary, and tertiary procedures should be indicated on the claim form using appropriate Current Procedural Terminology (CPT) codes.
• A copy of the Operative Report may be attached to claims for multiple surgeries to provide additional information. If not attached, a copy may be requested to assist with the claim processing.

Claims for multiple surgeries are allowed according to the following:

• 100% of the allowable fee for the major procedure.
• 50% of the allowable fee for the secondary procedure.
• 25% of the allowable fee for the tertiary procedure(s).

Bundled Value Code - Medicare UB-04 Part A Institutional Claims

July 29, 2014

The “Bundled Value Code” field is a new field located on the electronic Medicare UB-04 Part A Institutional crossover claim form. When entering a claim in emomed, this field is located within the Header section of the online claim form. Providers may reference the Emomed Help button located on the upper right corner of the online claim form for definitions of the fields. The Help option defines the new “Bundled Value Code” field with the following: “Crossover bundled value codes are used if a group code of patient responsibility is entered on the other payer attachment with a reason code of 247 or 248. The valid codes are: Y5-Professional Deductible or Y3-Professional Coinsurance.”

The Claim Adjustment Reason Codes (CARC’s) 247 and 248 may be found on the Washington Publishing Company website, which is linked from the MO HealthNet Provider Participation page. The CARC 247 will appear on the Medicare Explanation of Benefits (EOB) when there is a deductible for professional service rendered in an institutional setting and the service was billed on an institutional claim. The CARC 248 will appear on the Medicare EOB, when there is a coinsurance for professional service rendered in an institutional setting and the service was billed on an institutional claim.

When billing a Medicare Part A crossover claim in which professional services were billed to Medicare, and there is a Patient Responsibility (PR) amount with reason code 247 or 248, select the appropriate bundled value code from the drop down box. When there is PR 247, choose the value code Y5; and for a PR 248, choose the value code Y3.

If the CARC’s 247 or 248 do not appear on the EOB, do not enter anything in the Bundled Value Code field. This is not a required field unless CARC’s 247 or 248 appear on the Medicare EOB.

Provider Participation page

July 14, 2014

MO HealthNet Division (MHD) provides useful information for providers of all types, who participate in the MHD programs. Providers and their staff can find multiple links from the Provider Participation web page or links may be obtained from emomed, under the feature links section, Provider Information.

MHD staff encourages all providers to use the Provider Participation page to obtain ongoing updated information regarding Provider Quick Links, Provider Options for Education and Billing, General Information, and Provider Enrollment. Other useful categories may be found under the section titled Featured Links.

Scheduled Webinars for Listed Claim Types

July 7, 2014

MO HealthNet Division (MHD) Provider Education Unit provides webinar-based trainings to enrolled providers. Please access the Webinar Training schedule to attend any training that pertains to the provider’s specific training needs. Provider Education representatives want to ensure providers are given the full allotted time to go over the listed claim(s) type that pertain to the Webinar.

The training staff encounter questions about other types of claims not pertaining to the scheduled webinar.  Please limit questions to that specific webinar, due to the time allotted for training sessions. Please e-mail the Provider Education Unit or call (573) 751-6683 with additional training questions that were not addressed during the scheduled webinar.  

Providers, who are registered for a webinar and unable to join the scheduled listed date and time, may cancel their attendance by e-mailing the Provider Education Unit, or calling at (573) 751-6683, to cancel the registration.

Providers needing immediate assistance with submitted claims, may contact the Provider Communication call center at (573) 751-2896, or submit questions by e-mail to Provider Communications through emomed.

Claims Processing and Payment Schedule for Fiscal Year 2015

June 30, 2014

Please access the Claims Processing Schedule for Fiscal Year 2015, for the updated claims processing schedule located on the MO HealthNet website.

Claims Processing and Payment Schedule for Fiscal Year 2015

Note 1: Closeout is 5:00 PM. on the date shown

Contacting the Provider Education Unit

June 23, 2014

Inquiries regarding proper claim filing, claim denials, Remittance Advices, and participant eligibility should be directed to the Provider Communications Unit at  (573) 751-2896.  The Provider Education Unit should be contacted for training and education on proper billing methods and procedures for MO HealthNet Claims.
Requests for provider training can be directed to the Provider Education Unit at   (573) 751-6683 or made by email to mhd.provtrain@dss.mo.gov.  Please include the Provider’s Name, National Provider Identifier (NPI), reason for the inquiry, and type of training needed.  By providing the pertinent information described above, your request for assistance can be directed to the appropriate staff. The names of the Provider Education representatives and their training programs are listed below:

Rhonda Schenewerk– personal care/homemaker-chore, home health, private duty nursing, behavioral health, adult day health care, channeling (Elderly Waiver), psychologist, community mental health agency, speech/occupational/physical therapy, school-based services, including these providers within a group or clinic;

Katherine Hinkle-Black– durable medical equipment, ambulance, audiologist (hearing aid) , nursing homes, private home, dental, hospice, optical (optometrists), targeted case management-MR/MI, rehabilitation center, non-emergency transportation, MRDD Waiver, psychiatric rehabilitation, including these providers within a group or clinic;

Gina Overmann and Kim Morgan– nurse practitioners, podiatrists, hospitals, physician/clinics, nurse midwife, CRNA services, chiropractor, professional medical billing concerning Federally Qualified Health Centers and Rural Health Clinics, state institution-long term care, targeted case mgt (foster care), case management, diabetes self mgt training, lead environmental assessment, public health agency, planned parenthood clinic, teaching institution, independent laboratory, independent x-ray services, QMB only services;
NOTE: Gina is responsible for providers West of MO Hwy. 63, and Jefferson City and South.
NOTE: Kim is responsible for providers East of MO Hwy. 63, and North of Jefferson City.

Hospital Medical Record Documentation

June 16, 2014

As stated in the Introduction to the International Classification of Diseases Ninth Edition (ICD-9) Official Guidelines for Coding and Reporting, a joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses.

The importance of consistent and complete documentation in the medical record cannot be overemphasized. The medical record documentation, from any provider involved in the care and treatment of the patient, may be used to support the determination of whether a condition was present on admission or not.

Reasons some Crossover Claims do not Process Automatically

June 9, 2014

Some crossover claims cannot be processed in the usual manner for one of the following reasons:

• The provider’s National Provider Identifier (NPI) number is not on file in the MO HealthNet Division’s (MHD) provider files. If you are in doubt as to what NPI number is on file, you should contact the Provider Enrollment Unit by e-mail at mmac.providerenrollment@dss.mo.gov.
• The Medicare contractor does not send crossovers to MHD. For instance, Medicare Advantage/Part C plans do not forward electronic crossover claims to MHD. Therefore, providers must submit Medicare Advantage/Part C crossover claims through the MHD Web portal at www.emomed.com.
• The provider did not indicate on the claim to Medicare that the beneficiary was eligible for MO HealthNet.
• The MHD participant information on the crossover claim does not match the fiscal agent’s participant file.

Benefit Matrix

June 02, 2014

The Benefit Matrix is a practical tool now linked from the MO HealthNet Division’s Provider Participation page. Once a provider navigates to the Provider Participation page, the Benefit Matrix may be found on the left side of the page in the General Information section, underneath the “MO HealthNet Guide — Puzzled by the Terminology?” link. The Benefit Matrix is an Excel spreadsheet that outlines the various benefits and limitations for each of the MO HealthNet programs, as well as cost-sharing, and co-pay amounts.

Providers are encouraged to review this tool and utilize it as a quick reference, when determining what general types of services are covered by each Medicaid Eligible (ME) plan code. While the Benefit Matrix is not meant to replace the Fee Schedule, it has proven to be valuable to providers that want a quick reference of services and ME plan codes.

Temporary Assistance for Pregnant Women Benefits and Limitations for Hospital

May 26, 2014

The Temporary Assistance for Pregnant Women (TEMP) program, ME codes 58 and 59, is fee-for-service only and is limited to ambulatory prenatal care.

A pregnancy or prenatal diagnosis code is required on the claim form in one of the diagnosis fields. If the TEMP participant is provided illness care, the illness diagnosis code must appear as the primary diagnosis code. However, a pregnancy or prenatal diagnosis code must also appear on the claim form.

Inpatient hospital services are not considered “ambulatory prenatal services;” therefore, inpatient hospital claims billed for participants with only TEMP eligibility are denied.

Refer to Hospital Manual, Section 13.3.C – Presumptive Eligibility Program (TEMP) for further information on the TEMP program for hospital services.

B. Ray Storm, DDS, MBA, MO HealthNet Dental Director

May 19, 2014

Dr. Ray Storm is currently the State Dental Director for Missouri, a position just recently re-established at the Department of Health and Senior Services through the efforts of the Missouri Coalition for Oral Health, Delta Dental of Missouri, Missouri Foundation for Health, the REACH Healthcare Foundation, and many other stakeholders committed to improving oral health for all Missourians. Dr. Storm will also be working with MO HealthNet in this role. Prior to his appointment to that position he practiced general dentistry for 32 years in his private practice in St. Peters, Missouri. He is a graduate of the University of Missouri at Columbia, UMKC School of Dentistry in Kansas City, and Lindenwood University in St. Charles, Missouri. He and his wife fostered the establishment of two non-profits for increasing access to dental care and oral health education both globally and in Missouri. The most recent organization is Give Kids A Smile, which was adopted by the American Dental Association as their premier outreach program for children.

Dr. Storm is a Fellow in the International College of Dentists and the American College of Dentists. He is a two-time recipient of the MDA Dentist of the Year for Missouri. Most recently, he was honored with the Special Alumni Award for Dentistry at the University of Missouri-Kansas City for his community outreach programs.

Durable Medical Equipment Prior Authorizations

May 12, 2014

Durable Medical Equipment (DME) providers are required to obtain prior authorization (PA) for certain services before delivery of the services. The prior authorization (PA) process is a paper process. Providers are encouraged to submit their PA requests by facsimile (fax) to 573-659-0207. The following criteria apply when submitting PA requests by fax:

• Only one PA request may be submitted per fax call. Multiple PA requests per call will not be processed. Please do not mail PA requests that have been faxed.
• Attachments to the PA request should not be scaled down in an attempt to fit multiple pages on one sheet, this causes the document to be difficult to read. Requests that are not legible will be returned to the provider for resubmission.
• Use a business fax cover sheet, when faxing the PA request. The cover sheet should include the return fax number. This will assist in the return of disposition letters by fax.
• Regardless if the PA request is approved or denied, providers will receive a MO HealthNet Authorization Determination (disposition) letter containing all of the detail information related to the PA request. Please ensure the fax number from which the PA request is sent is not a blocked number. A blocked fax number will prevent the disposition letter from being returned by fax and delay notification. Disposition letters that cannot successfully be returned via fax will be mailed to the provider.

A list of DME services requiring prior authorization can be found in Section 19 - Procedure Code of the DME MO HealthNet provider manual.

PA requests can also be completed and mailed to:

Infocrossing Healthcare Services
PO Box 5700
Jefferson City, MO 65102-5700

Services submitted on a PA request should not be provided/delivered until an approved PA has been received. Do not resubmit a PA request until a MO HealthNet Authorization Determination letter (disposition letter) has been received.

Do not mail a PA which has been faxed. Request for Changes (RFC) – process is outlined: Section 8.7, REQUEST FOR CHANGE (RFC) OF PRIOR AUTHORIZATION (PA) REQUEST.

Participant Administrative Lock-In

May 5, 2014

Some MO HealthNet participants are restricted (or locked-in) to a provider or providers, such as a certain physician/clinic and/or pharmacy, where the participant can receive treatment or services. 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 on the MO HealthNet Web portal, 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.

Nursing Facilities and Patient Surplus

April 28, 2014

Patient surplus or “patient liability” is the participant’s income less certain deductions; i.e., personal allowance, medical insurance and any allotments to a spouse and/or eligible dependents and is computed by an FSD caseworker. It is a federal requirement that the MO HealthNet payment to a nursing home be reduced by the patient surplus. MO HealthNet payment to a nursing home is not collected by the nursing facility the first month a participant is admitted if admission is after the first day of the month. If admission is the first day of the month, then surplus is charged to the participant for the first month.

When there are Medicare and MO HealthNet days in the same month, surplus is applied to the MO HealthNet days only. If the participant is in the hospital on the first day of the month and Medicare covers the cost of the remainder of the month, no surplus is due. For any month following the month of readmission in which there are Medicare and MO HealthNet days, the surplus is applied to the MO HealthNet days in the month regardless of the date of readmission.

If a participant enters a hospital during one month and is not readmitted to the nursing home until after the first day of the following month, surplus is to be billed to the participant or the participant’s representative (responsible party) for the month of readmission. If a participant is out of a nursing home for more than thirty (30) days, the Family Support Division Eligibility Specialist informs the nursing home, and the participant or the participant’s representative, if surplus should be collected for the month of readmission.

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

Dual Eligible Hospice Participants

April 21, 2014

Participants who are eligible for both Medicare and MO HealthNet at the time of hospice election must simultaneously elect the hospice benefit for both programs. Electing both Medicare and MO HealthNet Hospice benefits enables MO HealthNet to avoid duplication of payments for services covered under the Medicare Hospice benefit.

If a participant’s MO HealthNet eligibility begins, or the Hospice becomes aware of the participant’s MO HealthNet eligibility after Medicare hospice benefits have been elected, providers must 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.

For more information on MO HealthNet’s Hospice program, providers can reference Section 13 of the Mo HealthNet hospice manual and MO HealthNet Hospice Election Statement.

Delivery and Placement Dates Versus Date of Service

April 14, 2014
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).

HIPPA-Related Code Lists

April 7, 2014

Providers continue to question the explanation of the codes shown on their claim confirmation report, as well as their remittance advices.

MO HealthNet no longer reports MO HealthNet-specific explanation of benefits and exception message codes on any type of remittance advice. As required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) national standards, administrative code sets, such as Claim Adjustment Reason Codes, Remittance Advice Remark Codes, and NCPDP Version 5.0 Reject Codes for Telecommunication Standard are used.

Explanations for claim status codes, remittance advice remark codes and claim adjustment reason codes can be found on the Internet at Washington Publishing Company under the HIPAA-Related Code Lists. A listing of the NCPDP Version 5.0 Reject Codes for Telecommunication Standard can be found in the NCPDP Version 5.Ø Reject Codes For Telecommunication Standard appendix.

More information on HIPAA-Related Code Lists can be referenced in Section 17 (Claims Disposition) of your provider manuals.

Double-Check Your Faxes

March 31, 2014

Please take a few minutes to double-check faxes you may send to the State. When faxes leave a location, they are “stamped” with a Calling-Station ID across the top of the fax by the receiving agency. This Calling-Station ID is programmed into the fax machine and tells the receiving agency the fax number of the sender.

Recently, a fax came to the State containing the Calling-Station ID of a restaurant. The restaurant had leased a fax machine that was returned to an office equipment company. The company leased the machine again to a provider. Unfortunately, the office equipment company did not change the Calling-Station ID within the machine. When the provider began to send faxes, receiving fax machines printed the restaurant’s fax number. The provider became aware of the problem and immediately contacted the office equipment company who reprogrammed the fax machine.

The State uses an automated process of responding to faxes it receives, including faxes requesting authorization of products and services. It pulls the programmed fax number and populates it on outgoing faxes. This process is designed to remove the potential for human error by misdialing the number of the originating fax machine, and it expedites the process of responding to requests. If the automated process pulls a programmed fax number that is wrong, a breach of private health information can occur.

This quick check may save you and the State from the possibility of unintended breaches.

Missouri Medicaid Audit and Compliance Notification to Providers

March 24, 2014

Update on Recovery Audit Contractor (RAC) and Medicaid Integrity Contractor (MIC) Activities.

Section 6411 of the Affordable Care Act, Expansion of Recovery Audit Contractor (RAC) Program, amends section 1902(a)(42) of the Social Security Act and requires states to contract with a RAC vendor and allows states to reimburse contractors who assist in the identification and recovery of improper payments. Missouri contracted with Cognosante, LLC in December, 2011 to serve as Missouri’s RAC.

Also, as part of the Deficit Reduction Act of 2006, the Medicaid Integrity Program was established. This program utilizes Medicaid Integrity Contractors (MICs) to analyze Medicaid claims data to identify high-risk areas and potential vulnerabilities, as well as conduct post-payment audits. Missouri’s MIC is Health Integrity, LLC. The MICs are assigned by geographic location. Both the RAC and the MIC may utilize subcontractors. A list of the contractors’ and subcontractors’ names is located below. Should you receive any communication from an entity representing itself on behalf of Missouri Medicaid Audit and Compliance (MMAC), or one of the companies listed below, and you are concerned about the legitimacy of the person or company, you should contact MMAC at (573) 751-3399 to verify the communication or request is legitimate.

Currently, Missouri’s MIC is conducting audits of Missouri hospice providers. The MIC may request documentation that supports Medicaid-enrolled participants’ eligibility for hospice, and other documents to ensure proper billing. The Missouri RAC is preparing to conduct audits of enrolled Missouri pharmacy providers. The RAC will be reviewing paid claims for proper billing, and to ensure the claims were not paid twice (duplicate billing) and that proper quantities were billed. They may request documentation to include items such as a copy of the original prescription, the dispensing record, documentation of offer to counsel, and the signed delivery record.

The RAC is also preparing to conduct audits of enrolled Missouri durable medical equipment providers. The RAC will be reviewing paid claims for proper billing, and to ensure the claims were not paid twice (duplicate billing). They may request documentation to include items such as precertification and prior authorization forms and supporting documentation, prescriptions, physician’s orders, invoices, proof of delivery, and certificate of medical necessity. Medicaid Integrity Contractor (MIC): Health Integrity, LLC; Recovery Audit Contractor (RAC): Cognosante, LLC; RAC Subcontractors: Recovery Audit Specialists LLC, CDR Associates

Do you want your claims to pay after October 1, 2014? Take the ICD-10 Clinical Survey Challenge Today!

March 17, 2014

With the ICD-10 implementation date of October, 1, 2014, quickly approaching, MO HealthNet would like to extend an invitation to providers to complete the ICD-10 Clinical Survey.

The survey is intended for MO HealthNet enrolled providers billing for services to MO HealthNet participants. Providers are encouraged to participate in the survey that tests providers’ readiness in billing for ICD-10. The survey will provide data for MO HealthNet to determine if providers are ready to bill when ICD-10 is implemented on October 1, 2014. After MO HealthNet evaluates the data, we will provide feedback as applicable to the findings.

The survey can also be found on the emomed site. When on the emomed login page, simply find the new Clinical Scenarios section on the right, located below “Login” and “ERA Enrollment” sections. You do not need to login to emomed to take the survey.

You need to enter the following information to get started: NPI, Taxonomy (if applicable), Contact Name, Contact Phone Number, and Contact Email. Then, select all scenarios you want to test. It’s as easy as that! You will be able to test as many scenarios as you choose, and your results will be helpful in determining what areas of training are most needed by our providers. Test your knowledge today!

Provider Addresses Must Be Kept Current

Missouri Regulation 13 CSR 70 – 3.020(7) requires providers to inform the state of any changes affecting their MO HealthNet enrollment records. These changes, including change of address, are to be reported by the provider on specific forms within 90 days of the change (except for change of ownership or control, which must be reported within 30 days). In addition, section 2.2 of the MO HealthNet Provider Manual requires providers to notify the Provider Enrollment Unit (PEU) of a change of address.

In Missouri, these updates and changes are reported to the PEU at Missouri Medicaid Audit and Compliance (MMAC).

In accordance with the regulation above, the PEU at MMAC inactivates enrolled providers whose mail has been returned to MMAC or MO HealthNet as undeliverable. This action suspends providers’ claims for 180 days, during which time the claims are neither paid nor denied. If the provider does not submit an address update form to PEU by the end of the 180 days, the provider’s claims will then be denied. This is done to help ensure provider enrollment records are accurate. Upon receipt and processing of the required form for updates, provider numbers are reactivated by the PEU.

In order to update your address with Provider Enrollment, please submit a Provider Update Request form. If you know your enrollment has already been made inactive due to undeliverable mail, write RETURNED MAIL in the upper right hand corner of the Update Request form. This will alert Provider Enrollment staff to forward any mail that has been returned.

When to Contact Wipro Provider Communications

March 3, 2014

Providers are encouraged to contact Wipro Provider Communications at (573) 751-2896 with inquiries, concerns or questions regarding proper claim filing, claims resolution and disposition, and participant eligibility questions and verification. Wipro Provider Communications is the provider’s first line of communication. When claims require further review, the provider’s claim will be forwarded to the appropriate section in MO HealthNet for assistance.

When providers call Wipro Provider Communications, they are transferred automatically to the IVR (interactive voice response). Anytime during the IVR options, select "0" to speak to the next available specialist. The call will be put into a queue and will be answered in the order it was received.

The interactive voice response (IVR) system also addresses participant eligibility, last two check amounts, and claim status inquiries. Providers must use a touchtone phone to access the IVR. If a touchtone phone is not available, the system will process the options several times before transferring you to the next available specialist.

Providers may send and receive secure electronic mail (email) inquiries to MO HealthNet Provider Communications and Technical Help Desk staff. This application is available through the MO HealthNet Web portal page. Once logged in and on the eProvider/Welcome to eProvider page, click on “Provider Communications Management”. This opens the “Manage Provider Communications” page. Click on “New Request” to access the “Create New Request” form. Providers are limited to one inquiry per email. The user submitting the email inquiry will be notified via email, when a response is available to the inquiry.

The Provider Communications Unit also processes written inquiries. Written inquiries should be sent to:

Provider Communications Unit
PO Box 5500
Jefferson City, Missouri 65102-5500

MO HealthNet Medicaid Program Webinars

February 24, 2014

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

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

Using the Timely Filing Tab To Correct Claims

February 18, 2014

The Timely Filing Tab found on the MO HealthNet billing web portal 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 billing web 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 Internal Control Number (ICN) 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 process.

• First you must void the paid claim.
• Then go back into the original ICN number and click on the Timely Filing tab, make any applicable corrections and resubmit the claim.

Reason Codes on Denial of Claims

February 10, 2014

Washington Publishing Company (WPC) provides Health Care Code Lists. The WPC web site can be accessed from the MO HealthNet Provider Participation page. Under Featured Links, found on the right side of the web page, choose HIPPA Related Code Lists.

On the WPC page you will find the following Health Care Code Lists:

Claim Adjustment Reason Codes (CARC)

Claim adjustment reason codes communicate an adjustment, meaning that they must communicate why a claim or service line was paid differently than it was billed. If there is no adjustment to a claim/line, then there is no adjustment reason code.

Remittance Advice Remark Codes (RARC)

Remittance Advice Remark Codes (RARCs) are used to provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or to convey information about remittance processing.

Claim Status Category Codes

Claim Status Category codes indicate the general category of the status (accepted, rejected, additional information requested, etc.) which is then further detailed in the Claim Status Codes.

Claim Status Codes

Health Care Claim Status Codes convey the status of an entire claim or a specific service line.

Health Care Service Type Codes

Health Care Service Type Codes are used to identify the classification of service or benefits.

Health Care Services Decision Reason Codes

Health Care Services Decision Reason Codes are used to indicate the primary reason for the certification action code assigned as part of a health care services review.

Provider Characteristics Codes

This code list is for use with health care provider information for enrollment and credentialing transactions and their corresponding responses.

Insurance Business Process Application Error Codes

This code set is for use in reporting application errors for insurance business processes.

ICD-10 Educational Series by Conference Call

February 03, 2014

Physician practices MUST begin using the ICD-10 codes by Oct. 1, 2014. The Missouri State Medical Association (MSMA) and Kansas Medical Society will be hosting an ICD-10 educational series by conference call. No registration is required for these free sessions which will be from 12:00 PM to 1:00 PM on February 27, 2014; March 6, 2014; and March 13, 2014.

Brenda Edwards, CPC, CPB, CPMA, CPC-I, CEMC of the Kansas Medical Mutual Insurance Co. will discuss what you need to be doing in the months leading up to October 1, 2014, when use of ICD-10 is mandated. Be sure and check the Missouri State Medical Association web page for more information on these sessions including handouts and dialing information to join the conference calls.

Planning for and Implementing ICD-10

January 27, 2014

Providers should develop a plan of action now in order to succeed with ICD-10. Your organization must identify available resources, assess training needs, build a training plan, and manage productivity during the transition process. During the transition, it will also be necessary to provide additional time for the coders to code. There are several free online resources available for implementing ICD-10, such as the Centers for Medicare and Medicaid Services (CMS). CMS provides a helpful ICD-10 planning checklist and frequently asked questions for providers. The CMS link discussing ICD-10 can be found on the Centers for Medicare and Medicaid Services IDC-10 page.

In order to achieve a smooth ICD-10 transition, CMS recommends your organization create and follow a variety of plans tailored to your unique needs and culture, including plans for:

• Project management
• Communication
• Assessment
• Implementation
• Testing
• Post-transition operations

ICD-10—It’s Not Just for MO HealthNet Providers

January 21, 2014

Currently, the United States uses the ICD code set, Ninth Edition (ICD-9), originally published in 1977. Since implementation of ICD-9, the medical field has undergone much advancement in diagnosis and treatment, and more codes are needed than ICD-9 can provide. The ICD code set, Tenth Edition (ICD-10) will be implemented on October 1, 2014. ICD-10 will provide the much needed space for expansion of codes, more specific data than ICD-9, and will better reflect current medical practice. The additional detail within ICD-10 codes will better inform healthcare providers of patient history and will improve the effectiveness of case management and coordination of care.

ICD-10 will have an effect on all medical and hospital claims that contain a diagnosis, and will be required for all providers covered by the Health Insurance Portability Accountability Act of 1996 (HIPAA), no matter what level of coverage carried by the patient. All healthcare professionals and facilities must be aggressively involved or risk nonpayment for services provided on or after the ICD-10 implementation date of October 1, 2014.

Diabetes Self-Management Training Services

January 13, 2014

Diabetes self-management training services are not available to adults receiving a limited benefit package. If the service is non-covered for a participant due to their benefit package, the service may be requested through the Exceptions Process program prior to the service being provided. Information related to the Exceptions Process can be found on the Exceptions Process web page.

Information regarding diabetes self-management training service limitations can be found in Section 13.60.B of the physician provider manual.

About ICD-10

January 6, 2014

On October 1, 2014, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets.

Centers for Medicare and Medicaid Services (CMS) has stated that the October 1, 2014 date is the date of conversion to ICD-10.

CMS Resources that may be helpful are:

• View the ICD-10 Introduction fact sheet and FAQs to get a general overview on ICD-10.
• See official resources designed to help providers, payers, vendors, and non-covered entities with the transition to ICD-10 on October 1, 2014.
• Access two free Medscape Education modules that provide guidance to small practices making the transition to ICD-10:
  • ICD-10: A Roadmap for Small Clinical Practices
  • ICD-10: Small Practice Guide to a Smooth Transition
  Continuing medical education (CME) and continuing education (CE) credits are available to physicians and nurses who complete the learning modules.
• CMS ICD-10 Industry Email Updates.

The transition to ICD-10 is required for everyone covered by the Health Insurance Portability Accountability Act (HIPAA). Please note, the change to ICD-10 does not affect CPT coding for outpatient procedures and physician services.

Many providers question if they stop using ICD-9 completely come October 1, 2014. Dates of service on October 1, 2014, and after, require ICD-10 codes. Any dates of service prior to October 1, 2014, should be submitted using ICD-9 codes.

MO HealthNet Provider Bulletin, ICD-10 Status Update, Vol. 36 No. 10, dated October 16, 2013, is available for viewing on the Provider Web page.