2006 Provider Tips

Finding Descriptions of Medical Eligibility (ME) Codes

December 26, 2006

Medicaid, MC+ or state funded Medical Assistance benefits are available to individuals who are determined eligible by the local Family Support Division (FSD) office. Each eligibility group or category of assistance has its own eligibility determination criteria that must be met. Some eligibility groups or categories of assistance are subject to Day Specific Eligibility and some are not.

Providers should know that one of the reasons for checking a patient’s eligibility before each visit or service is to see what the patient’s category of assistance, or Medical Eligibility (ME), code is. Checking eligibility is especially critical since many ME code categories have co-pays and limited benefits. But a common question from providers is "Where do we find a list of the ME codes?".

The ME codes and their descriptions are found in the Medicaid Provider Manual, Section 1.1.A, Description of Eligibility Categories.

Descriptions of the ME codes can be found also in the MC+ Guide.

Hospital Observation Room Billing

December 18, 2006

Section 13.45 of the Medicaid Hospital Provider Manual provides information on billing for hospital observation room charges.

Observation room charges may be shown separately on an outpatient claim and are billed using revenue code 0762 in accordance with the following schedule.

Observation Room Revenue Code Quantity
1-5 hours 0762 1
6-11 hours 0762 2
12-17 hours 0762 3
18-24 hours 0762 4

Only one observation code per date of service may be used.

If the provider has a patient in an observation room more than 24 hours, the charges beyond that time must be absorbed as an expense to the provider. Those charges cannot be billed to Medicaid or to the recipient. Only one observation code is billed per stay. If the stay spans past midnight, only one date of service is billed, which is the date the patient came in to the hospital.

Example - A patient is admitted for observation at 11:00 p.m. and is released from observation and the hospital at 3:00 a.m. the following day. Since the patient was in observation for a total of four hours which included the three hours past midnight, the hospital would bill revenue code 0762 with a quantity of one and the date of service being the date patient was admitted for observation.

There are circumstances in which a facility charge may be shown on a claim in addition to the observation room charge. An example is emergency room services or operating room services provided prior to observation status.

The hospital provider manual is available on the Internet.

Adult Psychology Prior Authorization Closing Date

December 11, 2006
updated December 14, 2006

All psychology prior authorizations (PA) issued for adults during any calendar year will have an authorized through date of December 31st of that same year. For example, any psychology PA issued during 2006 will close effective December 31, 2006 regardless of any remaining unused units left on the PA. Please reference Psychotherapy Provider Bulletin dated December 1, 2005 for more information.

Should a patient currently in treatment need ongoing services, a new PA period will begin on January 1, 2007. Providers may begin requesting a new authorization immediately under the guidelines established in the December 1, 2005 bulletin.

Reminder: Providers who have been paid for services in excess of four (4) hours for a recipient in the last rolling year will not receive four (4) additional non-prior authorized hours for that recipient.

Reminder: A PA will close when a child becomes 21 years of age even if there are units remaining on the PA. Providers will need to seek a PA for units under the adult policy guidelines to continue services.

Rural Health Clinic Billing for Immunization Administration

December 4, 2006

Missouri Medicaid is receiving inquiries from rural health clinics (RHCs) regarding correct billing for immunizations for children through the Vaccines for Children (VFC) program, and for adult immunizations.

For immunizations, including VFC immunizations, there must be an encounter with a core service provider during which the immunization was given. If there is no encounter with a core service provider, then the RHC cannot bill Medicaid for the RHC visit.

Vaccine For Children (VFC) Billing

Independent RHCs may not bill an administration fee for VFC immunizations. The administration fee is included in the all-inclusive encounter rate for the visit.

Provider-based RHCs may bill an appropriate level Evaluation and Management (E & M) code when a VFC immunization is given if there is a medically necessary encounter with a core service provider in addition to the VFC immunization. An immunization administration fee, including a VFC administration fee, can not be billed in addition to the RHC visit.

Adult and non-VFC Immunization Billing

Independent RHCs may not bill an administration fee for immunizations. The administration fee is included in the all-inclusive encounter rate for the visit if there is a medically necessary encounter with a core service provider.

Provider-based RHCs may bill an appropriate level E & M code if a medically necessary E & M service is provided in addition to an immunization. An administration fee may not be billed in addition to the RHC visit as the immunization administration is included in the encounter charge for the visit. Provider-based RHCs cannot bill the CPT immunization codes 90471 or 90472 in addition to the E & M code for the encounter. If there is no encounter with a core service provider, the provider- based RHC may bill only for the vaccine using the appropriate HCPCS J-code or CPT code but may not bill for the encounter.

Hospital Weekend Passes and Leave of Absence Days

November 27, 2006

In accordance with Section 13.30.I of the Missouri Medicaid Hospital Provider Manual, Medicaid does not reimburse for any day the patient is not in the facility.

The "from" and "through" dates on either the paper UB-92 claim or an electronic claim must be for continuous stay days and must represent only days that the patient was in the hospital. The midnight bed count is a guideline for this.

If a patient takes a temporary leave of absence and is gone overnight or on a weekend pass, the provider must submit two claims. The first claim must indicate a patient status of "30," Still a Patient. The through date entered should be the last date that the patient was in the facility at midnight. The second claim must show the same admission date and certification numbers as the first claim, but the "from" date is the date the patient returned to the hospital.

Example - a patient is given a weekend pass, leaves the hospital on Friday afternoon at 5:00 p.m. and returns the following Monday at 7:00 a.m. The hospital would bill two claims. The first would be for services from the admission date to and including the Friday when the patient left the hospital on the weekend pass. Patient status on the claim must be "30", Still a Patient. The second claim would be for services from the Monday the patient returned to the hospital to the date of discharge.

Note - all inpatient hospital claims, unless specifically exempted, are subject to pre-certification requirements.

The hospital provider manual is available on the Internet.

Inpatient Hospital Admission Date

November 20, 2006

The Division of Medical Services often receives inquiries concerning when a patient is to be considered formally admitted to a hospital.

Missouri Medicaid follows federal Medicare policy on this issue. Medicare’s policy regarding inpatient admission followed by a death or discharge prior to room assignment reads in part:

“A patient of a hospital is considered an inpatient upon issuance of written doctor orders to that effect. If a patient either dies or is discharged prior to being assigned and/or occupying a room, a hospital may enter an appropriate room and board charge on the claim.”

Section 13.28 of the Missouri Medicaid Hospital Provider Manual defines an inpatient hospital service as follows:

“An 'inpatient' service, which requires the submission of an inpatient claim, is one in which the hospital expects to provide service to the patient in the hospital for a 24 hour period or longer. The service is still considered inpatient if the intent is to stay 24 hours or longer even though the patient dies, is discharged or is transferred to another institution and does not actually stay in the hospital 24 hours. Services in an observation room, regardless of the length of time, without a formal admission are not considered inpatient services.”

Claim Confirmation Report

November 13, 2006

Providers submitting claims to Missouri Medicaid using Internet applications can learn the status of such claims the day following the submission (Monday-Friday) by going to the Medicaid billing Web site. At this site in the "Receive Provider Files" box, click on 'claim confirmation' to retrieve your report. Claim confirmation reports are generated for each transmission and available for 30 days following each submission.

Claim status codes on the confirmation report can be viewed by using the 'Help' option on the report page, but some of the most common 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 on the WPC HIPAA-Related Code Lists page.

Sending Medicaid Your NPI

November 6, 2006

Providers, have you sent your National Provider Identifier (NPI) to Missouri Medicaid?

All healthcare providers meeting the HIPAA definition of a healthcare provider are required to obtain an NPI to use in all electronic claim transactions to healthcare payors. Even if you submit claims by paper, Missouri Medicaid will also require use of the NPI on paper claims. Providers must add their NPIs to the Missouri Medicaid Provider Master Record by May 23, 2007, when all claims, prior authorizations, attachments, etc. will be required to be submitted using your NPI.

It is easy to submit your NPI to Missouri Medicaid by going to the Medicaid billing Web site. Individuals having "administrator" or "provider" access may enter one NPI to the Missouri Medicaid Provider Master Record by using the option titled "Add/View NPI". If these options are not visible to you, you do not have the proper access to add the NPI to the Missouri Medicaid Provider Master Record. If you need assistance in submitting NPIs for multiple providers, please contact the Infocrossing Help Desk at 573/635-3559.

If you need information on how to obtain an NPI from the Centers for Medicare and Medicaid Services (CMS), please refer to the NPI Transition Plan Bulletin dated May 18, 2006. Additional information regarding NPI, Phase 1 and Phase 2 consolidation with Missouri Medicaid is available in the following bulletins:

Eligibility II

October 30,2006
Revised November 02, 2006

A May 9, 2005 Hot Tip stressed the need for providers to check patient eligibility. Unfortunately, eligibility issues continue to be a major reason for claim denials. Providers must check patient eligibility before each visit. 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: 01, 04, 05,10, 11, 13, 14, 16,19, 21, 24, 26, 55, 58, 59, 80, 81, 82, 83 and 84 have limited benefits and may require a co-payment based on the service provided.
  4. To check to see if the patient is Medicare eligible as a 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. Claims for a patient so enrolled must be submitted to the MC+ managed care plan.
  7. To determine if the patient is locked-in to another provider. If the patient is lock-in, there must be a lock-in referral form, PI-118, on file in order for the claim to be paid.

Eligibility can be checked by utilizing of the following methods:

  1. Using the Medicaid internet Web site
  2. Using the Interactive Voice Response system at 573/635-8908; or
  3. Using a Point of Service machine (card swipe machine).

Medicaid Resources

October 23, 2006
Revised November 02, 2006

Division of Medical Services
615 Howerton Court
Jefferson City, MO 65109
573-751-3425
Provider Resources Phone Number
Provider Communications Unit 573-751-2896
IVR (Interactive Voice Response System)
Check recipient eligibility, claim status and check amount information
573-635-8908
Provider Education Unit 573-751-6683
Third Party Liability Unit 573-751-2005
Pharmacy and Clinical Services 573-751-6963
Assistance with pharmacy claims and pharmacy program edits 1-800-392-8030
Psychology prior authorization help desk 1-866-771-3350
MORx 1-866-256-3937 or 573-522-3070
Inpatient hospital admission certification 1-800-766-0686
Infocrossing Help Desk 573-635-3559
Division of Medical Services (renamed to MO HealthNet Division) Web site:
http://dss.mo.gov/mhd/
Provider manuals, forms and Internet application:
http://dss.mo.gov/mhd/providers/
Infocrossing Healthcare Services, Inc. Internet services:
http://www.emomed.com
Description of the HIPAA-related code sets:
http://www.wpc-edi.com
View decisions on certification requests:
http://www.hce.org
Provider Enrollment Unit E-mail:
providerenrollment@dss.mo.gov
Recipient Resources Phone Number
Recipient Services Unit 1-800-392-2161 or 573-751-6527
Premium Collections Unit 1-877-888-2811

Resource Publications For Providers

October 16, 2006

The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) is the publication used for proper diagnostic coding. The diagnosis code is a requirement on claim forms and attachments. The accuracy of the code describing the patient’s condition is important.

The Health Care Procedure Coding System (HCPCS), National Level II is a listing of procedure codes and descriptive terminology used for reporting the provision of supplies, materials, injections and certain services and procedures.

The Current Procedural Terminology (CPT) is an informational guide regarding coding and reporting of medical services, supplies and procedures. The information includes procedure codes and complete descriptions.

The Current Dental Terminology (CDT) is a basic guide of dental procedure codes and descriptions used for reporting procedures and services to agencies involved in coding dental claims.

All of the above publications can be ordered from the following:

Practice Management Information Corporation
4727 Wilshire Boulevard, Suite 300
Los Angeles, CA 90010
800/633-7467
http://pmiconline.stores.yahoo.net/
Ingenix Publications
PO Box 27116
Salt Lake City, UT 84127-0116
800/464-3649
Fax Orders: 801/982-4033
http://www.ingenixonline.com

Duplicate Claims

October 9, 2006

A May 23, 2005 Hot Tip called providers' attention to duplicate claims being a major reason for claim denials. Unfortunately, this continues to be a major cause for denials. For this reason, the May 23, 2005 Hot Tip is being sent again.

"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 (RAs) are issued twice monthly. RAs are available electronically directly after a claims processing cycle at www.emomed.com. 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."

Billing for Administering Immunizations

October 2, 2006

Medicaid’s Program Integrity Unit has seen instances where some medical providers are improperly billing for administering Vaccine For Children (VFC) immunizations by using a VFC administration code in conjunction with CPT code 90471 or 90772. This is contrary to Medicaid policy and is improper billing as only the VFC administration code can be billed for a VFC vaccine. CPT codes 90471 or 90772 are only used for non-VFC vaccines.

Section 13.24.B of the Medicaid Physician Provider Manual clearly gives the Medicaid policy and reads in part:

“Providers may bill procedure code(s) 90471-90472 for the administration of vaccines/toxiods. These procedure codes do not apply to the immunizations included in the Vaccine for Children VFC Program. Providers should use the appropriate VFC Administration Codes to bill for the administration of VFC immunizations.”

It is recommended that providers review their procedures for immunization billing. If a provider has billed both the VFC administration code and CPT code 90471 or 90772 for a VFC vaccine, the provider must initiate an adjustment request to have the payment for code 90471 or 90472 recouped.

Provider Enrollment Questions

September 25, 2006

The Provider Enrollment Unit (PEU) is responsible for processing provider enrollment applications and maintaining all information in the Provider Enrollment Master File. Communication with the unit must be either by E-mail to provider enrollment@dss.mo.gov or in writing to the following address. PEU does not take phone calls.

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

Changes that must be submitted in writing to PEU would include, but are not limited to: change of ownership, tax ID change, name change, address change, Medicare number. The notice must contain the original signature of the provider. Detailed instructions concerning changes, program requirements, and other pertinent information are addressed in the enrollment guide page.

An individual with provider or administrator access may add their National Provider Identifier (NPI) to their provider number via EMOMED.

An individual with provider or administrator access may also add, change, and delete additional practice location addresses via EMOMED. However, this does not change the provider information on the Provider Enrollment Master File. It only allows additional practice locations to be displayed on the Provider Search used by recipients and other interested parties.

Providers who currently do not have a Medicare number on file, can fax a copy of the letter from Medicare assigning them their Medicare number to 573/526-2054. Only documentation from Medicare is accepted. A listing or letter produced by the provider, clinic, group, or other entity is not acceptable documentation.

The Application for Provider Direct Deposit must be used for first time enrollment of direct deposit, to change the routing and/or account number, cancel direct deposit, or make any other changes. Written notice is not acceptable for provider direct deposit. The form must be printed, completed, signed with the providers original signature, and sent by postal mail to the address listed above.

Medicaid Electronic Mailing Lists and Subscriptions

September 18, 2006

Medicaid has received several inquiries concerning the Medicaid E-mail news program mailing list and how it is maintained.

The Division of Medical Services (DMS) does not maintain separate mailing lists for Medicaids various programs or provider types. Only one mailing list is maintained for all subscribers. Each person subscribed to the Medicaid E-mail news service receives every message sent regardless of the Medicaid program or provider type. The subscriber chooses which E-mail notices to read and keep. Only one mailing list is maintained because a number of subscribers represent multiple provider types.

Medicaid E-mail news subscribers are encouraged to keep their E-mail addresses current. If a subscriber no longer wants to receive the E-mails, go to the following Internet site and complete the "Unsubscription Form".

http://dss.mo.gov/mhd/global/pages/mednewsunsub.htm [The subscribe page below now offers the unsubscribe feature -12/2007]

To change an E-mail address, you first must unsubscribe as noted above and then complete a new subscription form at:

http://dss.mo.gov/mhd/global/pages/mednewssubscribe.htm.

Emergency Services Definition

September 11, 2006

The Division of Medical Services receives inquires regarding the agency’s definition of emergency services. Emergency medical services are defined in various provider manuals as follows.

Emergency medical services are defined as those health care items and services furnished or required to evaluate and treat a sudden and unforeseen situation or occurrence or a sudden onset of a medical or behavioral condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the failure to provide immediate medical attention could reasonably be expected by a prudent lay person, possessing average knowledge of health and medicine, to result in:

  1. death; or
  2. placing the patient’s health in serious jeopardy; or
  3. permanent impairment of bodily functions; or
  4. serious dysfunction of any bodily organ or part; or
  5. serious harm to an individual or others due to an alcohol or drug abuse emergency; or
  6. injury to self or bodily harm to others; or
  7. with respect to a pregnant woman who is having contractions:
    1. that there is inadequate time to effect a safe transfer to another hospital before delivery or,
    2. that transfer may pose a threat to the health or safety of the woman or the unborn.

Medicaid Fee Schedules

September 4, 2006

Did you know the Medicaid Provider Fee Schedule is located online at: http://dss.mo.gov/mhd/providers/pages/cptagree.htm? This brings you to the License For Use Of "Physicians' Current Procedural Terminology", Fourth Edition (CPT™) agreement, which must be accepted before entering the fee schedule information.

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.

Ensure Your Medicare Claims Crossover to Medicaid

August 28, 2006

The main reason claims do not cross over automatically 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 emomed.com 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 automatically to Medicaid.

To verify the Medicare number on file, you can contact the Provider Enrollment Unit via E-mail. Inquiries are processed in date order received. If you have not submitted your Medicare number to Medicaid, you must FAX or mail 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. The mailing address is: Provider Enrollment Unit, Division of Medical Services, PO Box 6500, Jefferson City, MO 65102.

Contacting Provider Communications

August 21, 2006

Missouri Medicaid providers often express frustration getting through to the Provider Communications Unit via the 573/751-2896 phone line. There are currently 14 Correspondence and Information Specialists answering calls and correspondence from more than 21,000 enrolled Missouri Medicaid providers. To expedite the handling of calls, please have the following information ready:

  • Nine digit Missouri Medicaid provider number
  • Recipient’s eight digit DCN (departmental client number)
  • Date(s) of service for the claim in question

Confidential information regarding a Medicaid recipient, including eligibility and claim status, will not be provided without an active Missouri Medicaid provider number.

Provider Communications may also be contacted at the following address:

Provider Communications Unit
Division of Medical Services
PO Box 6500
Jefferson City, MO 65102

When submitting written requests to Provider Communications, please include a contact name and phone number in addition to the Medicaid provider number, recipient’s DCN and the date(s) of service.

On-Line Medicaid Billing Training Session

August 14, 2006

The response to the On-Line Medicaid billing training sessions, has been overwhelming. Here are a few tips for providers wishing to participate in future trainings. Click onto http://dss.mo.gov/mhd/providers/pdf/oworkshops.pdf to access Medicaid Help On-Line Training sessions.

To ensure you are registering for the appropriate training refer to the provider type noted on the right hand side of the schedule. The provider type should correspond to the first two (2) digits of the Medicaid provider number. For instance, a personal care provider number begins with a "26". This type of provider would not want to register for a home health training beginning with a "58". Also, several types of clinics have Medicaid provider numbers beginning with a "50" and the person registering needs to be sure they are requesting the appropriate type of clinic training.

When registering all "required information" must be included: the provider name and Medicaid number, a contact person name and phone number, as well as an E-mail address. Also include the type of training, date and time of training. A response will be returned to you confirming your registration along with instructions for accessing the training presentation.

Providers are asked to mute their speaker phones unless asking a question because any background noise is distracting to other participants.

Providers are also reminded there is to be only one (1) telephone line connection per provider site per training presentation. Multiple provider staff members may observe the training from computers that are connected to that single telephone line. Providers who need additional staff training opportunities may register for other additional training demonstrations.

Clarification On Coverage For Pregnant Women

August 07, 2006

When verifying eligibility for pregnant women 21 years of age and older, it is important to make certain their medical eligibility (ME) code reflects an assistance category for pregnant women. Services provided to pregnant women with ME codes 18, 43, 44, 45 and 61 continue to receive a full comprehensive package. Certain optional Medicaid services eliminated September 1, 2005, are not covered for pregnant women with ME codes other than ME codes 18, 43, 44, 45 and 61. If the recipient feels their coverage is inappropriate, they should contact their eligibility specialist in the Family Support Division office in their county where they live.

A helpful tool in clarifying which recipients who receive a full comprehensive package and recipients who receive a limited benefit package is the MC+ Guide.

Getting "Timed Out" While Using Emomed.com

July 31, 2006

Missouri Medicaid receives occasional complaints from providers that they are "timed out" while entering claims through the Medicaid Internet claims filing service, emomed.com. This occurs because there has been no communication for two hours between the provider’s computer system and the emomed server. Entering claims data without clicking on the submit button does not constitute communication with the emomed server. Communication with the emomed server occurs when the provider actually clicks on the claim submission button and receives the confirmation screen stating that the claim has been received. Other examples of communication with the emomed server are checking recipient eligibility, obtaining a daily claims summary or accessing a remittance advice. In each of these examples there is communication with the emomed server when task is completed by clicking on appropriate button.

If there has been communication as described but you are still timed out, immediately contact the Infocrossing Help Desk at 573/635-3559.

FQHC Change of Ownership

July 24, 2006

Before a Federally Qualified Health Center (FQHC) may submit a change of ownership to Medicaid, the FQHC must contact the Centers for Medicare and Medicaid Services (CMS) and receive written approval for the change. CMS may be contacted at 816/426-6471.

After CMS approves the change of ownership, a new Medicaid FQHC provider enrollment application must be completed on-line which can be accessed from dss.mo.gov/mhd/providers/. A copy of the approval letter from CMS must be attached when faxing the applicable enrollment forms. In addition, the FQHC must also fax a list showing the provider names and provider numbers of all practitioners working at the practice location.

Additional Medicaid enrollment questions can be sent by E-mail to providerenrollment@dss.mo.gov.

Medicaid Fraud and Abuse Sanctions

July 17, 2006

Much emphasis has been placed on Medicaid fraud and abuse. The Division of Medical Services is charged by federal and state law with the responsibility of identifying, investigating, and referring to law enforcement officials cases of suspected fraud or abuse of the Title XIX Medicaid Program by either providers or recipients.

Sanctions may be imposed by the Medicaid agency against a provider for any violation of 13 CSR 70-3.030. While the regulation provides specific details for sanctioning, this hot tip will mention some of the main reasons for provider sanctioning:

  • Submitting, or causing to be submitted, false information for the purpose of obtaining greater compensation than that to which the provider is entitled under applicable Medicaid program policies or rules;
  • Being suspended or terminated from participation in another governmental medical program such as Workers Compensation or Medicare;
  • Billing the Medicaid program more than once for the same service when the billings were not caused by the single state agency or its agents;
  • Failing to reverse or credit back to the medical assistance program (Medicaid) within thirty (30) days any pharmacy claims submitted to the agency that represent products or services not received by the recipient; and
  • Failure to submit and document, as defined in subsection (2) (A) the length of time (begin and end clock time) actually spent providing a service, except for services as specified under 13 CSR 70-91.010(4) (A) Personal Care Program, regardless to whom the reimbursement is paid and regardless of whom in his/her employ or service produced or submitted the Medicaid claim or both.

Providers should reference their respective provider manual for proper billing guidelines and program benefits and limitations to avoid a Medicaid sanction. Providers can also be notified by E-mail when bulletins and other information are posted to the Medicaid Web site by subscribing to Medicaid news.

Recipient Citizenship Verification

July 10, 2006

Effective July 1, 2006, new applicants for Medicaid benefits must provide documentation establishing identity and citizenship. This change also applies to reinvestigations completed beginning the month of July, 2006.

For complete information, please refer to the Family Support Division Income Maintenance Memorandum dated June 23, 2006.

Provider Practice Addresses

July 3, 2006

Providers now have control over which of their practice addresses are seen by recipients and other providers.

With consolidation of provider numbers, you now have the opportunity to maintain the listing of your practice addresses. For example, you have only one Medicaid provider number, but you may practice at several different locations that you want others to be aware of. Or you may need to update or delete practice location information. Therefore, a feature has been added to the Medicaid billing Web site at www.emomed.com that allows you to do this. You must be the enrolled provider or the provider administrator to access the option to maintain addresses.

At emomed.com, click on 'Add/Update Provider Practice Locations' to make all changes. Then click on the 'Help' button at the bottom of the page to guide you step-by-step through the process of adding, updating or deleting provider practice locations. You can also update your provider specialty or add multiple specialties.

Changing your address at emomed.com does not change your enrollment address on the Medicaid Provider Master Record. Changes to the Master Record must still be done by contacting the Provider Enrollment Unit via E-mail at providerenrollment@dss.mo.gov.

Information on this topic as well as the NPI Transition Plan is located in the  NPI Transition Plan Bulletin dated May 18, 2006.

Contacting Medicaid

June 26, 2006

Have you misplaced Medicaid contact information? Following is the most frequently requested contact information:

  • Provider Communications Unit 573-751-2896;
  • Provider Education Unit 573-751-6683;
  • Pharmacy Exceptions Helpdesk (Providers only) 1-800-392-8030;
  • MORx 1-866-256-3937 or 573-522-3070;
  • Third Party Liability Unit 573-751-2005;
  • Pharmacy and Clinical Services 573-751-6963;
  • Recipient Services Unit (for recipients) 1-800-392-2161 or 573-751-6527;
  • Premium Collections Unit (for recipients) 1-877-888-2811;
  • Non-Emergency Medical Transportation (for recipients) 1-866-269-5927;
  • Provider Enrollment — Send E-mail to providerenrollment@dss.mo.gov;
  • Division of Medical Services Web site — dss.mo.gov/mhd/;
  • Medicaid Billing Web site — www.emomed.com;
  • Infocrossing Health Care Services Help Desk (for technical assistance) 573-635-3559 or send E-mail to internethelpdesk@momed.com

The mailing address for Medicaid:

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

RHC Core Service Providers

June 19, 2006

In a recent report, Medicaid’s Program Integrity Unit determined that some rural health clinics (RHCs) are billing for the services of podiatrists and licensed professional counselors under the RHC’s Medicaid provider number. This is contrary to Medicaid policy and is improper billing.

Section 13.1 of the Rural Health Clinic Addendum (Independent and Provider Based) to the Missouri Medicaid Physician Provider Manual states that the following are considered core service providers: physicians, nurse practitioners, nurse midwives, physician assistants, licensed clinical social workers, and clinical psychologists. An RHC can contract with a non-core service provider to provide services at the clinic. However, the services of the non-core service provider must be billed under the provider’s individual Medicaid provider number.

If a RHC has been billing for the services of a non-core service provider under its Medicaid provider number, the clinic should file an adjustment to have Medicaid void the payments for these claims or request that the Division of Medical Services recoup them. Once the payments have been voided or recouped, the non-core service provider can bill for his/her services under their individual Medicaid provider number.

Third Party Liability - Liens

June 12, 2006

Missouri Medicaid is payor of last resort. In other words, if there is another source that can pay for services, that source must be utilized by providers prior to billing Medicaid. Some common sources of other payors include auto accident insurance policies, worker’s compensation or property liability.

It is not uncommon for providers to file a casualty/tort lien with the appropriate circuit court against the liable third party for reimbursement of services. Providers cannot file a lien after they have billed Medicaid. If a lien was filed prior to billing Medicaid and the provider subsequently receives payment from Medicaid, the provider must file a notice of lien withdrawal for the covered charges.

If a lien was not filed, but the provider receives payment from a third party resource after receiving Medicaid reimbursement for the covered service, the provider must promptly submit an adjustment to Medicaid for the partial or full recovery of the Medicaid payment.

If providers receive requests from recipients for a copy of the provider’s bill for a claim filed or to be filed with Medicaid, the provider should obtain information such as name and address of liable party and name and address of attorney, if there is one and provide that information to the Medicaid Third Party Liability Unit at 573/751-2005. The provider must also stamp or write across the bill, “Paid by Missouri Medicaid” or “Filed with Missouri Medicaid”.

Additional information on third party liability can be found in Section 5 of your provider manual.

Adult Dental Services

June 5, 2006

Missouri Medicaid will only consider dental services for adults (except individuals under a category of assistance for pregnant women the blind or vendor nursing facility residents) if the dental care is related to trauma or a medical condition. Dental services for adults is covered when the absence of dental treatment would adversely affect the recipient’s pre-existing medical condition or as related to trauma of the mouth, jaw, teeth or other contiguous site.

Dental Provider Bulletin Volume 28, Number 14 , dated September 28, 2005, contains dental codes which may be covered in relation to trauma or a medical condition. Attachment A of the dental bulletin contains dental procedure codes related to trauma or treatment of a medical condition for treating adults. Attachment B is the dental codes that are considered support codes and are only billable for the adult population when provided in addition to services from attachment A.

The patient record must include documentation to substantiate that the services billed are related to trauma or other medical condition. The documentation must be provided to the state upon request.

Billing Hospital Outpatient Facility Charges

May 29, 2006

In a recent report, Medicaid’s Program Integrity Unit discovered that some hospitals are billing two outpatient facility charges for the same patient for the same date of service for the same facility. An example from the report is a hospital that billed for an outpatient facility code, revenue code 510, and an outpatient surgical facility code, revenue code 490, for the same patient for the same date of service. This is contrary to Medicaid policy and is improper billing.

Section 15.23 of the Medicaid Hospital Provider Manual states:

"Only one facility code may be shown per date of service. If several physicians or clinics are seen, the charges must be combined into one facility code.

A charge for an observation service is not considered a facility charge. Therefore, as an example, a provider can show a surgery facility code and an observation code for the same date of service."

Medicaid News E-mail

May 22, 2006

This hot tip is regarding the Medicaid news E-mail you just received. Many providers try to reply to the E-mail or ask questions. Please note that Medicaid news is a notice to you and reply E-mails you generate will not receive a response. If you have a question, you can call 573/751-2896 or correspond in writing to:

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

To UNSUBSCRIBE and no longer receive Medicaid news, you must complete the Unsubscribe Form. [updated 01/08 - use the subscription link below to also unsubscribe]

If you have a new E-mail address, you must first complete the Unsubscribe Form to unsubscribe your old E-mail address and then complete a new Subscription Form for your new E-mail address.

Incarcerated Individuals

May 15, 2006

There is no Medicaid/MC+ coverage for an individual that is an inmate residing in a public institution. An individual is an inmate when serving time for a criminal offense or confined involuntarily to a state or federal prison, jail, detention facility or other penal facility. An individual voluntarily residing in a public institution is not an inmate. A facility is a public institution when it is under the responsibility of a government unit, or a government unit exercises administrative control over the facility.

However, if an inmate is admitted as an inpatient in a hospital, nursing facility, juvenile psychiatric facility or intermediate care facility, the Family Support Division office in the county in which the penal institution is located, may take the appropriate type of application for Medicaid/MC+ benefits. If approved, Medicaid/MC+ eligibility is limited to the days in which the individual was an inpatient in the medical institution.

Complete information regarding Medicaid/MC+ coverage for inmates of a public institution is found in Section 1.5.P, Section 1.5.P(1) and 1.5.P(2) of your Medicaid provider manual.

Top Two Reasons Claims Deny

May 8, 2006

Missouri Medicaid processes over six million claims each month and the top two reasons claims deny continues to be for recipient ineligibility and duplicate claims. Providers are going through unnecessary hassle of working the patient accounts over and over because they are not checking recipient eligibility and they are filing duplicate claims.

Recipient Eligibility: Providers must check patient eligibility before each visit. This can be done by calling the Interactive Voice Response system at 573/635-8908, through the Internet at www.emomed.com or through a Point of Service terminal.

Duplicate Claims: Remittance Advices (RA’s ) are issued twice monthly. RA’s are available electronically directly after a claims processing cycle at www.emomed.com. This allows you to post accounts quickly. Also, 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.

Non-Emergent Transportation Trips

May 1, 2006

When individuals are transported by ambulance to an emergency room for treatment and then released without admission to the hospital, the return trip is not covered under the Medicaid ambulance program. The same holds true for a nursing home resident who is discharged from a hospital stay; the return trip to the nursing home is not covered under the ambulance program. However, these transports are covered under the non-emergency medical transportation (NEMT) program for eligible recipients.

Hospital staff, nursing home staff, social workers, case managers, family members and other related parties may call LogistiCare Solutions, L.L.C., the NEMT broker for Missouri Medicaid toll-free at (866)269-5927 to arrange NEMT to and from medical providers for eligible recipients. For hospital discharges, the 3 day prior notice is not required. LogistiCare will arrange transport within 3 hours of the hospital discharge request.

Partial HCY Screen

April 24, 2006

Providers often inquire about the required components for a partial Healthy Children and Youth (HCY) unclothed physical and history screen (CPT codes 99381EP-99385EP and 99391EP-99395EP).

An HCY unclothed physical and history includes the first five sections of the age appropriate screening guide including:

  • Interval history;
  • Unclothed physical exam;
  • Anticipatory guidance;
  • Laboratory/Immunizations; and
  • Age appropriate lead screening. Federal regulations require a mandatory blood lead testing by either capillary or venous method at 12 months and 24 months regardless of risk.

Medicaid policy on unclothed physical and history screens is found in Section 9.7.B of the Medicaid Provider Manual.

Adjusting/Replacing a Claim Electronically

April 17, 2006

Often providers will make an inadvertent mistake when entering claim information for payment such as a wrong recipient Medicaid number, wrong date of service, wrong dollar amount billed, etc.

It is easy to adjust/replace a claim electronically after Medicaid has processed the claim. This is done through the Medicaid billing Web site at www.emomed.com by following these steps:

  • Anything on the claim can be changed except for the provider number. If a claim was billed under the wrong provider number, providers must void the claim (claim frequency type 8) and then resubmit under the correct number.
  • Select the claim type you want to adjust/replace (medical, inpatient, outpatient, dental, nursing home)
  • In the 'Claim Frequency Type Code' field, select '7' to replace the claim.
  • In the 'Medicaid Resubmission' field, enter the ICN (claim number) of the claim that you want to adjust/replace.
  • Key all the information on the claim (i.e., patient name, diagnosis, units, etc.) and change only the information you want to correct.

The process above may be completed on any type of claim on the Internet with the exception of pharmacy claims. Pharmacy adjustments must be done through point-of-sale.

Psych Services for State Custody Kids

April 10, 2006

Currently, most psychological services for children in state custody do not require Prior Authorization (PA). When verifying Medicaid eligibility, the Medical Eligibility (ME) code must reflect a child is in state custody. The state custody ME codes are: 07, 08, 29, 30, 35, 36, 37, 50, 51, 52, 53, 54, 56, 57, 63, 64, 66, 68, 69 and 70. If the ME code is anything other than one of those above, a PA must be obtained.

Psychological services for children under the age of three (3), interactive therapies, and family therapy without the patient present require a PA, even when the child is in state custody.

At this time the Psychology/Counseling provider manual is under construction and not available on-line, however a complete listing of the ME codes may be found in Section 1 of any provider manual. The Psychology/Counseling manual is tentatively planned to be back on-line in April, 2006.

Groups/Clinics — Performing Provider

April 3, 2006

Since the consolidation of Medicaid provider numbers on January 23, 2006, providers billing under a group/clinic provider number seem to be confused on the use of performing provider numbers and have received claim denials under Remittance Remark Code N55 (Procedures for billing with group/referring/performing providers were not followed). Some providers even think it is no longer necessary to show the performing provider number. This is not correct.

The requirements have not changed for groups/clinics to show the performing provider number. The individual provider number of the provider rendering the service must be shown in the performing provider number field; on the paper HCFA-1500 form, this is field 24k and electronically, it is the performing provider field.

Checking Recipient Eligibility Is Easy

March 27, 2006

Providers must check recipient eligibility prior to rendering services. This is quick and simple to do at no charge other than your service connections. There are two options available to choose from:

  1. By dialing 573/635-8908 — This number is answered by an interactive voice response system (IVR) which allows an active Missouri Medicaid provider several options, including the ability to check recipient eligibility. Providers have the ability to key directly to the selection option when answered. Providers must enter their Medicaid provider number and recipient information. A confirmation number is reported to you of the information given and should be kept in your records.
  2. Through the Internet at www.emomed.com — This is known as the Missouri Medicaid billing Web site and includes the option to check recipient eligibility in real time. The information displayed can be printed for your records.

Some providers have chosen to use a point of service (POS) terminal to check eligibility by swiping the recipient Medicaid card. Eligibility information is then returned to the provider usually in a register-tape fashion. The state contracts with various companies to do this. This option is not free. If you are interested in this option, refer to Section 3.3.C of your provider manual.

Adult Eye Exams

March 20, 2006

Prior to September 1, 2005 adult Medicaid recipients were allowed one (1) eye exam during a twelve-month period. For instance, if an eye exam was rendered on August 5, 2004 the recipient was not eligible for another eye exam until August 5, 2005.

Effective September 1, 2005 due to the passage of Senate Bill 539, optical benefits changed for adults in the following medical categories of assistance: 01, 04, 05, 10, 11, 13, 14, 16, 19, 21, 24, 26, 83 and 84. Eye exams for these adults are now limited to one exam every two (2) years.

Providers are confused how the 2 years are calculated. The calculation of the 2 years depends on when the recipient received their eye exam in 2005. The following examples are provided to help clarify. In example 1, the adult patient received their eye exam prior to September 1, 2005. In example 3, the eye exam was received after September 1, 2005.

  • Example 1: Adult patient had an eye exam on August 5, 2005. Another eye exam is not covered until August 5, 2006 and then not again until August 5, 2008.
  • Example 2: Adult patient had an eye exam on August 5, 2005 and another one on October 5, 2005. The October 5th eye exam is not covered. Another eye exam is not covered until August 5, 2006.
  • Example 3: Adult patient had an eye exam on September 5, 2005. Another eye exam is not covered until September 5, 2007.

Providers can reference the Optical Bulletin, Volume 28, Number 29 dated November 29, 2005 for more information.

Note: Medicaid/MC+ children and those recipients who reside in a nursing home or who are in an assistance category of pregnant women or blind can continue to receive eye exams every twelve months.

Bilateral Procedures

March 13, 2006

Bilateral procedures are described as exact procedures identified by the same CPT codes which are performed on anatomically bilateral sides of the body during the same session; for example the right and left arm.

The Centers for Medicare and Medicaid Services (CMS) publishes the CPT codes that are eligible for reimbursement through Medicare as bilateral procedures. These procedures are referenced in Attachment A of the Indicators/Global Surgery Percentages/Endoscopies table located at Missouri Medicare Services. Although Missouri Medicaid references this publication to determine bilateral procedures, not all bilateral procedures listed in the CMS publication are covered by Missouri Medicaid. Providers should refer to the Missouri Medicaid fee schedule.

The important things to remember when billing bilateral procedures to Medicaid are to add a modifier of '50' to the procedure code and indicate a unit of '1' in the unit’s field.

Medicaid Records

March 06, 2006

Adequate medical records are records which are of the type and in a form from which symptoms, conditions, diagnosis, treatments, prognosis and the identity of the patient to which these things relate, can be readily discerned and verified with reasonable certainty. The medical record must be legible and kept at the same site at which the services were rendered or at the provider’s address of record with the Medicaid agency.

Providers must also retain in legible form worksheets, financial records, appointment books, appointment calendars (for those providers who schedule patient/client appointments), adequate documentation of the service, and other documents and records verifying data transmitted to a billing intermediary, whether the intermediary is owned by the provider or not.

Upon request by the Medicaid agency, or its authorized agent, providers must make available all records relating to services provided to Medicaid recipients or records relating to Medicaid payments.

All Medicaid records must be kept a minimum of five (5) years from the date of service (seven (7) years from the date of service for long-term care providers). The retention period continues to apply in the event of a change of ownership or discontinuing enrollment in Medicaid.

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 and can result in sanctions to the provider’s application with the Medicaid program.

Complete information on Medicaid records can be found in 13 CSR 70-3.030 or the Medicaid bulletin, Volume 28, Number 35 dated January 25, 2006.

Adequate Documentation

February 27, 2006

If you were to be audited, would your medical records of Missouri Medicaid recipients contain adequate documentation to support the codes and level of services billed?

Enrolled providers should note that the Code of State Regulations 13 CSR 70-3.030, Section (2) (A) has been updated effective November 30, 2005 to define 'adequate documentation' more specifically.

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, diagnosis, 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. An adequate and complete patient record is a record which is legible, which is made contemporaneously with the delivery of the service, which addresses the patient/client specifics, which include, at a minimum, individualized statements that support the assessment or treatment encounter that includes specific information as stated in the regulation.

In addition to the State Regulation, providers can also reference Medicaid bulletin, Volume 28, Number 35 dated January 25, 2006 titled 'Conditions of Provider Participation Reimbursement and Procedure of General Applicability' for more information.

Recipient Liability

February 20, 2006

Enrolled Medicaid providers often ask about certain situations that would make the Medicaid recipient responsible for payment of medical services.

The guidelines for non-covered services are reflected in the Missouri Code of State Regulations 13 CSR 70-4.030 — Recipient Liability for Medical Services Not Reimbursable to the Provider by the Medicaid Agency.

In simple terms, this regulation states that an enrolled provider must accept Medicaid reimbursement based on the recipient’s Medicaid benefits unless the Medicaid recipient agrees in writing, prior to receiving the service that Medicaid will not be billed and the recipient accepts financial responsibility for the service. The statement must include the date of service, the service for which the recipient has accepted financial responsibility, the recipient’s signature and the date signed. This should be maintained by the provider in the patient record.

A recipient signed statement is not needed for systematically denied amounts reported on the provider remittance advice, such as ineligibility, limited benefits, copayment or spend down amounts.

If Medicaid denies payment for a service because all the policies, rules and regulations of the Medicaid program were not followed by the enrolled provider, (such as Prior Authorization or Sterilization Consent Form), the recipient is not responsible and cannot be billed for the item or service.

Provider Enrollment Application Changes

February 13, 2006

Beginning Tuesday, February 14, 2006, the Medicaid online provider enrollment application form changes to allow a couple of new features:

  1. New fields have been added to the application to allow providers to enter their National Provider Identifier number (NPI) and taxonomy numbers.
  2. After providers complete the application on-line, all pages of the application except the signature page will automatically be submitted to Medicaid when the 'Print and Continue' button is selected. The entire application no longer needs to be downloaded, printed, and faxed to Medicaid. The only page of the application that must be faxed is the signed signature page, along with the required attachments for each particular program. The provider is required to maintain the original signed signature page in their records.

The fax database number 573/634-3105 remains the same.

Medicaid - Important Phone Numbers & Addresses

February 6, 2006

Missouri Medicaid (Division of Medical Services)

Web site:  http://dss.mo.gov/mhd/
Mailing Address:
P. O. Box 6500
Jefferson City, MO 65102

Recipient

  • General Questions:  800-392-2161 or 573-751-6527
  • Premium Collections:  877-888-2811
  • Non-Emergency Medical Transportation:  866-269-5927

Fraud

  • Recipient: 573-751-3285
  • Provider: 800-286-3932 or 573-751-7192

Provider - Medicaid Billing Assistance

  • Provider Manuals, Forms and Internet Application, http://manuals.momed.com/;
  • Provider Enrollment Questions, send e-mail to: providerenrollment@dss.mo.gov;
  • Technical Assistance on electronic billing, call 573-635-3559 or send e-mail to: internethelpdesk@momed.com;
  • Assistance with pharmacy claims and pharmacy program edits, call 800-392-8030;
  • To check recipient eligibility, claim status or check amount information, call the Interactive Voice Response System at 573-635-8908 or through the Internet at www.emomed.com;
  • To speak to a provider communication phone specialist, call 573-751-2896;
  • For third party insurance questions, call 573-751-2005;
  • For provider training, call 573-751-6683;
  • To access a description of the HIPAA-related code sets, log onto www.wpc-edi.com;
  • For inpatient hospital admission certification, call 800-766-0686. To view decisions on certification requests, long onto www.hce.org.

Recipient Copayments

January 30, 2006

Eligible recipients are required to pay a small portion of the cost of certain Missouri Medicaid services. This is referred to as cost sharing or copayment.

The recipient is responsible for paying the required copayment amount due. Whether or not the recipient has the ability to pay the required copayment amount at the time service is furnished, the amount is a legal debt and is due and payable to the provider of service.

Providers are responsible for charging and collecting (or attempting to collect) the copayment amount. Providers may not deny or reduce services to eligible recipients solely on the basis of the recipient’s inability to pay the copayment when charged. A recipient’s inability to pay a required copayment, as due and charged when a service is delivered, in no way extinguishes the recipient’s liability to pay the amount due. As a basis for determining whether an individual is able to pay the charge, the provider is permitted to accept, in the absence of evidence to the contrary, the recipient’s statement of inability to pay at the time the charge is imposed. If the patient has been informed that a copayment is due, it remains a practice decision whether a bill for the copayment amount is mailed to the recipient.

To be in compliance with state regulation, 13 CSR 70-4.050, providers of service must keep a record for five years of cost sharing and copayment amounts collected and the cost sharing and copayment amount due but uncollected because the recipient did not make payment when the service was rendered.

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

For more information on copayment requirements, please reference the Missouri Medicaid Program Changes Bulletin dated July 12, 2005.

Consolidation of Multiple Provider Numbers

January 23, 2006

Medicaid provider numbers have been consolidated if you are a provider that had more than one Medicaid number that begins with '20', '24', '42' or '91'. The consolidation process is in preparation for the National Provider Identifier (NPI) mandated by the Health Insurance Portability & Accountability Act of 1996 (HIPAA). Providers affected were notified by letter.

This is a reminder that effective for dates of service January 23, 2006 and after, all claims for the provider types listed above for services that are performed in a group/clinic, must be submitted with the group/clinic provider number in the billing provider number field and the '20', '24', '42' or '91' remaining active provider number in the performing provider number field. Groups/clinics must contact the performing provider to obtain their remaining active provider number. Group/clinic claims billed with individual provider numbers as the billing provider after January 23, 2006 may deny or pay to the wrong provider.

For more information on the consolidation process that was followed, refer to the National Provider Identifier Transition Project Bulletin dated November 30, 2005 or the Hot Tip dated December 5, 2005.

ME Code '82' - Implementation of Missouri Rx Plan

January 16, 2006

In order to implement the new Missouri Rx Plan (MORx), a new Medical Eligibility (ME) code, 82, was created and became effective January 1, 2006. Recipients with this ME code only have pharmacy Medicare Part D wrap-around benefits through the MORx. Recipients with the ME code 82 are NOT eligible for Medicaid benefits.

Please visit the MORx Plan page for more information.

Reporting Suspected Medicaid Fraud

January 9, 2006

Medicaid Recipient Fraud

To report suspected Medicaid Recipient (Client) Fraud contact:

E-mail: Ask.MHD@dss.mo.gov

Or

Department of Social Services
Division of Legal Services, Investigations Unit
PO Box 1527
Jefferson City, MO 65109

Telephone Number: 573-751-3285
Fax Number: 573-751-0196

Medicaid Provider Fraud

To report suspected Medicaid Provider Fraud contact:

E-mail: Ask.MHD@dss.mo.gov

Or

Missouri Attorney General’s Office
Medicaid Fraud Control Unit
PO Box 899 Jefferson City, MO 65102

Telephone Number: 573-751-7192 or 1-800-286-3932
Fax Number: 573-751-0207

Please be ready to provide as much information as possible, including:

  • The name of the Medicaid client
  • The name of the health care provider
  • The date of service
  • A description of the acts that you suspect involve fraud

The Department of Social Services, Division of Medical Services (DMS) is committed to eliminating all forms of healthcare fraud and abuse. The primary responsibility of the Program Integrity (PI) Unit, within the DMS, is monitoring utilization and program compliance by providers and recipients.

You may contact the PI Unit at: PO Box 6500, Jefferson City, MO 65102; via telephone at 573-751-3399; or by fax at 573-526-4375.

Changes To The Medicaid Web Site

January 3, 2006

The Division of Medical Services (DMS) has reorganized the web site at dss.mo.gov/mhd/ which now employs a user-friendly design to get providers, recipients and others to the information they need with the least amount of clicks. Information has been separated into categories such as provider, recipient, pharmacy, etc. for easy navigation. If you have not had the chance to view the reorganized site, please click the link above.

The web addresses (URL) for the online Medicaid provider manuals, forms, and internet application, have changed . Their new home page is http://manuals.momed.com/. The old URL, http://www.medicaid.state.mo.us/ is no longer valid as of December 31, 2005. Providers can also find the online manuals through the DMS pages under provider information.

All bookmarks should be changed to the URLs of the new pages.