2021 MO HealthNet Provider Hot Tips

The MO HealthNet Division publishes Hot Tips to supply information to clarify and assist in receiving timely reimbursement for services provided and claims disposition.

COVID-19 Oral Antiviral Treatment

January 6, 2022

On December 22, 2021, the FDA issued an emergency use authorization (EUA) for Pfizer’s COVID-19 treatment, Paxlovid. Paxlovid is indicated for the treatment of mild-to-moderate coronavirus disease (COVID-19) in adults and pediatric patients (12 years of age and older weighing at least 40 kilograms) with positive results of direct SARS-CoV-2 testing and who are at high risk for progression to severe COVID-19, including hospitalization or death. Paxlovid is available by prescription only and should be initiated as soon as possible after a diagnosis of COVID-19 and within five days of symptom onset.

On December 23, 2021, the FDA issued an EUA for Merck’s molnupiravir for the treatment of mild-to-moderate coronavirus disease (COVID-19) in adults with positive results of direct SARS-CoV-2 viral testing, and who are at high risk for progression to severe COVID-19, including hospitalization or death, and for whom alternative COVID-19 treatment options authorized by the FDA are not accessible or clinically appropriate. Molnupiravir is available by prescription only and should be initiated as soon as possible after a diagnosis of COVID-19 and within five days of symptom onset.

While the federal government pays for the product, the product cost cannot be billed to MO HealthNet. Pharmacy providers filling prescriptions for Paxlovid or molnupiravir will be reimbursed the current professional dispensing fee, at the time the prescription is dispensed. For pharmacies to receive the full dispensing fee, the Usual & Customary charge submitted to MO HealthNet must be in excess of the current professional dispensing fee. Non-pharmacy providers (clinics, hospitals, ERs, etc.) do not receive a professional dispensing fee.

Information about Missouri’s distribution of COVID-19 oral antivirals is available here: https://health.mo.gov/living/healthcondiseases/communicable/novel-coronavirus/covid-therapeutics.php

For more information about Paxlovid: https://www.fda.gov/media/155052/download

For more information about molnupiravir: https://www.fda.gov/media/155053/download

DME Walker Criteria

January 4, 2022

MO HealthNet requires pre-certification for standard walkers, walkers with trunk support, walkers with variable wheel resistance, and heavy duty walkers. However, MO HealthNet does not cover rollator walkers. Therefore, rollator walkers cannot be billed to MO HealthNet under HCPCS E0143 or E0149.

Providers can obtain pre-certification for walkers by calling the DME Pre-Certification Hotline (800-392-8030 option 2) or by using CyberAccess.

For more information regarding specific walker criteria, please refer to our website at https://dss.mo.gov/mhd/cs/dmeprecert/pages/dmeprecert.htm.

Pharmacy Services for Participants with Presumptive Eligibility

December 22, 2021

The MO HealthNet Presumptive Eligibility Authorization (PE-3) form and the Show Me Healthy Babies Presumptive Eligibility (SMHB-PE) Authorization form serve as proof of presumptive eligibility. Pharmacy providers should check the dates of eligibility on the authorization form to determine if the presumptive eligibility period is active. Pharmacy providers should make a photocopy of the form and maintain the copy in the pharmacy files for documentation of eligibility.

MO HealthNet will reimburse any medication dispensed within the eligibility period shown on the form. Pharmacies may contact Pharmacy Administration at (573) 751-6963 if they have questions. For more information, please refer to Provider Bulletin on Presumptive Eligibility Authorization Notices.

Pharmacy Signature Log Requirement

December 8, 2021

Effective December 15, 2021, MO HealthNet will reinstate the requirement to document the offer to counsel and to maintain a signature log as proof of receipt of prescription delivery.

Providers may reference Section 13.11.B of the Pharmacy Provider Manual for additional information regarding this requirement. Providers may contact the Pharmacy Administration Helpdesk at (573) 751-6963 or email at MHD.PharmacyAdmin@dss.mo.gov with questions.

At-Home COVID Test Coverage

November 01, 2021

Effective November 1, 2021, MO HealthNet will cover at-home COVID-19 tests through the Fee-for-Service Pharmacy Benefit. MO HealthNet will reimburse the lesser of the MAC rate plus a dispensing fee or the Usual & Customary submitted by the provider. At-home tests must be prescribed by a MO HealthNet provider. MO HealthNet will monitor the use of at-home tests to prevent potential waste. Below are the covered at-home tests, including the MAC price per unit.

Durable Medical Equipment (DME) Program Policy Clarification for Custom and Power Wheelchairs Provided in a Skilled Nursing Facility

October 26, 2021

MO HealthNet has updated the Durable Medical Equipment (DME) Provider Manual to clarify policy related to the physician face-to-face evaluation when providing custom and power wheelchairs in a skilled nursing facility.  The policy clarification can be found in Section 13.18.C of the manual located here.

90 Day Supply Requirement

October 14, 2021

Effective October 21, 2021, MO HealthNet will implement a new Extended Supply Fiscal Edit.  This new edit requires participants to receive a 90 day supply on select medication.  The fiscal edit, including a complete list of medications included in the 90 day supply requirement, can be found on our website at https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm.

Durable Medical Equipment (DME) Program Policy Clarification for Custom and Power Wheelchairs Provided in a Skilled Nursing Facility

October 7, 2021

MO HealthNet has updated the Durable Medical Equipment (DME) Provider Manual to clarify policy related to the physician face-to-face evaluation when providing custom and power wheelchairs in a skilled nursing facility.  The policy clarification can be found in Section 13.18.C of the manual located here.

RSV Prophylaxis – Update #3

September 28, 2021

The MO HealthNet Division (MHD) is aware of the sustained increased positivity of RSV virology in the State of Missouri outside of the regular RSV season. MHD has considered RSV prophylaxis requests starting in July 2021. Effective September 28th: participants who meet the clinical edit requirements, including age restrictions, may receive approval for up to 6 doses. This includes 1 dose for October and up to 5 doses during the regular Missouri RSV season (November thru April). Previously approved doses given from July through September are not considered to be part of the 6 doses. Missed doses during the RSV season cannot be used to extend the season, the number and duration of approved doses is determined by date of prior authorization request receipt during the RSV season. Providers with questions may call MO HealthNet at 800-392-8030.

American Dental Association (ADA) Dental Claim Form

September 9, 2021

When completing and submitting a paper ADA Dental Claim form, dental providers should complete Field 23 with the participant’s MO HealthNet number exactly as shown on the participant's ID card. Anything other than the participant’s DCN, or leaving the field blank, will cause the claim to deny. For additional information regarding how to complete the ADA Dental Claim form, reference Section 15.7 of the Dental Manual at http://manuals.momed.com/collections/collection_den/print.pdf.

One Year of Birth Control per Fill

August 30, 2021

MO HealthNet covers up to a one-year supply of birth control in one prescription fill at the pharmacy. Pharmacies can convert a one-month prescription with refills to a three-month supply upon patient request without contacting the prescriber per RSMo 338.202.  Please see this statute for requirements:https://revisor.mo.gov/main/OneSection.aspx?section=338.202

RSV Prophylaxis – Update #2

August 27, 2021

The MO HealthNet Division (MHD) is aware of the sustained increased positivity of RSV virology in the State of Missouri. MHD will consider RSV prophylaxis prior authorization requests during July, August & September. For participants who meet the clinical edit requirements, approval will include up to three doses.

• For participants who were approved in July the doses were approved for July and August. These participants are eligible for an additional September dose upon prescriber request.
• For participants who were approved in August the doses will be for August and September.
• For participants who request doses in September the doses will be for September and October.

MHD will evaluate the need for additional doses on a month-to-month basis, dependent on RSV virology. The doses approved during this summer season will not count toward the 5 doses during the regular 2021-2022 RSV season. Providers with questions may call MO HealthNet at 800-392-8030.

RSV Prophylaxis - Update

August 2, 2021

The MO HealthNet Division (MHD) is aware of the increased positivity of RSV virology in the State of Missouri. MHD will consider RSV prophylaxis prior authorization requests during July & August. For participants who meet the clinical edit requirements, approval will include two doses. For participants who were approved in July the doses will be for July and August, for participants approved in August the doses will be for August and September. MHD will evaluate the need for additional doses on a month-to-month basis, dependent on RSV virology. The doses approved during this summer season will not count toward the 5 doses during the regular 2021-2022 RSV season. Providers with questions may call MO HealthNet at 800-392-8030.

RSV Prophylaxis

July 7, 2021

The MO HealthNet Division (MHD) is aware of the increased positivity of RSV virology in the State of Missouri. MHD will consider RSV prophylaxis prior authorizations requests during July. For participants who meet the clinical edit requirements, approval will include two doses. MHD will evaluate the need for additional doses on a month-to-month basis, dependent on RSV virology. Providers with questions may call MO HealthNet at 800-392-8030.

Long-Term Care Maintenance Medication Billing

July 2, 2021

Effective February 1, 2021, the dispensing fee policy for maintenance medications changed from paying each time the maintenance medication is dispensed to allowing only one dispensing fee every 25 days for a participant receiving the same strength and dosage form of the maintenance medication. This change allows long-term care pharmacies to submit claims in real-time according to their cycle fill schedule. MO Health Net requires all prior authorization and overrides to be obtained prior to dispensing and will no longer backdate approvals for pharmacies who fail to obtain approvals before dispensing.

Medical Device Recall

June 30, 2021

On June 14, 2021, Philips issued a recall notification for specific affected Continuous Positive Airway Pressure (CPAP), BiLevel Positive Airway Pressure (BiLevel PAP) devices, and Mechanical Ventilators.

Please contact Philips for recall information and repair/replacement process. MO HealthNet is not responsible for replacing items related to the recall.

https://www.usa.philips.com/healthcare/e/sleep/communications/src-update

Diabetes Prevention Program Services for Adults

June 21, 2021

On September 1, 2020, the MO HealthNet Division (MHD) implemented a Diabetes Prevention Program (DPP) for eligible adult participants.

These services are Centers for Disease Control and Prevention (CDC) recognized DPP services for at risk individuals, intended to prevent Type-2 Diabetes or delay the progression. DPP services are provided during sessions that occur at regular periodic intervals over the course of one year, and, if eligible based upon individual measurable health-outcomes, additional ongoing maintenance sessions at regular, periodic intervals for another year. At these sessions, DPP services include ongoing nutrition or behavioral counseling focusing on weight reduction and lifestyle changes and physical activity and fitness assessments.

More information about the DPP program can be found in Section 13.73 of the Physician’s Manual found on our website at: http://manuals.momed.com/collections/collection_phy/print.pdf.

If you are already an enrolled provider and would like to participate in this new program to provide DPP services and have the proper CDC recognition status, you will need an additional provider number to bill for these services (Provider Type 37).

The link to complete the electronic application is:
https://peu.momed.com/peu//momed/presentation/commongui/PeHome.jsp

Any questions regarding enrollment should be emailed to: MMAC.ProviderEnrollment@dss.mo.gov

Leukotriene Inhibitor Edit Change

June 2, 2021

Effective July 1, 2021 MO HealthNet will require a manual review of montelukast prescriptions for MO HealthNet participants by the pharmacy helpdesk when prescribed to participants with a history of suicidal thoughts, suicidal actions, and history of neuropsychiatric events. This change is due to the addition of the black box warning in the montelukast label (FDA Announcement). Health care professionals should consider the risks and benefits of montelukast when deciding to prescribe or continue patients on the medicine. Counsel all patients receiving montelukast about mental health side effects, and advise them to stop the medicine and contact a health care professional immediately if they develop any symptoms including but not limited to those listed in the FDA Announcement link above. Be aware that some patients have reported neuropsychiatric events after discontinuation of montelukast.

High Risk Therapies Clinical Edit

May 17, 2021

On April 15, 2021 MO HealthNet introduced a new High Risk Therapies Clinical Edit for patients receiving concurrent opioids and benzodiazepines.

The combination of opioids and benzodiazepines is considered a high risk therapy as both drugs cause sedation, impaired cognitive function, and respiratory depression potentially leading to an overdose death. Unfortunately, many patients are still prescribed this high risk therapy combination. In 2015, 23% of persons dying due to opioid overdoses also tested positive for benzodiazepines. Also, the number of patients prescribed both an opioid and a benzodiazepine increased by 41% between 2002 and 2014. In March 2016, the CDC released their Guidelines for Prescribing Opioids for Chronic Pain; further clarification of these guidelines was published in April 2019. These guidelines recommend avoiding the prescribing of benzodiazepines concurrently with opioids whenever possible. Also, both opioids and benzodiazepine prescription products now carry a boxed warning from the FDA highlighting the danger of using these agents together.

Naloxone is an opioid antagonist indicated for the emergency treatment of known or suspected opioid overdose, as manifested by respiratory and/or central nervous system depression. Pharmacists in Missouri are able to dispense naloxone according to the statewide standing order or upon presentation of a valid prescription. As part of the efforts to protect participants from the possible adverse effects of combining opioid and benzodiazepine medications, MO HealthNet will impose clinical criteria to require the presence of an opioid emergency reversal agent, such as naloxone, when these agents are used concomitantly.

The current statewide standing order is available at: https://health.mo.gov/data/opioids/pdf/naloxone-standing-order.pdf

The current High Risk Therapies Clinical Edit is available at: https://dss.mo.gov/mhd/cs/pharmacy/pdf/high-risk-therapies-clinical.pdf

HMS Hospital/Long Term Care Audits and Commercial Insurance Disallowance Audits

April 27, 2021

MO HealthNet (MHD) and Missouri Medicaid Audit and Compliance (MMAC) are contracted with Health Management Systems (HMS) to conduct post payment reviews of claims for Hospital and Long Term Care facility Credit Balance Audits and the Commercial Insurance Disallowance Audit Cycles.

MO HealthNet is the payer of last resort with all other insurances being primary to Medicaid.   The Long Term Care Audits and Hospital Credit Balance Audits are designed to assist providers in identifying when another insurer has paid and Medicaid is due a refund due to a coordination of benefits billing error.

The Commercial Insurance Disallowance Cycles are post payment reviews conducted by HMS to identify Liable Third Party resources that should have been billed prior to MO HealthNet.   HMS conducts a data match between the MO HealthNet participant eligibility data and the information they receive from the Commercial Carriers to identify insurers that may have been unknown to the provider at the time of service.  As part of Medicaid reclamation, the provider is instructed to bill the commercial plan identified for payment of the claim.   The Commercial Insurance Disallowance Audit Cycles are conducted every 90 days for medical and pharmacy claims.

HMS, acting on behalf of MMAC/MHD, has been instructed to send all audit notices via mail to the providers address on record with MMAC.   MO HealthNet provider’s should ensure HMS audit notices are being routed to the correct person or office within their organization.

If you have any questions, comments or concerns about this update, please contact MMAC/HMS Audits at 573-751-3399 OR Via Email at MMAC.Financial@dss.mo.gov

MO HealthNet providers can verify their addresses on file by sending an email to MMAC.ProviderEnrollment@dss.mo.gov

Billing for Behavioral Health Services for Dual Eligible Participants Performed by Non-Medicare Covered Practitioners

April 22, 2021

When a participant has both Medicare and MO HealthNet coverage, a claim must be filed with Medicare first. However, MO HealthNet enrolls the following practitioners that Medicare does not cover:

• licensed or provisional licensed professional counselors
• licensed or provisional licensed marital and family therapists
• provisional licensed psychologists
• licensed master social workers

Therefore, claims for services rendered by one of the above practitioners to participants who are dual eligible (Medicare and MO HealthNet) are not required to be filed with Medicare prior to submission to MO HealthNet or to the participant’s MO HealthNet Managed Care Plan.

Impacted claims with dates of services beginning July 1, 2018 have been recycled.

Correct Address for Mailing Paper Dental Claim Forms

April 12, 2021

MO HealthNet dental providers submitting paper dental claim forms for MO HealthNet fee-for-service participants, must mail claims to:

Wipro Infocrossing
P.O. Box 5600
Jefferson City, MO 65102

Paper claims sent to any other address will not be processed for payment. For additional information, reference Section 15.7 of the Dental Manual at http://manuals.momed.com/manuals/.

COVID-19: COVID Testing and Specimen Collection Codes – REVISED

March 24, 2021

The MO HealthNet Division (MHD) is responding to an outbreak of respiratory disease caused by a novel (new) coronavirus.  The virus has been named "SARS-CoV-2" and the disease it causes has been named "coronavirus disease 2019" (abbreviated "COVID-19"). 

MHD continues to monitor the Centers for Medicare and Medicaid Services (CMS) guidance related to COVID-19 testing and specimen collection.  The tables below list the COVID-19 testing and specimen collection procedure codes MO HealthNet currently covers as well as who can bill each code, effective dates, max units, and rates. 

Effective for dates of service on or after March 1, 2020, and through the end of the public health emergency, claims submitted by independent laboratories for COVID-19 testing will not require a referring physician.  Providers that perform other laboratory services on the same date as the COVID-19 test must bill for the COVID-19 test on a separate claim in order to be reimbursed.  MO HealthNet will recycle all claims submitted by independent laboratories for COVID-19 tests that did not include a referring provider.

Effective for dates of service on or after January 1, 2021, pharmacists and pharmacies are included in the providers that can bill COVID-19 testing codes.

Effective for dates of service on or after January 1, 2021, providers can bill COVID-19 testing code U0005 in addition to either HCPCS code U0003 or U0004 only after receiving results within two calendar days from date and time of specimen collection.

Quantity Prescribed Requirement

February 24, 2021

The final rule CMS-0055-F from the U.S. Department of Health and Human Services requires the reporting of the NCPDP Quantity Prescribed (460-ET) field for all Schedule II drugs on pharmacy claims as of September 21, 2020.

The MO HealthNet Division (MHD) completed system work to deny claims if the NCPDP Quantity Prescribed (460-ET) field is not populated for Schedule II drugs. Claims will deny with a reject code of ET - M/I Quantity Prescribed if the field is blank, has all zeros, or is missing. Pharmacies should work with their software vendors to capture the mandatory NCPDP Quantity Prescribed (460-ET) field on all Schedule II drug claims.

Pharmacy Early Refill

February 18, 2021

Effective February 18, 2021, MO HealthNet is changing the early refill policy for medications to 85% for controlled and non-controlled substances. Providers may contact the Pharmacy Help Desk at (800) 392-8030 option 3 if overrides are needed.

COVID-19: Radiology (Diagnosis Codes Added effective January 1, 2021)

January 19, 2021

The MO HealthNet Division (MHD) is responding to an outbreak of respiratory disease caused by a novel (new) coronavirus.  The virus has been named "SARS-CoV-2" and the disease it causes has been named "coronavirus disease 2019" (abbreviated "COVID-19").

As posted in the 05/21/2020 hot tip, effective with dates of service on or after March 1, 2020 providers do not need to obtain prior authorization for Chest CT Scan HCPCS codes 71250, 71260, and 71270 when the following COVID-19 related diagnosis codes are present: B34.2, B97.29, J12.89, J20.8, J22, J40, J80, J96.00, J96.01, J96.02, J96.20, J96.21, J96.22, J98.8, P22.0, P28.5, R05, R06.02, R09.02, R50.9, Z03.818, Z09, Z20.828, and Z86.19.  Effective January 1, 2021 the following COVID-19 related diagnosis codes have been added:  Z11.52, Z20.822, Z86.16, M35.81, M35.89 and J12.82. The MHD will continue to waive the co-payment for these procedures.

Prior authorizations for ALL procedures managed by the MHD’s Radiology Benefit Manager (RBM) will be approved for 90 days during the COVID-19 crisis. The list of procedures the RBM manages can be found here: https://www.healthhelp.com/wpcontent/uploads/MOHTN_PROCCODES.pdf

This Hot Tip also applies to providers that are contracted with the Managed Care Organizations.

Logisticare Solutions, LLC Changes Name to ModivCare Solutions, LLC

January 13, 2021

Effective January 6, 2021, MO HealthNet’s Non-Emergency Medical Transportation (NEMT) vendor for fee-for-service participants changed its name from LogistiCare Solutions, LLC to ModivCare Solutions, LLC as part of a company rebranding initiative.  Modiv is Latin for “way”, and reflects the company’s desire to lead innovation and change in terms of how people connect to care.  The new name will not change any of the services provided.

Other changes as part of the rebrand include:

• Company logo and colors
• The way staff answers the phone - for members’ consideration, staff will answer the phone as ModivCare, formerly LogistiCare, for 12 months following the transition.
• Company website - for members’ consideration, the website will reference ModivCare, formerly LogistiCare, for 12 months following the transition.

What is not changing as part of the rebrand:

• Phone numbers and the way clients, members, facilities and transportation providers contact them.
• Their staff will remain the same.
• The way members book their rides online – members will continue to use the same links to schedule their rides as they have been.

ModivCare’s purpose of this rebrand is to shift toward becoming a tech-enabled, value-based healthcare company that will translate into better member experience that delivers consistent, positive healthcare outcomes and leads the industry into a new era.

COVID-19: COVID-19 Testing for participants with Extended/Uninsured Women’s Health Services

January 12, 2021

The MO HealthNet Division is responding to an outbreak of respiratory disease caused by a novel (new) coronavirus. The virus has been named "SARS-CoV-2" and the disease it causes has been named "coronavirus disease 2019" (abbreviated "COVID-19").

Effective for dates of service on or after March 1, 2020, and through the end of the public health emergency, MO HealthNet will cover COVID-19 testing for participants with Extended/Uninsured Women’s Health Services benefits. Providers who perform other services on the same date as the COVID-19 test for these participants must bill for the COVID-19 tests on a separate claim in order to be reimbursed.