Medicare Part D

December 26, 2005

There are significant changes to the pharmacy benefit for Missouri Medicaid dual eligibles (individuals eligible for both Medicare and Medicaid) and Missouri Senior Rx members beginning January 1, 2006. The Missouri Rx Plan (MORx) is Missouri’s new State Pharmacy Assistance Program that will coordinate benefits with Medicare’s (Part D) Prescription Drug Plans and will be administered by the Division of Medical Services (DMS). On January 1, 2006, MORx will replace the Senior Rx Program. The current Senior Rx Program members and all dual eligibles are being automatically enrolled into MORx.

Dual eligible members will continue to have coverage for Medicare-excluded drugs. Medicare-excluded drugs include specific over-the-counter drugs, vitamins, minerals, limited cough and cold drugs, Benzodiazepines and Barbiturates as they are currently covered by Medicaid, as noted on the DMS Pharmacy pages.

Senior Rx members and dual eligibles that are being automatically enrolled into MORx will not need to fill out any paperwork, nor is there any cost to them to enroll in MORx. DMS hopes to hold open enrollment for MORx in the fall of 2006 so that other low-income Medicare beneficiaries may apply.

DMS is sending our members' information to the Centers for Medicare and Medicaid Services (CMS) to share with all PDPs. By sharing this data, the PDP’s response to pharmacy claim submission will identify MORx as a secondary payer. In the event that CMS has not shared member data with all PDPs and MORx is not indicated as a secondary payer, pharmacy claim submission for all MORx members will be paid as long as the Medicare plan did not deny the claim.

To submit a pharmacy claim:

  1. Electronically bill the Medicare Drug Plan covering the beneficiary
  2. Input Missouri Rx Plan as a secondary payer for Missouri Senior Rx Members and Dual Eligibles
    • MORx PCN is P021011511, MORx BIN is 004047
    • The member’s Medicare Beneficiary ID number will be their MORx ID number. All drug claims for these individuals should be submitted through MoRX.
  3. Collect the reported remaining funds from the beneficiary.

The MORx Plan is not issuing ID cards to members. If you have any questions about processing claims for MORx, please call (573)751-6963 or refer to the MORx Frequently Asked Questions page .

Non-Emergency Medical Transportation

December 19, 2005

Non-emergency medical transportation (NEMT) is a Medicaid program for eligible Medicaid/MC+ recipients who do not have access to free appropriate transportation to and from scheduled Medicaid/MC+ covered services.

Some Medicaid/MC+ services include transportation. As a result, NEMT is not covered for those specific services. Below is a listing of services that include transportation:

  • Mentally Retarded Developmental Disabilities (MRDD) Waiver program;
  • Comprehensive Substance Treatment Abuse and Rehabilitation (CSTAR) program;
  • Community psychiatric rehabilitation services (psychosocial rehabilitation and to receive medication services); and
  • Adult day health care services.

Eligible recipients who receive any of the above services can, however, utilize NEMT to other Medicaid/MC+ covered services.

For more information on the NEMT program, you can reference the NEMT bulletin, Volume 28, Number 26 dated October 28, 2005 .

Medical Eligibility Code “80”

December 12, 2005

When you check a female patient’s eligibility, you might find that she has medical eligibility (ME) code “80”. Women with ME code “80” have Medicaid for Women Following Pregnancy and have very limited benefits. The woman’s eligibility starts approximately 60 days following the birth of a child or the termination of a pregnancy (miscarriage). She maintains this eligibility for approximately 12 months unless it is changed by the caseworker.

Following are the restrictions for a woman with ME code 80:

  • Services are provided on a fee-for-service basis only.
  • Services are limited to family planning, and testing and treatment of Sexually Transmitted Diseases (STDs) including:
    • approved methods of birth control including sterilization and radiology services related to the sterilization;
    • family planning counseling and education on birth control options;
    • testing and treatment for STDs;
    • pharmacy, including birth control devices & pills, and medication to treat STDs (excluding anti-retrovirals); and,
    • Pap test and pelvic exams to identify an STD, as well as urinalysis and related blood work.

The treatments of medical complications occurring from the STD are not covered by this program.

The cost of any services that are not part of the womans ME Code 80 benefits are her responsibility and can be billed to the patient. If the patient is pregnant, the provider should strongly encourage the person to immediately contact her caseworker to have eligibility determined for another category of assistance since services related to the pregnancy are not covered under ME code 80.

Preparing For NPI

December 5, 2005

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) mandates the use of a standard unique identifier [National Provider Identifier (NPI)] for all health care providers no later than May 23, 2007. This federal mandate limits an individual provider to only one (1) NPI number. It will no longer be necessary for health care providers to keep track of multiple third party payor numbers (e.g., multiple Missouri Medicaid provider numbers).

To prepare for the use of the NPI on all health care claims, Missouri Medicaid will be consolidating multiple provider numbers for an individual provider to one (1) Medicaid provider number in several phases. The effective date of Phase 1 will be January 23, 2006. The following provider types will be affected by Phase 1:

  • 20 & 24 - Physician, M.D. & D.O.
  • 42 - Nurse Practitioner
  • 91 - Certified Registered Nurse Anesthetist (CRNA)

Missouri Medicaid providers whose numbers have been consolidated may have received several different types of letters regarding consolidation:

  • Letter inactivating the provider number(s) that have been consolidated:
    These letters were sent to the address of the provider number(s) that is being inactivated. If more than one provider number has been made inactive, each practice location being made inactive has been sent a separate letter.
  • Letter stating the consolidated (active) remaining provider number:
    This letter was sent only to the remaining active provider number location. It is the provider’s responsibility to supply the consolidated (active) provider number to all clinics/groups where they practice.
  • Clinic letter:
    Each clinic/group provider who has an active Medicaid provider number should have received a letter explaining the new consolidation process for physicians, nurse practitioners, and CRNAs.

If the Missouri Medicaid provider had only one (1) active provider number, they were not sent a letter. The current active provider number will remain after consolidation.

There are providers enrolled as part of a clinic/group, but the clinic/group provider has never enrolled with Missouri Medicaid. With consolidation of provider numbers, the clinic/group provider is required to enroll in order to bill and receive payment for the performing provider’s services. Each provider will have only one (1) provider number. The clinic/group enrollment application must be completed online. You may contact the Provider Enrollment Unit via e-mail if you have questions regarding enrollment.

Below are specific billing instructions relating to the billing provider and performing provider fields for medical claims. To receive payment for provider services rendered through a clinic/group, claims must be filed using the clinic/group provider number as the billing provider and the individual provider number as the performing provider.

  • CMS-1500 Claim Form:
    • Performing Provider Number must be submitted in Field 24K
    • Billing Provider Number must be submitted in Field 33
  • Medical (CMS-1500) on Missouri Medicaid Billing Web site:
    • Performing Provider Number must be entered in the field marked ‘Performing Provider’
    • Billing Provider Number is the provider number selected from the drop-down box at the top of the emomed page
  • 837 Professional Health Care Claim:
    • Please refer to the 837 Implementation Guide
  • Clearinghouses or Contracted Billers:
    • Please refer to the clearinghouse or contracted billers for instructions

Prior Authorization requests or attachments submitted on or after January 23, 2006, must be submitted using the remaining active provider number.

If it is necessary for providers to void or credit a previously paid claim, providers must use the provider number submitted on the original claim.

If providers resubmit a previously denied claim which is affected by timely filing limitations, providers must use the provider number submitted on the original claim.

For information on obtaining an NPI, please refer to the Missouri Medicaid National Provider Identifier (NPI) Bulletin, Volume 28, Number 21, dated November 1, 2005.

Postoperative Care

November 28, 2005

Postoperative care includes 30 days of routine follow-up care for those surgical or diagnostic procedures having a Medicaid reimbursement amount of $75.00 or more. For counting purposes, the date of surgery is the first day.

This policy applies whether the procedure was performed in the hospital, an ambulatory surgical center or an office setting, and applies to subsequent physician visits in any setting (e.g., inpatient and outpatient hospital, office, home, nursing home, etc.).

Pain management is considered part of postoperative care. Visits for the purpose of postoperative pain control are not separately reimbursable.

Physician (surgeon or physician other than the surgeon) services are audited against claims that have already been paid as well as against those claims currently in process.

Supplies necessary for providing the follow-up care in the office, such as splints, casts and surgical dressings in connection with covered surgical procedures that meet the postoperative care policy, may be billed under the appropriate supply code. Attach an invoice if applicable.

For procedures subject to postoperative editing, please see Section 13.41.B of the Physician Manual.

Sometimes providers fail to use the appropriate modifier when billing for surgical care only or post operative management only. Use modifier 54 with the surgical procedure code to indicate surgical care only. Use modifier 55 with the surgical procedure code to indicate postoperative management only.

Immunizations For Nursing Home Residents

November 21, 2005

In a final rule published in the Federal Register on October 7, 2005, skilled nursing facilities (SNFs) serving Medicare and Medicaid recipients are required to provide immunizations against influenza and pneumococcal disease to all of their residents. SNFs are required to offer the immunizations as a condition of participation in Medicare and Medicaid programs according to Center for Medicare and Medicaid Services (CMS). Residents who cannot receive the vaccine for medical reasons are exempt from this requirement.

The rule requires that each resident be offered timely influenza immunizations and the lifetime pneumococcal vaccine unless it is medically contraindicated or the resident has already been immunized. SNFs must ensure before offering the immunizations that each resident, or the residents legal representative, received education regarding the benefits and potential side effects of immunizations.

Facilities are required to document in each residents medical record the administration of an annual influenza vaccination unless:

  1. vaccination was medically contraindicated because of the residents medical condition;
  2. the resident personally or through a representative refused the treatment after education and consultation about the benefits of vaccination; or
  3. the resident had already been vaccinated.

According to the rule, CMS may exercise its enforcement discretion by instructing the State Survey Agencies not to take enforcement actions against facilities that are out-of-compliance with this requirement if the SNFs were unable to obtain vaccine for their residents because of a vaccine shortage, declared by the federal department of Health and Human Services (HHS).

Optical Claims Submission Errors

November 14, 2005

Optical providers with Medicaid provider numbers beginning with 31, 32 or 53 have experienced claim denials when filing claims through the Medicaid billing Web site at The error occurs when entering the recipients optical prescription.

At the Medicaid billing Web site, select the "Medical (HCFA-1500)" claim format to enter your claim. As an optical provider, additional fields are provided at the bottom of the claim format to enter the recipients optical prescription. To enter a valid prescription, additional periods (.) should not be included in the 'Diopter' or 'Add' fields. The Internet fields already contain the periods; adding additional periods will cause the claim to deny. For example, the recipient’s prescription is "-4.50-1.75 Add 2.00". Should additional periods be added when entering the prescription, the Medicaid system recognizes it as "-4..50-1..75 Add 2..00", resulting in an invalid prescription.

Providers reconciling their remittance advices should check the data entry of their prescriptions when denials are related to invalid or missing information.

Medical Referral Form (PI-118) Revised

November 7, 2005

The Medical Referral Form of Restricted Recipients (PI-118) has been revised. A 'Date of Service' field has been added which must show the appointment date for the referred service. If the appointment date is unknown at the time of the referral, the actual date that the referral service is rendered must be entered. The PI-118 referral form is effective for thirty (30) days from the Date of Service entered in this field and NOT thirty (30) days from the physicians signature date field. You may submit the information from this form electronically on the Medicaid billing Web site.

More information on restricted recipients can be found in the hot tip dated May 16, 2005.

If you have questions regarding the Administrative Lock-In program, please contact the Division of Medical Services, Program Integrity Unit at 573/751-3399.

Nursing Home Therapy Crossover Claims

October 31, 2005

Missouri Medicaid reimburses nursing homes for the coinsurance and/or deductibles associated with Medicare Part B therapy claims. Crossover claims are sent to Medicaid electronically by the Medicare contractor or submitted by the provider through the Medicaid billing Web site. Medicaid will continue to pay these crossover claims as long as the recipient has a nursing home level of care on their eligibility file. There will be no new restrictions applied to the eligibility or reimbursement criteria for the coinsurance, deductible or both associated with Medicare Part B therapy claims.

Medicaid recipients residing in a vendor nursing home, regardless of ME code, are able to use their surplus to pay for medically necessary services as required by federal law. Adjudicating claims through the Medicaid claims processing system to ensure the best price, quality, and program integrity does this. All therapy services provided to Medicare/Medicaid recipients must be medically necessary. You must have documentation to substantiate the need for these services.

For non-nursing home recipients who receive Medicare Part B therapy services at a nursing home on an outpatient basis, Medicaid covers the coinsurance, deductible or both, only for those with Qualified Medicare Beneficiary (QMB) coverage, Medicaid/MC+ children and those in the assistance categories for pregnant women or blind.

Optional Medicaid Services That Were Eliminated for Certain Adults on September 1, 2005

October 24, 2005

Providers were notified through Medicaid bulletins dated July 12, and September 14, 2005 of certain optional Medicaid services that were eliminated such as dental, therapies, eyeglasses, etc. for recipients 21 years of age and older beginning September 1, 2005. The medical eligibility groups affected are 01, 04, 05, 10, 11, 13, 14, 16, 19, 21, 24, 26, 83 and 84.

If children 20 years of age and under are eligible under one of the above eligibility groups, they are not affected by the changes and can continue to receive services otherwise eliminated for certain adults.

Categories of assistance for pregnant women and the blind are not affected by the changes and can continue to receive services otherwise eliminated for certain adults.

In addition, recipients residing in nursing homes who are eligible under one of the above eligibility groups are not affected by the changes. Medicaid recipients residing in a vendor nursing home, regardless of ME code, will be able to use their surplus to pay for medically necessary services as required by federal law. This will be done by adjudicating claims through the Medicaid claims processing system to ensure the best price, quality, and program integrity. The vendor nursing facility level of care must be indicated on the Medicaid eligibility file. When providing services to a recipient who is living in a vendor nursing facility, providers should continue to submit claims to Missouri Medicaid in the same manner they did prior to September 1, 2005.

Childrens Health Insurance Program Changes

October 17, 2005

Those uninsured children who qualify for MC+ for Kids (also known as Childrens Health Insurance Program) can be identified by medical eligibility codes 71, 72, 73, 74 or 75. To qualify, these children must be under age 19, have a family income below 300% poverty, have been uninsured for 6 months or more (except special needs children) and have no access to other health insurance coverage.

Effective September 1, 2005, changes were made to medical eligibility groups 73, 74 and 75. Medical eligibility group 73 (Children ages 1 through 18; family income above 150-185% of the federal poverty level) and medical eligibility group 74 (Children ages 0 through 18; family income above 185-225% of the federal poverty level) must now pay a monthly premium to become eligible. In the past, there was no monthly premium. Also effective September 1, 2005, copays were eliminated for medical eligibility groups 74 and 75. Medical eligibility groups 71, 72 and 73 never had a required copay and that remains unchanged.

A recipient who has not paid a required premium will not show to be eligible when verifying eligibility. Recipients can contact the Medicaid Premium Collections Unit at 877-888-2811 if they have questions concerning their premium.

Pharmacy Claims With Third Party Liability (TPL)

October 10, 2005

Effective September 9, 2005 Missouri Medicaid began editing pharmacy claims for those recipients who have active third party coverage. Pharmacy insurance coverage was verified as being active prior to September 9, 2005. Missouri Medicaid will deny payment if the active third party pharmacy insurance for the recipient is not billed prior to submitting the claim to Medicaid. This process uses the NCPDP 5.1 Other Coverage Code field 308-C8. Please refer to your software supplier for the appropriate coverage codes.

If payment is received from the other insurance carrier, please indicate the amount received in the "other insurance payment collected" field along with the corresponding other coverage code. If the other insurance is a discount card, or does not cover the prescription, Missouri Medicaid will consider the claim for payment dependent on the coverage code used.

Pharmacies should encourage the recipient to contact their caseworker in the local Family Support office or call the Recipient Services Unit at 1-800-392-2161 to report expired/discontinued pharmacy coverage.

Nursing Home - Personal Funds Balance

October 3, 2005

Personal funds balances should not be released prior to notifying the Third Party Liability Unit in the Medicaid office by use of the Personal Funds Account Balance Report form.

The Revised Missouri Statutes (RSMo), Section 198.090, states the total amount paid to the decedent or paid upon his behalf by the department shall be a debt due the state and recovered from the available funds upon the department’s claim on such funds. The department shall make a claim on the funds within sixty (60) days from the date of the accounting of the funds. The nursing facility shall pay the claim made by the Department of Social Services (DSS) from the resident’s personal funds within sixty (60) days from the date of the department’s claim.

The nursing home provider manual, Section 13.13.H states that nursing homes are required to submit a written account of the remaining personal funds for any deceased resident who has received aid, care, assistance or services provided by DSS.

The resident’s personal funds account balance must be submitted on the ‘Personal Funds Account Balance Report’ form within sixty (60) days from the date of the resident’s death. The form should be sent to:

Division of Medical Services
Third Party Liability Unit
Attention: PF Recovery
P. O. Box 6500
Jefferson City, MO 65102-6500

If you have questions regarding this program, you can contact the Third Party Liability Unit at (573) 751-2005.

Non-Emergent Ambulance Trips

September 26, 2005

Missouri statute 208.152 authorizes Medicaid coverage of emergency ambulance services. Only those transports considered an emergency and made to the nearest appropriate hospital are covered and should be submitted to Medicaid for payment. The definition for emergency transport can be found in Section 13.3.A of the Medicaid provider ambulance manual located on the Internet at Exceptions to this policy can be found in sections 13.3.P (Healthy Children and Youth services); 13.3.O (transfer of patient to another hospital); and 13.3.L (transports for specialized testing).

Services not considered emergent or within the exempted categories should not be submitted to Medicaid for processing. Non-emergent trips, as well as services provided to a recipient not eligible on the date of the transport, may be billed to the recipient. Medicaid recipients who dispute a bill from an ambulance provider may contact the Medicaid Recipient Services Unit (RSU) at 1-800-392-2161. It is not the responsibility of the ambulance provider to submit a claim to Medicaid in order to receive a denial before billing the recipient.

If the recipient contacts RSU regarding a bill, the ambulance provider may be contacted by RSU staff requesting a copy of the trip ticket. This documentation must be sent to RSU by the requested date in their letter. A medical consultant then reviews the trip ticket. After review, both the ambulance provider and the recipient will receive written notification. If the review determines the transport meets emergency criteria, the provider will be instructed to submit the claim to Medicaid and the recipient is not financially responsible. If the review determines the transport does not meet policy, the recipient is notified they are responsible for payment of the bill. If the ambulance provider does not comply with RSU’s request for documentation, the recipient is notified they are not responsible for payment of the bill.

A list of non-covered ground and air ambulance services can be found in section 13.3.U of the Medicaid provider ambulance manual.

Contacting The Provider Enrollment Unit

September 19, 2005

The e-mail address for the Medicaid Provider Enrollment Unit has changed to If you have submitted an inquiry to the Provider Enrollment Unit using the previous e-mail address, please be assured the Division of Medical Services will respond to your request.

Changes regarding address, ownership, tax identification number, name (provider or practice), or Medicare number must continue to be submitted in writing to:

Provider Enrollment Unit
Division of Medical Services
P. O. Box 6500
Jefferson City, MO 65102

Claim Confirmation File

September 12, 2005

When claims are submitted through the Medicaid billing Web site at, providers can view the claim confirmation file the next business day at the same site. Claim confirmation files are dated the business day following the date the claims are processed and are available for thirty (30) days.

From the ‘Home’ page in the ‘Receive Provider Files’ box, click on ‘Claim Confirmation’. A screen will display with claim confirmation posted dates. Click on the date of the file you want to view.

There are two options available for viewing the claim confirmation file; one is by each individual provider number that is selected from the drop down box (cc by provider), and the other option is by submitter, which displays the claim confirmations for a submitter that includes all provider numbers in the drop down box (cc by submitter).

Another option allows the selection of the type of report to view. The HTML report brings the report up on the screen as a HTML file in a chart. The TEXT report allows the file to be imported on the computer and utilized as desired (i.e., Excel spreadsheets).

The Claim Confirmation report contains claim information such as the Internal Control Number (ICN), provider number, claim type, claim status, from and through dates, billed and paid amounts, reason codes, patient account numbers and error messages if applicable.

Common claim status codes are: “I” – to be paid; “K” – to be denied; and “C” – suspended/still processing.

Claim status codes and reason codes can be found on the Internet at under the HIPAA-related code sets.

Viewing Claims You Keyed

September 5, 2005

A feature on the Medicaid billing web site at is the ability to view all claims that you individually keyed for the same business day.

At the Medicaid billing web site, click on ‘Daily Claims Summary’ option. This gives a summary of all claims that were submitted that business day (5:01 PM central standard time of previous business day to 5:00 PM of the current day).

Claims on the ‘Daily Claims Summary’ are broken down by claim type and provider number. The claims summary at the bottom of the screen will show the breakdown of each provider number billed, how many claims were individually keyed, and the total billed amount ($) of all of the claims billed.

Claims on the ‘Daily Claims Summary’ are pulled in the Missouri Medicaid system and processed that evening. You can view claims processing results the next business day at the same web site by clicking on ‘Claim Confirmation’.

Next Monday, the hot tip will provide information on the ‘Claim Confirmation’ file.

Recipient Copayment

August 29, 2005

Beginning September 1, 2005, recipients receiving services under certain programs are required to pay a small portion of the costs of the services. The copayment will range from fifty cents ($.50) to three dollars ($3.00) depending on the service received, except for inpatient hospital copayment, which is ten dollars ($10.00).

Copayments will apply to the following hospital and physician related services and is applied to the billing provider type:

Copay Service Provider
$10.00 Inpatient Hospital 01
$  3.00 Outpatient or Emergency Room 01
$  1.00 Physician 20, 24
$    .50 Clinic Service 50, 51, 54, 55
$  1.00 X-ray and Laboratory 70, 71
$  1.00 Nurse Practitioner and Nurse Midwife 25, 42
$    .50 CRNA 91
$  2.00 Rural Health Clinic 59
$  1.00 Case Management 18, Specialty A7
$  2.00 Federally Qualified Health Care 50, Specialty C8
$  2.00 Psychology 49, Specialty 45

For dental, optical and podiatry services, copayment is based on the amount Medicaid pays per date of service or item as shown below:

Amount paid /
date of service or item
$10.00 or less $  .50
$10.01 to $25.00 $1.00
$25.01 to $50.00 $2.00
$50.01 or more $3.00

The following recipient groups or services are exempt from copayment:

  • Recipients under 19 years of age;
  • Managed Care enrollees
  • Persons receiving Medicaid under a category of assistance for pregnant women or the blind;
  • Services to residents of a skilled nursing facility; intermediate care nursing home; residential care home; adult boarding home or psychiatric hospital;
  • Services to recipients who have both Medicare and Medicaid;
  • Emergency or transfer inpatient hospital admissions;
  • Emergency services provided in a hospital outpatient clinic or emergency room to treat a life threatening condition;
  • Certain therapy services (physical therapy; chemotherapy; radiation therapy; chronic renal dialysis) except when provided as an inpatient hospital service;
  • Family planning services;
  • Services provided to pregnant women, directly related to the pregnancy or complications of the pregnancy.
  • Foster care recipients;
  • In-home/personal care services;
  • Hospice services;
  • Medically necessary services identified through an Early Periodic Screening, Diagnosis and Treatment screen (EPSDT);
  • Department of Mental Health services;
  • Medicaid waiver services.

Providers of services subject to a copayment may not deny or reduce services based on the recipient’s inability to pay when charged. A recipient’s inability to pay a required copayment when charged does not extinguish the recipient’s liability to pay the due amount or prevent a provider from attempting to collect a copayment.

If a provider has uncollected copayment debt and it is the routine business practice to discontinue future services to an individual with uncollected debt, the provider may include uncollected copayment under this practice. The provider must however, give the recipient reasonable opportunity to pay and advance notice to arrange care with a different provider before services can be discontinued.

For detailed information regarding Medicaid copayments, please reference the Missouri Medicaid Program Changes bulletin dated July 12, 2005.

Durable Medical Equipment (DME) Program Changes

August 22, 2005

Senate Bill 539 passed by the 93rd General Assembly made reductions in some of the Medicaid programs including the Durable Medical Equipment (DME) program. Changes become effective September 1, 2005. The following addresses the most commonly asked questions regarding the DME program reductions:

  • Services for eligible Medicaid recipients under the age of 21, as well as eligible Medicaid recipients in the categories of assistance for pregnant women or the blind, remain unchanged. Additionally, the same services allowed through the DME program for residents of nursing facilities will not be affected by program reductions.
  • Section 19 of the DME provider manual has been updated to show which items are covered (C) and which are non-covered (NC) under the reduced benefit package.
  • Providers will not be reimbursed for an eliminated item even if the item was prior authorized and the prior authorization is in effect after 09/01/05. Items ordered or fabricated prior to 09/01/05 but delivered after 09/01/05 may be covered under the custom made policy. The complete custom made policy may be found in Section 13.15 of the DME provider manual.
  • Repairs to patient owned equipment are covered if the procedure code for the item is covered with a ‘RP’ modifier and the procedure code is identified as a covered item in section 19 of the DME provider manual.
  • Recipients who currently are using breathing equipment such as CPaps, BiPaps and nebulizers should talk to their physician so the physician can determine if the needs of the recipient can be met by the Medicaid exception criteria. Physicians should refer to Section 20 of their provider manual for information on the Medicaid Exception process. Recipients currently using CPaps, BiPaps or nebulizers will not lose coverage if an exception has been requested until a determination of medical necessity is made.
  • Effective 07/01/05, if services covered by Medicare are not covered by Medicaid, the coinsurance and/or deductible amounts will not be reimbursed to providers as a crossover payment. Services included in the reduced benefit package effective 09/01/05 will follow these same guidelines. The exception to this policy will be those Medicare/Medicaid patients who are also covered by the Qualified Medicare Beneficiary (QMB) program. Missouri Medicaid will be responsible for coinsurance and/or deductible amounts for the QMB eligibles even if Medicaid does not cover the service. Determination of QMB coverage may be obtained through the IVR at (573) 635-8908 or through the Real Time Query at
  • The Certificate of Medical Necessity (MN) and the Oxygen and Respiratory Equipment Medical Justification (OREMJ) forms are now available on the Medicaid billing Web site at and can be sent electronically.

Adequate Documentation

August 15, 2005

The Missouri Medicaid program has specific requirements regarding adequate documentation that must be included in the medical record by the provider for the services rendered to a Medicaid patient.

The Code of State Regulations, 13 CSR 70-3.030, Section (1)(A) defines “adequate documentation” and “adequate medical records” as follows:

“Adequate documentation means documentation from which services rendered and the amount of reimbursement received by a provider can be readily discerned and verified with reasonable certainty. Adequate medical records are records which are of the type and in a form from which symptoms, conditions, diagnoses, treatments, prognosis and the identity of the patient to which these things relate can be readily discerned and verified with reasonable certainty. All documentation must be made available at the same site at which the service was rendered.”

Providers must maintain documentation for five (5) years. Long-term care providers are required to retain financial records for seven (7) years.

Temporary Medicaid For Pregnant Women

August 8, 2005

When you check Medicaid eligibility for a female patient, you might find that she has medical eligibility (ME) code “58” or “59”. Women with ME code “58” or “59” have temporary (TEMP) Medicaid for pregnant women and have very limited benefits.

A TEMP Medicaid patient’s benefits cover only routine ambulatory prenatal care. She is not covered for services such as deliveries, inpatient hospital care, non-pregnancy related medical care, and non-medical services (home health care, mental health care, etc.) Non-ambulatory services become the responsibility of the patient and the provider can bill her for them. The provider should check eligibility before each visit to see if the recipient is still eligible for TEMP Medicaid or if she is now eligible for another ME code with additional benefits.

A claim for routine ambulatory prenatal services for a TEMP patient must include a pregnancy/prenatal diagnosis code (V22-V23.9 or V28-28.9).

If the provider determines that the lack of a treatment or service would adversely affect the outcome of the pregnancy, and said treatment or service is not considered part of routine prenatal care, the provider may bill the service to Medicaid. The provider must show one of the above diagnosis codes on the claim and must maintain a properly completed Certificate of Medical Necessity form in the patient’s file.

Assuring Your Medicare Claims Crossover Electronically

August 01, 2005

The main reason claims do not cross over electronically from Medicare to Medicaid is because Medicaid enrolled providers have not provided Medicaid with a Medicare provider number or have provided an invalid Medicare provider number. To decrease the number of claims that must be filed on the Medicaid billing Web site, make sure your Medicare provider number(s) is on file with Medicaid.

If you are enrolled as a group with Medicare, you must also enroll as a group with Medicaid. Both your group Medicare number and each individual practitioner’s Medicare number must be on file with Medicaid. Keep in mind that some provider groups cannot enroll with Medicaid as a group or clinic such as therapy and psychology groups.

If you have more than one provider number with Medicare and Medicaid, be sure you provide the proper Medicare number to each specific Medicaid provider number or else claims will not cross electronically.

To verify the Medicare number on file, you can contact the Provider Enrollment Unit via e-mail at If you have not submitted your Medicare number to Medicaid, you can FAX a copy of the Medicare letter showing the Medicare provider name and Medicare number assigned, along with a cover page explaining why the information is being submitted. The FAX number is 573/526-2054.

Electronic Filing of Medicare/Medicaid Crossover Claims

July 25, 2005

Medicare/Medicaid (crossover) claims that do not cross automatically from Medicare to Medicaid, must now be filed through the Medicaid billing Web site at or through the 837 electronic claim transaction. Reference the July 1, 2005 Bulletin regarding Elimination of Paper Claims and Attachments. Before filing an electronic crossover claim, please wait sixty (60) days from the date of your Medicare payment to avoid duplication. Following are tips to make filing a claim at the Medicaid billing Web site successful:

  • At the Medicaid billing Web site at, choose the same crossover claim form that you completed to bill Medicare. Enter the information exactly as you did on your Medicare billing.
  • There are HELP screens to provide instructions in completing the crossover claim forms, the “Other Payer” header and “Other Payer” detail screens. Print each HELP screen in their entirety for reference when completing claims on the Internet.
  • There must be an “Other Payer” header form completed for every crossover claim type. This provides information that pertains to the whole claim.
  • Part A crossover claims need only the “Other Payer” header form completed and not the “Other Payer” detail form.
  • Part B and Part B of A crossover claims need the “Other Payer” header form completed without group code, reason code and adjustment amount information. An “Other Payer” detail form is required for each claim detail line.
  • The five (5) codes that can be entered in the "Group Code" field on the "Other Payer" Header and Detail forms are in a drop down box and you can choose the appropriate code. For example, the "PR" code (patient responsibility) is understood to be the code assigned for deductible and/or coinsurance amounts shown on your Medicare EOMB.
  • The codes to enter in the "Reason Code" field on the "Other Payer" Header and Detail forms are found on your Medicare EOMB. If not listed there, you would choose the most appropriate code from the list of Claim Adjustment Reason Codes. For example, the code shown on the "Claim Adjustment Reason Codes" list for "deductible amount" is 1 and for "coinsurance amount" is 2. Therefore, you would enter a "Reason Code" of "001" for deductible amounts due and a "Reason Code" of "002" for coinsurance amounts due.
  • The "Adjust Amount" should reflect any amount not paid by Medicare including deductible, coinsurance, and any non-allowed amounts.
  • If there is a commercial insurance payment or denial to report on the crossover claim, you must complete an additional "Other Payer" Header form. You must also complete an additional "Other Payer" Detail form(s) as appropriate.

Understanding the Options at

July 18, 2005

The information below helps to explain some of the options available at the Medicaid billing Web site at

Submitting Individual Claims - This option allows submission of individual claims by claim type. The ‘Help’ button at the bottom of each claim screen gives further detail for the individual fields on the form.

Submitting Attachments - This option allows submission of select attachments electronically to Missouri Medicaid.

Update Submitter/Provider Information - This option provides update capabilities to submitter demographic and contact information registered for this site. Allows the ability to add/remove provider numbers for access at this site. Note: This does not change Provider Enrollment information (i.e. pay-to addresses and provider registration information).

Submitting Batch Files - This option is used to send files by utilizing a software program that creates a batch file in an approved format. Click on ‘Send Files’ to send the batch file to Missouri Medicaid.

Submitting HIPAA Test Files – This option is used to test HIPAA compliant ASC X12 batch files such as the 837, 270 or 276 layouts. A Trading Partner Agreement must be on file in order to begin HIPAA testing. Results are returned through the ‘Receive HIPAA Test Files’ box.

Daily Claims Summary – This summary is available daily to verify all individually keyed claims through the ‘Submit Claims’ box at this site. The claims on the Daily Claims Summary are processed at 5:00 p.m. each business day, and the results are reported back the next business day through the ‘Claim Confirmation’ option.

Real Time Queries – Allows real time queries to verify select information with Missouri Medicaid, such as verify recipient eligibility, view claim status, payment check inquiries, view PA status and view attachment status.

Request Aged RA’s - This link allows requests for archived remittance advices from June 2004 to current. The RA will be posted the next business day at this site under the ‘Printable Aged RA’s option.

Claim Confirmation – This report is available the day after claims are submitted at this site (Monday-Friday) to provide information on claim status. Claim confirmations are available for 30 days after claim submission. Claim status codes are: I – To Be Paid K – To Be Denied C – Suspended (Still processing) Detailed descriptions of the Claim Adjustment Reason Codes on the claim confirmation report can be found at

Retrieve Remittance Advices – This option allows the download and retrieval of Missouri Medicaid RA’s in approved formats. The remittance advice can be viewed from the ‘Receive Provider Files’ box.

Claim Adjustment Reason Codes and Remittance Advice Remarks Codes – This option links to for the HIPAA mandated codes used on reports and RA’s.

Claims Processing Schedule – This link shows cycle and check dates for the current fiscal year.

Help Screens – Help links are available on most options at this site. These screens provide helpful information and further explanation of fields and procedures.

Contact Us – Sends an e-mail to the Infocrossing Help Desk when assistance is needed with technical/electronic support questions.

Medicaid Claims Processing Schedule

July 11, 2005

Missouri’s fiscal year runs from July 1st through June 30th. July 1, 2005 is the start of state fiscal year 2006 (SFY06). With the beginning of SFY06, many changes are being implemented within the Medicaid program. One change not taking place is the number of times provider checks are produced each month.

Checks are mailed or directly deposited in to a provider’s account twice each month, the 5th and the 20th, for any amounts due them. If the 5th and/or 20th fall on either a Saturday, Sunday or state holiday, the check is mailed or directly deposited the following working day.

The claims processing schedule for SFY06 lists the dates the cycles are run and their corresponding check dates.

Providers who currently receive paper checks are encouraged to consider the convenience of direct deposit. Provider checks are not forwarded if there is a wrong address on file. With direct deposit, the check is deposited into the appropriate account on the check date. The application for direct deposit is located on the Medicaid Web site.

Medicaid Fee Schedules

July 4, 2005

Did you know the Medicaid provider fee schedule is located online at This brings you to the License For Use Of “Physicians’ Current Procedural Terminology”, Fourth Edition agreement, which must be accepted before entering the fee schedule information page.

The next page gives an overview of the information available as well as general fee schedule information. Once you have read the page, you have the option of either downloading an entire schedule for your provider type, or you can do an online search. Click on the appropriate button to advance to the next page.

When performing a “full search”, you must first click on a category on the left side of the screen. For instance, if you are a physician looking for the fee on a surgical code, you should click on “Surgery and Epidurals”. If you are looking for the fee of an evaluation and management code, click on “Medical Services”. After selecting a category, the quickest way to find a specific code is to enter the code under the search option. The next page displayed shows the procedure code along with any recognized modifiers for the code. By moving your pointer over a series of boxes on a specific code, you will be able to determine if a code has any program restrictions, the maximum quantity and reimbursement fee.

Use of Invalid Diagnosis Codes

June 27, 2005

Providers using invalid diagnosis codes on their claims is one of the top ten reasons claims deny.

For those claims requiring diagnosis codes for billing, providers must utilize the codes from the International Classification of Diseases 9th Revision Clinical Modification (ICD-9-CM). When selecting the appropriate code from the ICD-9-CM, be sure to review all codes in a range and code to the highest level of specificity. Some diagnosis codes require a 4th and 5th digit. Most denials occur when providers do not include the appropriate digits. The ICD-9-CM clearly specifies when codes require a 4th or 5th digit.

Diagnosis codes are updated each year on October 1 with no grace period between the old codes and new codes. It is important for providers to have the updated ICD-9-CM edition in their offices. The ICD-9-CM is available online through the National Center for Health Statistics or can be obtained from any medical bookstore.

Retaining Medicaid Records

June 20, 2005

Like many businesses, Medicaid providers are faced with the issue of the storage of records and how long records must be maintained.

Medicaid providers must maintain fiscal and medical records that coincide with and fully document services billed to the Medicaid agency for a period of five years from the date of service. The retention period is seven years for nursing homes, CSTAR and community psychiatric rehabilitation providers. The records must be furnished or made available for inspection and/or audit upon request by the Department of Social Services or its authorized representative.

A provider’s failure to furnish, reveal and retain adequate documentation for services billed to Medicaid can result in the recovery of the payments for those services not adequately documented and can result in sanctions to the provider’s participation in the Missouri Medicaid program. This policy continues to be applicable in the event the provider discontinues as an active participating Medicaid enrolled provider as the result of a change of ownership or any other circumstance.

Applying For Medicaid Internet Access

June 13, 2005

Many providers have recently asked how to gain access to bill electronically through the Medicaid Internet billing site.

Medicaid has developed a HIPAA compliant Web site for billing, and each user must apply for a user identification number (ID) and password prior to billing. The process is quick and the application can be completed online. Access is available immediately upon receiving the ID and password. . Complete all required fields and submit.

After you receive your user ID and password, you can log onto and begin using the site. In addition to filing claims, there are many other resources there to assist you. You can check eligibility for recipients in real time or by batch, retrieve your remittances, submit electronic attachments, check the status of claims and prior authorizations plus much more. This is also the site that you would access to update your submitter information. For instance, if a provider joins or leaves your office, you need to click on ‘Update submitter/provider information’ to add or delete access for that provider number.

Recipients with Commercial Insurance

June 06, 2005

When you check Medicaid eligibility for a patient, you may be surprised to learn that the patient has commercial insurance in addition to Medicaid. An individual who has commercial health insurance may still be eligible for Missouri Medicaid benefits. However, commercial insurance must be the first source of payment as Medicaid is payor of last resort. For those services that are covered by the commercial health insurance, that policy is billed first and there is no payment if the commercial insurance has paid more than the Medicaid allowable. If services are not covered by the commercial insurance policy, Medicaid pays for the covered services. There is no duplication of payment.

Private insurance information is initially obtained by caseworkers at the Family Support Division when an individual makes application for public assistance. Once eligible, the recipient is responsible for reporting to their caseworker any changes to the private insurance coverage.

When you check the patient’s eligibility, you are given information about known possible insurance coverages. The insurance information on file at the Division of Medical Services (DMS) does not guarantee that the insurance(s) listed is (are) the only resources available nor does it guarantee that the coverage is currently in effect. If the recipient has not informed the caseworker of changes, the information on file may need updated.

As a provider, you have the ability to inform DMS of changes to a recipient’s private insurance information by completing and submitting the Medicaid Insurance Resource Report form, commonly known as the TPL-4 form. The form is available through the Medicaid forms page. Third Party Liability (TPL) staff verifies the information before updating the TPL data on the patient’s enrollment file. TPL staff are currently verifying information within a month.

For detailed information on third party resources, see Section 5 of the Medicaid Provider Manual.

Timely Filing of Claims

May 31, 2005

A common reason claims deny is because of untimely filing. Here is some information that can help you easily understand the Medicaid timely filing limitation for claims:

  • Original claims must be filed by the provider and received by the state agency within 12 months from the date of service. The counting of the 12-month time limit begins with the date of service and ends with the date of receipt. Any claims that originally were submitted and received within 12 months from the date of service, but were denied or returned to the provider, must be resubmitted and received within 24 months of the date of service.
  • Medicare/Medicaid crossover claims that have been filed within the Medicare timely filing requirement must be received by the state agency within 12 months from the date of service or 6 months from the date on Medicare’s provider notice of payment of the claim, whichever is later.
  • Medicaid claims with third party liability must first be submitted to the insurance company in most instances. However, the claim must still meet the Medicaid timely filing guidelines strong above. Claim disposition by the insurance company after 1 year from the date of service does not serve to extend the filing requirement.

Duplicate Claims

May 23, 2005

By far each month, the largest reason for claims denying is because of duplicate claims. To avoid the additional and unnecessary hassle of working the same accounts over and over on your remittances, please adhere to the suggestions below:

  • Remittance Advices (RA’s ) are issued twice monthly. RA’s are available electronically directly after a claims processing cycle at . You no longer have to wait to receive RA’s in the mail as in the past. This allows you to post accounts quickly. If you want a copy of the Claims Processing Schedule, it is available at the same Web site under "Public Files".
  • When making changes to previously paid claims, you need to submit an adjustment rather than a new claim form. Adjustments can be done electronically under the appropriate claim type by using a 'Claim Frequency Type Code' of "7" to show you are replacing an original claim or "8" to void the original claim.
  • Claims for most dual-eligible recipients (those with both Medicare and Medicaid coverage), cross over electronically from Medicare to Medicaid for payment of the Medicare co-insurance and deductible. Please allow 60 days for the crossover claim from Medicare to appear on the Medicaid RA before resubmitting the claim.

Eligibility - Recipient Lock-In

May 16, 2005

When verifying recipient eligibility, you may sometimes find that a recipient is restricted (or locked-in) to treatment from a certain provider or providers, such as a certain physician, hospital and pharmacy. This is to help the recipient use the Medicaid/MC+ program properly. Payment of services for a locked-in recipient cannot be made to other providers except for emergency services or authorized referral services.

Claims for emergency services must have an attached Certificate of Medical Necessity.

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 recipient is referred. The form can then be submitted by the treating provider(s) via the Internet at or mailed to Infocrossing Healthcare Services, PO Box 5900, Jefferson City, MO 65102.

A provider checking patient eligibility is given the names and phone numbers of the lock-in providers.

Checking Recipient Eligibility

May 09, 2005

Did you know that approximately 225,000 claims deny each month because providers fail to check eligibility? Providers must check patient eligibility before each visit. This can be done by calling the Interactive Voice Response system at 1-800-392-0938, through the Internet at or through a Point of Service Terminal. Reasons to check the patient’s eligibility are:

  1. To determine the patient’s name as it appears on the enrollment file. The claim must be filed with the patient’s current file name.
  2. To check to see if the patient is eligible on the date of service.
  3. To determine the patient’s medical eligibility (ME) code. ME codes 55, 58, 59, and 80 have limited benefits. ME codes 74, 75, 76 and 79 require a co-payment.
  4. To check to see if the patient is Medicare eligible. The claim must be filed to Medicare first.
  5. To see if the patient has commercial insurance in addition to Medicaid. A claim must be filed to the commercial insurance plan first.
  6. To see if the patient is currently enrolled in a Medicaid MC+ managed health care plan. If so, claims must be submitted to the appropriate MC+ managed care plan.
  7. To determine if the patient is locked-in to another provider(s). If so, the patient must receive services from the lock-in provider(s) unless a lock-in referral (PI-118 form) is submitted from the lock-in provider(s).

Checking Claim Status

May 02, 2005

One of the most frequent reasons providers call to speak to someone at Medicaid is to check claim status. Because of the volume of enrolled providers and limited staff, this often results in a busy signal. Why spend precious time redialing when you can check claim status yourself electronically in one of two ways?

  1. You can check claims individually at by scrolling to the "Real Time Queries" box and then click on 'View Claim Status'. Enter identifying claim information for the provider number under which services were billed. The Medicaid response is then returned using claim status category codes and claim status codes.
  2. The other method to check claim status electronically is by batch transaction. This is known as the HIPAA 276/277 Health Care Claim Status Request and Response. At scroll and click on "Send Files". The Medicaid response (or the 277 transaction) is then returned the following day. You can access the response files at the same Web site under "Receive Provider Files" and then click on 'Claim Status (277) Response'.

A description of the claim status category codes and claim status codes is posted on the Washington Publishing Company Web site.

Prior Authorization Status

April 25, 2005

Missouri Medicaid enrolled providers now have the ability to check the status of a Prior Authorization (PA) request online at In the “Real Time Queries” box at this site, click on the ‘View PA Status’. PA status requests are restricted to the Medicaid provider number the PA was submitted under. PAs must be in ‘approved’ status before services can be delivered. Drug PAs are not displayed with this option.

Access to the status of prior authorized psychological services is currently being researched for inclusion in the near future.