2015 Archived MO HealthNet Provider Hot Tips

Periodicity Schedule for Health Children and Youth (HCY)/ Early Periodic Screening and Diagnosis & Treatment (EPSDT) Services

December 1, 2015

The HCY Program is a comprehensive, primary and preventative health care program for MO HealthNet Division (MHD) eligible children and youth under the age of 21.  The MO HealthNet Division Provider Manuals Section 9 describes the HCY Program.

The periodicity schedule, described in Section 9.11 of the provider manuals, represents the minimum requirements for frequency of full medical screening services. Its purpose is not to limit the availability of needed treatment services between the established intervals of the periodicity schedule.  Please reference Section 9.6 for the procedure code list.

Children may be screened at any time the provider feels it is medically necessary to provide additional screening services. If it is medically necessary for a full medical screen to occur more frequently than the suggested periodicity schedule, then the screen should be provided. There must be documentation in the participant’s medical record that indicates the medical necessity of the additional full medical screening service.

Behavioral Health Manual Update

November 24, 2015

On October 1, 2015, and after, MO HealthNet Division (MHD) claims will require an International Classification of Diseases (ICD), 10th Revision, and Clinical Modification/Procedure Coding Systems for codes reporting Mental, Behavioral, and Neurodevelopmental disorders. The Behavioral Health Services Manual has been updated reporting current ICD codes in the following sections.

• Section 13.24.B diagnosis codes:
  In order to be reimbursed by MHD, the claim for the behavioral intervention must report one of the ICD codes provided in this section.
• Section 13.25.A Partial Early Periodic Screening and Diagnosis and Treatment (EPSDT)/Healthy Children and Youth (HCY) Screen:
  The appropriate diagnosis codes for partial EPSDT/HCY screens are shown in this section. Section 13.25.A (1) shows a table demonstrating the procedure code, description, and maximum allowable reimbursement amount. 
• Section 18.2 EPSDT/HCY screening services:
  One of the following must report as the primary diagnosis on the claim: Z00110, Z00111, Z00121 or Z00129.  
• Section 18.3 Behavioral Health Services:
  The diagnosis code must be a valid ICD, current edition, diagnosis code and must be mental health or substance use disorder related. This does not include developmental disabilities. A table listing the ICD codes is provided in this section.

Centers for Medicare & Medicaid Services (CMS) provides many free tools and resources.

Interactive Voice Response (IVR) System

November 17, 2015

Providers can access the MO HealthNet Division (MHD) Interactive Voice Response (IVR) system by calling (573) 751-2896.  The IVR allows active MHD provider inquiries for the following options:

1. MHD participant eligibility
2. Check amount Information
3. Claim information
4. Participant annual review date 

The IVR system is for active MHD providers or inactive providers inquiring on dates of service during their period of enrollment as an active MO HealthNet provider.  The 10-digit National Provider Identification (NPI) number must be entered each time any of the IVR options are accessed.

Providers may notice that this IVR system has changed. There is no longer an option for providers to select option “0” to speak to a MO HealthNet specialist during the main options.  After going through one of the main options, the provider can be transferred to a MO HealthNet Provider Communications specialist.

Specialists are on duty between the hours of 8:00 A.M. and 5:00 P.M., Monday through Friday (except holidays) to provide information not available through the IVR system.  Providers should do the following:

• Review the provider manual and bulletins before calling the IVR.
• Have all material related to the problem (such as Remittance Advice, claim forms and participant information) available for discussion.
• Have the provider’s NPI number available.
• Limit the call, if possible, to three questions or three to four minutes.
• Note the name of the specialist who answered the call. This saves a duplication of effort, if the provider needs to clarify a previous discussion or ask the status of a prior inquiry.

Providers may also submit an email to the Provider Communications Unit by selecting the Provider Communications Management field on the MHD electronic billing website emomed. 

The MHD Provider Manuals Section 3.3.A Interactive Voice Response System is in the process of being updated.

International Classification of Diseases (ICD) MO HealthNet Claim Filing Guidelines

November 03, 2015

MO HealthNet Division (MHD) providers filing claims should choose the correct International Classification of Diseases (ICD) code. The date of service will determine whether the diagnosis code set value must be ICD-9th revision or ICD-10th revision.  The date of service determines the ICD code, not the filing date.   Providers are encouraged to file claims on the MHD electronic billing portal, emomed.

When dates of service span across September 2015, and October 2015, the provider has to choose the correct ICD code to record on the claim.  The provider cannot bill both an ICD-9th revision and ICD-10th revision diagnosis code on the same claim.  Reference the following guidelines for recording the appropriate ICD code.

Medical, Outpatient, Home Health, Dental, Professional Crossover claim types:

The provider choses the appropriate ICD code based off the Date of Service (DOS), which can be referenced as from or through DOS.

• Use the ICD-9 Codes: From DOS and through DOS are on and prior to September 30, 2015.
• Use the ICD-10 Codes: On and after October 1, 2015.

Medical, Professional Crossover claim types for Durable Medical Equipment (DME):

The provider choses the appropriate ICD code based off the start DOS, which can be referenced as from DOS.  If the DOS starts in September 2015, and ends in October 2015, the provider records the ICD-9 code on the claim.

• Use the ICD-9 Codes: From DOS are on and prior to September 30, 2015.
• Use the ICD-10 Codes: On and after October 1, 2015.

Inpatient, Nursing Home, Institutional Crossover claim types:

The provider choses the appropriate ICD code based off the discharge DOS, which can be referenced as end or through DOS.  If the DOS starts in September 2015, and ends in October 2015, the provider records the ICD-10 code on the claim.

• Use the ICD-9 Codes:  Discharge DOS are on and prior to September 30, 2015.
• Use the ICD-10 Codes: Discharge DOS are on and after October 1, 2015.

Please reference the Provider Bulletin, International Classification of Diseases (ICD) 10th Revision, discussing MHD claims processing.

ICD-10 is Nearly Here!

September 8, 2015

Starting with dates of service on October 1, 2015, and later, claims will require an International Classification of Diseases (ICD), 10th Revision, Clinical Modification (CM)/Procedure Coding System (PCS), medical diagnosis and/or inpatient procedure code. While October 1, 2015, is fast approaching, there is still time to transition to ICD-10. Centers for Medicare & Medicaid Services (CMS) provide many free tools and resources at www.cms.gov/icd10.

The ICD-10 Quick Start Guide outlines 5 steps health care professionals should take to prepare for ICD-10.

On August 7, 2015, CMS posted a complete list of the 2016 ICD-10-CM valid codes and code titles in the 2016 Code Descriptions in Tabular Order ZIP file on the 2016 ICD 10-CM and General Equivalence Mappings (GEMs) web page.  Access the file named “icd10cm_2016.txt” in the ZIP file for the list. A similar list of the 2016 ICD-10-PCS valid codes and code titles is available in the 2016 PCS Long and Abbreviated Titles ZIP file on the 2016 ICD-10 PCS and GEMs web page. See the file named “icd10pcs_codes_2016.txt” in the ZIP file for the list.

Use of Unspecified Codes in ICD-10-CM Resources:

• MLN Matters® Article SE1518, “Information and Resources for Submitting Correct ICD-10 Codes to Medicare”
• ICD-10 Basics MLN Connects National Provider Call - Call Materials from August 22, 2013
• More ICD-10 Coding Basics MLN Connects Call - Call Materials from June 4, 2014
• ICD-10 Coding Basics MLN Connects Video - January 2014
• Coding for ICD-10-CM: More of the Basics MLN Connects Video - December 2014
• Visit the ICD-10 Medicare Fee-For-Service Provider Resources web page for a complete list of Medicare Learning Network educational materials.

To keep up to date on ICD-10, visit the CMS ICD-10 website and Roadto10.org for the latest news and resources. You can also sign up for CMS ICD-10 Industry Email Updates.

Non-Emergency Medical Transportation Program

September 1, 2015
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.

To arrange transportation for an eligible participant, call 1-866-269-5927, Monday through Friday, 8:00 AM to 5:00 PM, at least 5 calendar days before an appointment. Urgent appointments and hospital discharges may be called in 24 hours a day, 7 days a week.

Participants must be eligible on the date of transport.  Transportation shall be authorized and arranged for the participant to MO HealthNet Division (MHD) covered services such as to their primary care physician, labs, and outpatient facilities within the travel standards.  Not all eligibility categories are eligible for transportation.  See the NEMT Section 22 in the appropriate provider manual for information on eligible NEMT services.

In addition to transportation, ancillary services (meals and lodging) are covered if:

• The medical appointment requires an overnight stay, and
• Volunteer, community, or other ancillary services are not available at no charge to the participant.

For participants under the age of 21, ancillary services may include an attendant and/or one parent/guardian to accompany the child.  Participants under the age of 17 must be accompanied by a parent/guardian.

If the participant is under the age of 21, ancillary services will be arranged for a parent/guardian when the participant is inpatient in a hospital setting and meets the following criteria:

• Hospital does not provide ancillary services without cost to the participant’s parent/guardian, AND
• Hospital is more than 120 miles from the participant’s residence, OR
• Hospitalization is related to a MO HealthNet covered transplant service.

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.

Claims Processing and Payment Schedule for Fiscal Year 2016

July 6, 2015

Please access the Claims Processing Schedule for Fiscal Year 2016, for the updated claims processing schedule located on the fiscal agent’s website.

Coverage for Pregnant Women

June 15, 2015

The purpose of this hot tip is to provide further clarification on allowable ME codes for physicians providing obstetrical services to Medicaid Pregnant Women (MPW).

In addition to the commonly used ME 18, ME 43, ME 44, ME 45, and ME 61, the following ME Codes are also allowable for payment:

• MHF Adults: ME 05 (but limited dental benefit)
• MHABD: ME 13 (but limited dental benefit)
• MHF Children: ME 06 (full range of dental benefits)
• CHIP: ME 71, 72, 73, 74, 75 (full range of dental benefits)

If you are providing care to a patient with one of these ME codes (as well as many others) and they subsequently become pregnant, the obstetrical services you provide to them will be covered by Medicaid.

By changing the adult designation to one of the MPW ME codes listed above, it will provide the full range of dental benefits to pregnant adults.

Behavioral Health Precertifications

June 8, 2015

Providers may request a new behavioral health precertification 30 days prior to the start date.  Providers will be able to request the precertifications electronically through CyberAccess and will receive an immediate electronic response.  In addition to requesting precertification, providers will be able to access a patient’s health record, precertification history, and diagnosis history.  Providers who choose to fax for precertification must use the Behavioral Health Services Request for Precertification form.

Please reference the provider bulletin, Precertification of Behavioral Health Services Through CyberAccess, dated October 31, 2014, Volume 37, Number 06 for more information regarding precertification.

Documentation for Offer to Counsel

June 1, 2015

Pharmacies are required to document the offer to counsel MO HealthNet participants on their prescription medications. The pharmacy must obtain the signature of the participant or his/her representative for each prescription received, with the exception of participants living in long-term care facilities, i.e. nursing facilities, intermediate care facilities/mentally retarded (ICF/MR) and/or psychiatric residential treatment facilities (PRTF).

The signature log serves as verification that the participant received the prescription dispensed and must document in a uniform fashion, whether the offer to counsel was accepted or refused. The absence of the appropriate signature indicates the participant did not receive the prescription, and funds will be recouped from the pharmacy. The absence of notation of acceptance or refusal of the offer to counsel will also lead to recoupment of funds.

As referenced in section 13.11B of the Pharmacy Manual, electronic signatures are acceptable. One signature per prescription is required.  For shipped or delivered prescriptions, the pharmacy must obtain the signature of the participant or his/her representative and their relationship to the participant.

Missouri Medicaid Audit and Compliance Screening Requirements

May 26, 2015

State and federal regulations, 13 CSR 65-2.020, require all currently enrolled MO HealthNet Division (MHD) providers to revalidate their enrollment at least every five (5) years. MMAC has established a revalidation schedule for all currently enrolled providers.

MMAC will contact currently enrolled providers approximately 120 days prior to their scheduled revalidation due date. Instructions and forms will be provided by mail or e-mail. Please reference additional information available on MMAC’s website.

Missouri Medicaid Audit and Compliance Enrollment or Revalidation Process

May 18, 2015

All MO HealthNet Division (MHD) providers are required by federal regulations, 42 CFR 455, and state regulations, 13 CSR 65-2.020, to disclose certain information to Missouri Medicaid Audit & Compliance (MMAC), during their initial enrollment or revalidation processes. Those mandatory disclosures include information such as date of birth and social security number for certain persons.

MMAC is required to collect the disclosed information to screen individuals and legal entities with ownership and control interest against various state and federal exclusion databases. Please reference additional information available on MMAC’s website.

Provider Address Changes

May 11, 2015

Missouri Medicaid Audit & Compliance (MMAC) is implementing new provider enrollment procedures, including provider revalidation.  Any provider, whose address has changed since initial enrollment, should submit the updated information to MMAC by accessing the “Provider Update Request” form and submitting the changes to MMAC.

The completed forms can be scanned and sent by email to mmac.providerenrollment@dss.mo.gov, or faxed to the Provider Enrollment Unit at (573) 751-5065.

Be sure to check MMAC’s website regularly to get information on upcoming changes and other helpful tips for MO HealthNet providers.

Missouri Medicaid Audit and Compliance

April 27, 2015

The Missouri Medicaid Audit and Compliance (MMAC) website posts information for MO HealthNet Division (MHD) providers and participants. On the MMAC website, the "Contact Us" tab allows users to contact MMAC with their questions. Please utilize this function to submit questions directly to MMAC.

Primary Care Rate Increase Program Ending

March 09, 2015

After December 31, 2014, there will no longer be enhancement payments for MO HealthNet program providers that participate in the primary rate increase.

If you have questions concerning this announcement, please reference the Provider Bulletin, Volume 35, No. 31 Physician Primary Care Rate Increase For Certain Services.

Securing and Protection of Health Information

March 02, 2015

Please protect and secure health information.

Tips for Protecting Protected Health Information (PHI):

• Do not leave PHI, such as reports, claims, medical documentation, and other sensitive information, in a car.
• Double-check fax numbers.  Faxing is secure, when it is sent to the correct fax number.
• If you maintain PHI on a flash drive, ensure the drive is encrypted to prevent unauthorized access.
• Shred PHI when it is no longer needed. Double-check to ensure PHI is going in the shred container

Reporting Sequestration for Medicare Part C Plans

February 23, 2015

On April 1, 2013, The Centers for Medicare and Medicaid Services (CMS) imposed a mandatory 2% reduction in the Medicare Fee-for-Service (FFS) Program, also known as “Sequestration.”  Sequestration reductions were reflected on the Medicare Explanation of Benefits (EOB) as Claim Adjustment Reason Code (CARC) number 223.  This action affects FFS claims with dates of service or dates of discharge on or after April 1, 2013. 

On January 6, 2014, CMS started using CARC number 253 for the sequestration reduction of 2%.  This action affects FFS claims with dates of service or dates of discharge on or after January 6, 2014.  Please reference the Washington Publishing Company for information on CARCs.   

MO HealthNet Division (MHD) requires providers to bill Medicare crossover claims electronically on emomed. When billing electronically, the appropriate CARC number 223 or 253, as reflected on your Medicare EOB, must be listed once for every applicable detail along with the corresponding Medicare Sequestration Reduction amount.  

The Medicare Part C replacement plans may be reporting the sequestration on the total paid amount on the EOB.  To ensure claims are paid appropriately, providers should enter each paid line and apply the CARC to each paid line indicating the 2% reduction.  Providers should calculate the 2% reduction for each paid line and ensure the CO-253s in the line detail equal the total amount of the reduction.

Denture Coverage Reminders

February 16, 2015

Not all MO HealthNet Division (MHD) participants are eligible for Dentures. Dentures are a covered benefit for the following MHD participants:

• Pregnant Women, Medical Eligibility (ME) codes 18, 43, 44, 45, and 61
  (MHD Managed Care health plans are responsible for coverage of dentures for pregnant members with these same ME codes)
• Eligible participants through one of the assistance categories for the blind, ME codes 02, 03, 12, and 15.
• Eligible participants residing in a nursing home with verification of vendor care/nursing home eligibility are determined by checking for “Nursing Home Information” when verifying participant eligibility on emomed.   
• Participants under the age of 21.

Dentures are not covered for participants with a limited benefit package.  A complete list of ME codes for participants receiving limited benefits can be found on the ‘MO HealthNet Guide – Puzzled by the Terminology’ document.  Please reference the Benefit Matrix to determine the ME codes and benefits for each of the MHD programs. 

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.

Hyperbaric Oxygen Therapy

February 09, 2015

Hyperbaric Oxygen Therapy (HBO) is only payable as a professional component charge using CPT code 99183. Please reference the MO HealthNet Division (MHD) Fee Schedule and Physician Manual, Section 13.61, to determine current reimbursement rate and units allowed. The fee schedule is updated quarterly.

Influenza Vaccines Updates for Vaccines for Children

February 2, 2015

On August 31, 2014, Current Procedural Terminology (CPT) code 90655 SL, Influenza virus vaccine, was made non-covered by MO HealthNet Division (MHD). 

The Department of Health and Senior Services, (DHSS) is offering an additional vaccine to providers enrolled in the Vaccines for Children (VFC) Program.

MHD reimbursement for the administration of the additional vaccine is effective for dates of service September 12, 2014, and after.  The additional vaccine provided through the VFC program is as shown below:

• Influenza virus vaccines, quadrivalent, split virus, when administered to individuals 3 years of age and older, for intramuscular use.  The administration procedure code is CPT 90688 SL.  MHD reimbursement for the administration of this vaccine is $5.00.
• Influenza virus vaccines, quadrivalent, split virus, preservative free, when administered to children 6 months of age to 35 months of age, for intramuscular use. The administration procedure code is CPT 90685 SL.  The reimbursement for vaccine is $5.00.

Please reference the Provider Bulletin Physician Bulletin Vaccines For Children, dated November 18, 2014, for further details.  Please reference the Fee Schedule for the allowable reimbursement for services for CPT codes.

Additional Services Available through the MO Tobacco Quitline

January 26, 2015

The Missouri Tobacco Quitline has expanded its eligibility for all tobacco users willing to set a quit date within 30 days.  The Quitline is free to anyone in Missouri.  The Quitline provides services to assist individuals who want to quit smoking or using other tobacco products.  The services include:

• Telephone-based counseling with a trained quit coach (all tobacco users now eligible for up to 4 sessions).
• Texting support services – evidence-based text messages personalized to a participant’s quit plan.
• Stand-alone web coaching services – include an interactive online community that offers learning tools, support, and information about quitting.
• Nicotine Replacement Therapy (NRT) (patches or gum) – available to all tobacco users willing to set a quit date, except MO HealthNet participants. MO HealthNet callers are referred to their health care providers for NRT, since Federal Drug Administration (FDA) approved medications and NRT are covered in the MO HealthNet Pharmacy program.
• Resource materials.

For more information, contact the Comprehensive Tobacco Control Program at (573) 522-2820.

Provider Manuals

January 20, 2015

On October 20, 2014, the MO HealthNet Division (MHD) Provider Manuals were consolidated to include the General Sections with the Program Sections into a single document for each specific provider manual.

Behavioral Health Cyber Access

January 12, 2015

Beginning December 19, 2014, MO HealthNet Division (MHD) allows Behavioral Health Providers to access CyberAcess electronic precertification process for Behavioral Health providers.

Providers can access a patient’s health record, precertification history, diagnosis history, and request precertification.

Please reference the Provider Bulletin Precertification of Behavioral Health Services Through CyberAccess, dated October 31, 2014 Volume 37, Number 06.

Non-Emergency Medical Transportation

January 5, 2015

MO HealthNet participants, who are eligible to receive Non-Emergency Medical Transportation (NEMT), should request for transportation at least five (5) calendar days in advance by calling (866) 269-5927. Requests may be made 24 hour a day, seven (7) days a week.

For additional questions, please reference the Non-Emergency Medical Transportation Bulletin, Volume 33, Number 6, dated August 31, 2010, and Section 22 NEMT of the Provider Manuals.