2007 Archives Hot Tip of the Week
2007 Provider Tips
- Concurrent Dates of Hospital Services
- Participants With Other Insurance Coverage
- Hospital Billing — Non Covered Days
- Medicare/MO HealthNet Crossover Claims
- Adjusting Claims Electronically
- Hospital Observation Room Billing
- Reporting Suspected MO HealthNet Benefits Fraud
- Give Us Your Suggestions
- UB-04 Inpatient Claim Form
- Mailing Address — Provider Communications
- On-line Fee Schedules
- Filing Claims That Medicare Has Denied
- Phone Calls To Provider Communications
- Participant Eligibility Card
- MO HealthNet Participant With Other Insurance
- The NPI is Here. The NPI is Now. Are You Using It?
- Fee Schedule
- Duplicate DME Prior Authorization Requests
- Claim Processing Schedule
- Proper Paper Alignment—UB-04 and CMS-1500
- Medicaid Coverage for Former Foster Care Youth
- Services of Physician Assistants, corrected
- Trading Partner Agreement
- NEMT — Where’s My Ride?
- IFOX Internet Help Desk
- Provider Enrollment E-mail Requests
- Faxing of DME Prior Authorization Requests
- Medicaid Mailing Addresses
- Frequently Asked Questions
- Nursing Home Room & Board/Crossover Claims
- Codes Reported on Remittance Advice
- Billing for Multiple Surgical Procedures
- National Correct Coding Initiative
- Services of Physician Assistants
- Eligibility Verification for Hospice Lock-in
- Adjusting Claims Electronically
- Provider Fee Schedule
- RHC and FQHC Injection Administrations
- Adult Physicals
- Tips on NPI
- Services Exempt from Hospital Admission Certification
- Timely Filing Updates to Regulation
- PA — Request For Change Durable Medical Equipment
- Provider Addresses
- Electronic Medical Necessity Form
- Daily Claims Summary
- HIPAA-Related Code Lists
- What Is Your NPI Number
- Checking Medicaid Eligibility
- Dually Eligible Hospice Patients
- Medicare HMOs and Medicaid
Concurrent Dates of Hospital Services
December 31, 2007
Section 13.22 of the Hospital Provider Manual discusses billing for outpatient/emergency room/observation services that occur on the same day that a patient is admitted for inpatient services but prior to the actual admission.
The section reads in part:
Any outpatient service performed after a recipient has been admitted as an inpatient must be shown as ancillary charges on the inpatient claim. It is an improper billing procedure for a provider to submit an inpatient claim and the same or a different provider to submit an outpatient claim for concurrent dates of service for the same recipient. Outpatient services provided on the day of admission, but prior to admission, or on the day of discharge, but following discharge, are not considered concurrent care for the purpose of this policy. Such outpatient services provided on the day of admission or the day of discharge are reimbursable as outpatient services.
Outpatient/emergency department/observation room services provided prior to and on the same date as an admission should be billed as an outpatient claim while the inpatient services are to be billed on a separate inpatient claim. Do not bill both types of services on the same claim.
The hospital provider manual is available from the Provider Home page.
Participants With Other Insurance Coverage
December 24, 2007
When you verify eligibility for a MO HealthNet participant, you may be surprised to learn the participant has commercial insurance in addition to MO HealthNet benefits. Individuals who have commercial health insurance may still be eligible for MO HealthNet benefits. Commercial insurance will always be the first source of payment as MO HealthNet is the payor of last resort.
The participant’s commercial health insurance carrier is billed first for consideration of coverage and payment. If services are not covered by the commercial insurance policy, MO HealthNet pays for the covered services with proof of a valid denial from the commercial insurance carrier.
There is no duplication of payment and if the other insurance pays as much as or more than MO HealthNet’s maximum allowed amount, the claim is considered paid in full. No additional payment will be made by MO HealthNet and the participant can't be billed for the balance.
Private insurance information is initially obtained by eligibility specialists at the Family Support Division when an individual makes application for public assistance. Once eligible, the participant is responsible for reporting to their eligibility specialist any changes to coverage by their commercial insurance carrier.
When checking the participant’s eligibility, you are given information about known possible insurance coverage. The insurance information on file at the MO HealthNet Division (MHD) does not guarantee the insurance(s) listed is (are) the only resource(s) available nor does it guarantee the coverage is currently in effect. If the participant has not informed the eligibility specialist of changes, the information on file may need to be updated.
As a provider, you have the ability to inform MHD of changes to a participant’s commercial insurance information by completing and submitting the MO HealthNet Insurance Resource Report form, commonly known as the TPL-4 form. This form should be mailed to: MO HealthNet Division, ATTN: TPL Unit, PO Box 6500, Jefferson City, MO, 65102-6500. Third Party Liability staff will verify the information before updating the TPL data on the participant’s eligibility file.
For detailed information on third party resources, refer to Section 5 of the MO HealthNet Provider Manual.
Hospital Billing — Non Covered Days
December 17, 2007
Health Care Excel (HCE) is designated by the State of Missouri, Department of Social Services as the medical review authority responsible for determining if the inpatient hospital services provided or proposed are medically necessary and delivered in the most appropriate setting.
If HCE approves an inpatient stay but denies a preoperative day, the provider may still bill the preoperative day but that day is not paid by MO HealthNet. In this situation, the provider would show the preoperative day in the admit field (field 12) of the UB-04 claim form or the corresponding field if billing electronically. Only the actual HCE approved dates should be shown in the "from" and "through" date fields (field 6). The "from" and "through" dates must match the HCE file.
The provider plans to admit the patient on Thursday for preoperative testing and surgery on Friday. HCE approves the surgery but says admission should be Friday. If the provider admits the patient on Thursday, enter that date in Field 12 (Admission field) and enter Friday’s date in Field 6 as the "from" day.
If the patient remains inpatient after the HCE discharge (cease payment) date, only the approved HCE days should be billed. If additional days are needed, providers should contact HCE prior to the last approved day in order to request a continued stay review beyond what was previously certified.
Additional information regarding inpatient hospital certification reviews can be found in Section 13.31 of the MO HealthNet provider hospital manual which can be accessed using the left navigation bar of the Provider home page.
Medicare/MO HealthNet Crossover Claims
December 10, 2007
As a reminder, paper Medicare/MO HealthNet crossover claims are no longer processed.
Since July 1, 2005, crossover claims that do not cross automatically from Medicare to MO HealthNet must be submitted electronically through the MO HealthNet billing Web site at www.emomed.com or through the 837 electronic claim transaction.
This information can be referenced in the bulletin dated July 1, 2005 and filing tips included in the Hot Tip dated July 25, 2005.
Adjusting Claims Electronically
December 3, 2007
Thank you for the many suggestions that were made in response to the hot tip dated November 13, 2007 asking for your ideas for hot tips. The hot tip today addresses the inquiry of how to file refunds to MO HealthNet through the Web site.
With the automated retrieval process in place at www.emomed.com, you can bring up the claim you want to adjust through the 'View Claim Status' option or the 'Claim Confirmation' option. The claim is automatically populated with the information you originally submitted. To void a claim, you merely change your claim frequency type code to '8'' (void) and click on 'Continue' or 'Resubmit'. To replace a claim that has been paid, you retrieve your claim through the same process stated above, however, you change your claim frequency type code to '7' (replacement) and correct or change the information in error and then resubmit.
For more information on retrieving and resubmitting claims through the MO HealthNet billing Web site, please reference the Provider Bulletin dated March 20, 2007.
Hospital Observation Room Billing
November 26, 2007
The hot tip dated November 13, 2007 generated many ideas for hot tips, one of them asking for rules for billing 24-hour observation care. This observation care hot tip is a duplicate to the one dated December 18, 2006.
Section 13.45 of the MO HealthNet 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|
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 MO HealthNet 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.
Reporting Suspected MO HealthNet Benefits Fraud
November 19, 2007
It is important to remind providers how to report suspected MO HealthNet participant or provider fraud. Please refer to the contact information below:
MO HealthNet Provider Fraud
Via E-mail at Ask.MHD@dss.mo.gov
Missouri Attorney General’s Office
Medicaid Fraud Control Unit
P. O. Box 899
Jefferson City, MO 65102
Telephone Number: 573-751-7192 or 1-800-286-3932
Fax Number: 573-751-0207
MO HealthNet Participant (Client) Fraud
Via E-mail at Ask.MHD@dss.mo.gov
Department of Social Services
Division of Legal Services, Investigations Unit
P. O. Box 1527
Jefferson City, MO 65109
Telephone Number: 573-751-3285
Fax Number: 573-751-0196
In either case of provider or participant fraud, please provide as much information as possible including the name of the MO HealthNet participant or health care provider, the date of service and a description of the acts that you suspect involve fraud. You may also contact Mo HealthNet’s Program Integrity Unit at PO Box 6500, Jefferson City, MO 65102-6500; via telephone at 573-751-3399.
Compliance Integrity Plans (Self-Disclosure)
The Mo HealthNet Division encourages providers and entities to establish and implement compliance integrity plans and to self-disclose or report those findings along with any deleted overpayment to the Program Integrity Unit at the address above.
Give Us Your Suggestions!
November 13, 2007
Since April, 2005, the MO HealthNet Division has been providing you with weekly hot tips. The Division has received many favorable comments on the various hot tips and hope that you find them useful.
The purpose of the hot tips is to help providers understand MO HealthNet policies and procedures of the various Mo HealthNet programs. Hot tips are usually developed when agency observations and reports indicate trends regarding billing errors or areas of misunderstandings surrounding benefits and limitations.
Now it is your turn to provide your suggestions for hot tips. Is there a topic that you would like to see covered as a hot tip that you believe would benefit other providers? As long as the information is contained in current MO HealthNet provider bulletins and/or manuals, a hot tip can be prepared by MHD staff. If you have suggestions, please send them by E-mail to: MHD.firstname.lastname@example.org.
UB-04 Inpatient Claim Form
November 5, 2007
The UB-04 (CMS-1450) Claim Form Transition Bulletin, Volume 29, Number 55, dated May 18, 2007, provided instructions on how to complete the new UB-04 claim form. However, recent inquiries to the agency indicate that hospital providers do not clearly understand what data is required in fields 39-41, Value Codes and Amounts, when filing claims for inpatient hospital services.
Fields 39-41, value codes and amounts, are required fields on the paper UB-04 for inpatient hospital services. Acceptable value codes for MO HealthNet are: “80”- Covered Days and/or “81” - Non-covered Days.
Field 39-41 Value Codes and Amounts
- Value Code “80” - Covered Days
- If the patient status code in field #17 is “30” - still a patient, the through date of service shown in the Statement Covers Period, field #6, is included in the covered days. Enter the value code “80” in the CODE field and the number of covered days in the VALUE CODE AMOUNT field.
- If the patient was discharged, patient status code other than “30”, the number of days shown in field 6 - statement covers period minus the discharge day are the covered days. The date of discharge is not a covered day and should not be included in the calculation of this field.
- Value Code “81” - Non-covered Days (Days of care not covered by MO HealthNet)
- An example of non-covered days is days for which a participant is not eligible. If applicable, enter the value code “81” in the CODE field and the number of non-covered days in the VALUE CODE AMOUNT field.
- Note: The total units entered for value code “80” and/or “81” must be equal to the total units listed in field 46 - SERV UNIT.
Mailing Address — Provider Communications
October 29, 2007
The MO HealthNet Division (formerly Division of Medical Services) is noticing that providers are sending correspondence to the wrong mailing address. Providers should send written inquiries regarding claims or benefits and limitation coverage to the following address:
Provider Communication Unit
P. O. Box 5500
Jefferson City, MO 65102-5500
On-line Fee Schedules
October 22, 2007
Providers recently have commented to MO HealthNet staff that the on-line fee schedules, accessible through the agency’s Web site, do not always match the reimbursements for their services.The on-line fee schedules are updated quarterly on a calendar year basis. Consequently, changes in reimbursements for services may not be shown in the on-line schedules until the next quarter’s update. The most recent update is noted at the bottom of the category column on the left hand side of the “Price List Search” screen.
Filing Claims That Medicare Has Denied
October 15, 2007
Medicare has denied your claim. Now you need to submit your claim to the MO HealthNet Program. How do you do that?
Medicare denied services may be considered for payment by MO HealthNet. The service must be a MO HealthNet covered service. When providers receive a Medicare Remittance Advice that has a denied service, the provider may submit a claim to MO HealthNet using the appropriate claim form. Providers are encouraged to submit MO HealthNet claims electronically.
To bill through the MO HealthNet billing Web site for a Medicare denied service select the appropriate claim form (CMS-1500, UB-04, Nursing Home, etc. Do not select the Medicare Crossover claim form). Complete all the required fields on the claim form. At the bottom of each claim form is a Claim Attachment Actions option, click on "Add Header Other Payers". Follow the instructions on the "Help" page to complete the attachment. If you are filing a Medicare Part B denial, you must also complete the detail "Other Payers" attachment for each line. This option is found on the claim form in the field entitled "Detail Line Attachment". Enter the Reason and/or Remark Codes exactly as shown on the Medicare Remittance Advice.
- For Part A denials complete the appropriate claim form and the "Add Header Other Payers" information only.
- For Part B denials complete the appropriate claim form, the "Add Header Other Payers" and the detail "Other Payers" information.
Phone Calls To Provider Communications
October 9, 2007
Providers can call the MO HealthNet Provider Communications Unit at 573/751-2896 with inquiries, concerns, questions on proper claim filing or claims resolution. As a result of the addition of a new feature, providers no longer get a busy signal when wanting to speak to a specialist. Calls instead are put into a queue and are answered in the order received.
Providers are limited to three inquiries per call. Limiting the number of inquiries to three allows the phone specialists to respond to more providers.
Participant Eligibility Card
October 1, 2007
Mo HealthNet is the new name for Missouri Medicaid. Please reference Provider Bulletin dated August 29, 2007 for more information.
Many providers have questioned whether the Mo HealthNet participant will receive a new eligibility card. Participants will continue to use the current red Missouri Medicaid card that includes their name, date of birth and Medicaid number. The red Medicaid card continues to be valid, and is being used by participants. Providers should continue to accept the red Medicaid card, but are urged to verify eligibility through the Interactive Voice Response (IVR) system at 573/635-8908 or through the MO HealthNet billing Web site at www.emomed.com.
MO HealthNet Participant With Other Insurance
September 24, 2007
MO HealthNet participants may have commercial health insurance coverage in addition to MO HealthNet benefits. When commercial health insurance information is known, it is reported to the provider when the provider verifies eligibility. In these cases, MO HealthNet is payor of last resort; commercial insurance must be billed first.
Often providers learn of a change in the participant’s insurance information prior to the MO HealthNet agency since the provider has an immediate contact with their patients. If the provider learns of new insurance information or of a change in the information, they may submit the information to the MO HealthNet Agency to be verified and updated on the participant’s eligibility file.
The provider may report this new information to the MO HealthNet Agency using the Missouri Medicaid Insurance Resource Report. Complete the form as fully as possible to facilitate the verification of the information. Do not attach claims to process for payment. They cannot be processed for payment due to the verification process.
If providers want confirmation when the participant’s insurance file is updated, they should indicate as such on the form and ensure the provider’s name and address information is completed in the spaces provided.
The NPI is Here. The NPI is Now. Are You Using It?
September 17, 2007
The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses will use the NPIs in the administrative and financial transactions adopted under HIPAA. MO HealthNet will soon require full use of the NPI in lieu of legacy provider identifiers in HIPAA standards transactions as well as on all paper claims.
If you are a health care provider who bills MO HealthNet for services, you will need an NPI. Getting an NPI is easy. Getting an NPI is free. The first step is to get your NPI. If you delay applying for your NPI, you risk delays in payments for yourself and clinic partners.
Not sure what an NPI is and how you can get it, share it and use it? More information and education on the NPI can be found at the CMS NPI page https://www.cms.gov/regulations-and-guidance/administrative-simplification/nationalprovidentstand on the CMS Web site. Providers can apply for an NPI online at https://nppes.cms.hhs.gov. Submitting your NPI to MO HealthNet is easy. You can:
- Use the Add/View NPI function on the MO HealthNet Billing Web site at www.emomed.com, or
- Submit a batch of NPIs with the associated MO HealthNet legacy provider numbers by contacting the Infocrossing Healthcare Services Help Desk at 1-573/635-3559, or
- Fax the National Plan & Provider Enumeration System (NPPES) approval letter with the associated MO HealthNet provider number to the Provider Enrollment Unit at 1-573/526-2054.
Providers must share their NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes.
September 10, 2007
The MO HealthNet (formerly Missouri Medicaid) fee schedule was recently updated to reflect the current reimbursement rates. On the fee schedule entry page, you must read the LICENSE FOR USE OF PHYSICIANS' CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (CPT ™) agreement before you can view the fee schedule information. To accept the terms and conditions, click on the 'Accept' button at the bottom of the page.
You have the option of downloading an entire fee schedule for your provider type or you can do an online search.
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.
Duplicate DME Prior Authorization Requests
September 3, 2007
A Prior Authorization (PA) Request for Durable Medical Equipment (DME) must not be faxed multiple times on the same day or within several days of each other. The duplication (same provider, same recipient and same procedure code) of faxed DME PA requests has become a significant issue.
The receipt of duplicate requests causes the consultants to review the same request several times, thus resulting in delays of approval/denial. You must first receive a disposition letter or “return to provider letter” prior to faxing a PA a second time. Therefore, once a PA request is faxed, do not fax the same request (same provider, same recipient, same procedure code) again until you receive one of these letters regarding the original PA request. If the disposition letter or return to provider letter indicates the PA request is denied or incomplete, the PA request form with all previously submitted documentation and additional documentation/corrections may be faxed again. If multiple faxes for the same PA request are sent prior to a determination of the original faxed request, the additional PA request(s) will be denied as duplicates.
DME Bulletin, Volume 29, Number 57 dated June 5, 2007 and the Hot Tip of the Week dated June 25, 2007 titled “Faxing of DME Prior Authorization Requests” contain additional information regarding the submission of DME PA requests by fax.
Claim Processing Schedule
August 27, 2007
Missouri’s fiscal year runs from July 1st through June 30th. July 1, 2007 was the start of state fiscal year 2008 (SFY08). With the beginning of SFY08, 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 SFY08 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.
Ordering Claim Forms
August 20, 2007
Claims sent to Missouri Medicaid for reimbursement should be filed electronically. There are, however, situations when claims must be sent on paper claim forms, such as multiple surgery claims that require an operative report attached to the claim or ambulance claims that require a trip report.
Enrolled providers can order paper claim forms through Missouri Medicaid by downloading and completing the Forms Request for the appropriate form (i.e., CMS-1500, UB-04, Dental, etc.). Any forms ordered and received by the enrolled provider are intended solely for Missouri Medicaid claims filing.
Providers may also order forms by calling the Provider Education Unit at 573/751-6683.
Proper Paper Alignment—UB-04 and CMS-1500
August 13, 2007
If you submit paper claim forms (UB-04 or CMS-1500) to Missouri Medicaid, make sure your paper is properly aligned with the printed information on the new claim forms. Improper alignment may cause information to appear in the wrong fields and cause claims to process incorrectly or deny. Please contact your software vendor for information on how to properly align the claims.
Medicaid Coverage for Former Foster Care Youth
August 06, 2007
The 2007 legislative session ended with the passage of Senate Bill 577, The Missouri Health Improvement Act of 2007. Among its many provisions, it extends healthcare coverage for former foster care youth.
Senate Bill 577 renames Missouri Medicaid to MO HealthNet and extends MO HealthNet coverage for all former foster care youth who were in the Children’s Division legal custody on their 18th birthday, were released from jurisdiction, and have not yet reached their 21st birthday. Youth are eligible without regard to income or assets.
MO HealthNet coverage is automatically available to eligible youth age 18-21 years if they were a former foster care youth and was in the custody of the Children’s Division on their 18th birthday and has not turned age 21. This means that they have medical and behavioral health care coverage through MO HealthNet. Former foster care youth should contact their local Children’s Division office to request a MO HealthNet card.
Similar to the coverage youth received while in foster care, former foster care youth will be required to enroll into a MO HealthNet Managed Care plan for their physical healthcare, if they reside in a Managed Care Region, while their behavioral healthcare will be provided on a fee-for-service basis.
Missouri is one of a limited number of states offering this service to older youth and we are pleased we can now provide healthcare to this population.
For additional information, please contact your local Children’s Division office or the Missouri Department of Social Services Children’s Division at 573/222-8024.
Services of Physician Assistants Correction to Hot Tip dated May 7, 2007
July 30, 2007
This hot tip corrects the wording in the May 7, 2007 hot tip regarding the services of physician assistants. The May 7, 2007 hot tip inadvertently stated the supervising physician could bill for the services of a physician assistant if there was direct personal supervision when done in a hospital setting. This is incorrect. The incident-to provision does not apply to the hospital setting.
Correction of the hot tip is stated below:
Missouri Medicaid does not allow Physician Assistants (PA) to enroll individually. However, PA services can be billed using the supervising physician’s Missouri Medicaid provider number when there is direct personal supervision. Direct personal supervision in the office or clinic setting does not mean that the physician must be present in the same room with the PA. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the PA is performing services. Supervising physicians cannot bill for the services of a PA in the hospital setting.
PA’s providing services in a Rural Health Clinic setting can bill services under the Rural Health Clinic Medicaid provider number. PA’s in a Federally Qualified Health Center must bill under the supervising physician’s Missouri Medicaid performing provider number when there is direct personal supervision.
Trading Partner Agreement
July 23, 2007
If you have received a new billing provider number and are receiving an X12 835 Remittance Advice from Medicaid, you must update your Electronic Data Interchange (EDI) Trading Partner Agreement to include your new billing provider number.
There are two parts to the Trading Partner Agreement. The first part is for inbound files (files that are being submitted to Medicaid) and the second part is for outbound files (files being received from Medicaid).
The outbound portion is for receiving files and must include the Medicaid provider number for which the Remittance Advice (835) is for. Each provider that wishes to receive the 835 electronically, must have a Trading Partner Agreement on file with Medicaid’s fiscal agent, Infocrossing Healthcare Services, for all of their billing provider numbers. Any time a new billing provider number is assigned, that provider number must be submitted on a Trading Partner Agreement to the fiscal agent. Even if the group already receives the 835 for other providers, the new billing number must be submitted before the information will be sent out on the 835.
The Trading Partner Agreement can be submitted by the provider’s office, the billing agency or the clearinghouse to Infocrossing Healthcare Services, PO Box 5800, Jefferson City, MO 65101 or faxed to 573/635-0316.
If you have already submitted a Trading Partner Agreement for your new billing provider number, you do not need to send another one. If your Medicaid billing is done through a billing agency or clearinghouse, check with your representative to see if a Trading Partner Agreement has been sent to the Medicaid fiscal agent for your new number.
If you have questions about the Trading Partner Agreement, please contact the Infocrossing Helpdesk at 573/635-3559.
NEMT — Where’s My Ride?
July 16, 2007
Non-emergency medical transportation (NEMT) is available to eligible Medicaid/MC+ recipients who do not have access to free appropriate transportation to and from scheduled Medicaid/MC+ covered services. NEMT services are arranged through LogistiCare Solutions L.L.C.
LogistiCare provides toll-free numbers to call if transportation has not arrived timely. If a transportation provider is more than 15 minutes late from the scheduled pick-up of your patient, you may call the "Where’s My Ride" line at the phone numbers below. The call should be made to the appropriate phone number for the county where the trip originates. For instance, if a recipient is picked up in Cole County (Western side), and goes to a provider office in St. Louis and their transportation does not arrive, you should call the "Where’s My Ride" phone number for the western side of the state.
- Western Side of the State — 1-866-269-5944 for the counties of:
- Adair, Andrew, Atchison, Barry, Barton, Bates, Benton, Boone, Buchanan, Caldwell, Camden, Carroll, Cass, Cedar, Chariton, Christian, Clay, Clinton, Cole, Cooper, Dade, Dallas, Daviess, DeKalb, Douglas, Gentry, Greene, Grundy, Harrison, Henry, Hickory, Holt, Howard, Howell, Jackson, Jasper, Johnson, Laclede, Lafayette, Lawrence, Linn, Livingston, Macon, McDonald, Mercer, Miller, Moniteau, Morgan, Newton, Nodaway, Ozark, Pettis, Platte, Polk, Pulaski, Putnam, Randolph, Ray, Saline, Schuyler, St. Clair, Stone, Sullivan, Taney, Texas, Vernon, Webster, Worth, and Wright.
- Eastern Side of the State — 1-866-269-5435 for the counties of:
- Audrain, Bollinger, Butler, Callaway, Cape Girardeau, Carter, Clark, Crawford, Dent, Dunklin, Franklin, Gasconade, Iron, Jefferson, Knox, Lewis, Lincoln, Madison, Maries, Marion, Mississippi, Monroe, Montgomery, New Madrid, Oregon, Osage, Pemiscot, Perry, Phelps, Pike, Ralls, Reynolds, Ripley, Scotland, Scott, Shannon, Shelby, St. Charles, St. Francois, St. Genevieve, St. Louis City, St. Louis County, Stoddard, Warren, Washington, and Wayne
For return trips called in after the appointment, the transportation provider has one (1) hour from the time the provider is notified to pick up the patient. Should the pick up be late, please call the "Where’s My Ride" line, not the transportation provider.
IFOX Internet Help Desk
July 9, 2007
Missouri Medicaid uses Infocrossing Health Care Services (IFOX) to process both paper and electronic claims. IFOX maintains a Help Desk to assist providers with the technical aspects of filing Medicaid claims. The Help Desk phone number is 573/635-3559 and is available Monday to Friday, 8:00 a.m. to 5:00 p.m.
The following are reasons a provider might want to contact the IFOX Help Desk. The Help Desk should not be contacted regarding denied claims or inquiries regarding patient eligibility.
- Assistance in converting from paper billing to Internet billing through emomed.com.
- Assistance with submitting electronic claims when technical errors occur, e.g. server error, batch file submission error, etc.
- Assistance in signing up for the emomed.com services.
- Resetting the emomed.com password.
- Assistance in understanding and navigating the emomed.com Web site.
- Questions regarding how electronic claims data was submitted by your clearinghouse.
- Questions regarding electronic claims data received from the provider’s clearing house.
- Technical questions about the claim confirmation file.
- Technical questions concerning the printable remittance advice.
- Technical questions regarding the submission of the provider’s NPI (National Provider Identifier).
- Assistance with first time HIPAA 837 claim submission and testing.
- Questions relating to the trading partner agreement and the HIPAA 835 remittance advice set-up.
- Where to find the HIPAA standard Claim Adjustment Reasons Codes and Remittance Advice Remark Codes.
Provider Enrollment E-mail Requests
July 2, 2007
The Medicaid Provider Enrollment Unit continues to receive numerous E-mails requesting Medicaid provider numbers. If you are enrolled as a clinic/group, you need to request the provider number from the individual providers prior to E-mailing the Provider Enrollment Unit. The Provider Enrollment Unit can advise whether a provider is active or inactive but cannot disclose the provider number via E-mail.
Missouri Medicaid provider numbers are confidential and are not released to anyone by telephone, facsimile, E-mail, or any other electronic method. Medicaid provider numbers are only sent by mail to the provider at the provider’s address listed on the Missouri Medicaid Provider Enrollment Master file. It is the provider’s responsibility to notify billing agents, clinics, groups, corporate offices, etc., of all pertinent information regarding their provider number and NPI number.
Missouri Medicaid provider numbers are no longer required to be “linked” to each clinic/group for which they practice. The clinic/group is required to use the clinic/group provider number in the billing field and the individual provider number in the performing provider field. Payment continues to go to the billing provider.
Provider Enrollment also receives numerous E-mails requesting copies of Medicaid approval letters for providers. Providers should be sure to keep all types of approval letters so they can be copied when required documentation is needed for enrollment or employment. Approval letters are generally sent from Medicare, Medicaid, NPPES, etc. This documentation is also required when enrolling or updating provider records.
If a clinic/group or other entity applies for and receives approval for the individual provider’s NPI number, that letter must be released to the provider and the provider should keep the letter in a safe place. Providers are responsible for presenting their documentation to whomever needs it and also responsible for updating their NPI number record when changes occur.
Faxing of DME Prior Authorization Requests
June 25, 2007
Providers are encouraged to submit Durable Medical Equipment (DME) prior authorization requests by facsimile (fax) to 573-659-0207 as stated in Missouri Medicaid Durable Medical Equipment Bulletin Volume 29, Number 57 dated June 5, 2007. Providers must adhere to the following criteria when submitting DME prior authorization requests by fax.
- Only one prior authorization request may be submitted per fax call. Multiple prior authorization requests per call will not be processed because the system views the multiple requests as attachments to the first request received from that call.
- Only prior authorization requests may be faxed. Any other type of request/document (i.e. questions, certificates of medical necessity) that is faxed will not be processed.
- Do not scale down attachments in an attempt to fit multiple pages on one sheet. This causes the document to be very difficult to read. Requests that cannot be read will be returned to the provider for resubmission.
- Utilize a business fax cover sheet when faxing the prior authorization request. The cover sheet should include the return fax number. This will assist the return of disposition letters by fax.
- Ensure the fax number from which the prior authorization request is sent is not a blocked number. A blocked fax number will prevent the disposition letter from being returned by fax. Disposition letters that cannot be successfully returned via fax will be mailed to the provider.
- Do NOT mail prior authorization requests that have been faxed. This will cause duplicates in the system and result in processing delays.
Medicaid Mailing Addresses
June 18, 2007
A May 9, 2007 Medicaid bulletin notified providers of a mailing address change for sending inquiries to the agency’s Provider Communications Unit. Unfortunately, providers also began sending claims to this post office box which results in a delay in processing them. Inquiries concerning items such as policy and procedure questions, and claim denials can be sent to the Provider Communications Unit. Claims submitted for processing should NOT be sent to the Provider Communications Unit address.
The mailing addresses to be used for submitting items to Medicaid are:
Infocrossing Health Care Systems,
PO Box (select the appropriate PO Box from the following list)
Jefferson City, MO 65102.
|PO Box 5100||Inpatient hospital claims|
|PO Box 5200||Outpatient hospital, rural health clinic, hospice and home health claims|
|PO Box 5300||Dental claims|
|PO Box 5500||Provider Communications (for claim inquiries only)|
|PO Box 5600||Medical, mental health, optical, durable medical equipment, therapy (speech, occupational and physical), private duty nursing, personal care, adult day care, hearing aid, homemaker/chore claims, ambulance|
|PO Box 5700||Prior Authorization requests|
|PO Box 5900||Attachments (Second Surgical Opinion form, Sterilization Consent form, Acknowledgement of Hysterectomy Information form, Program Integrity 118 Lock-in Referral form, Oxygen and Respiratory Equipment Medical Justification and Certificate of Medical Necessity form (DME program only).|
The street address for Infocrossing Health Care Systems is: 905 Weathered Rock Road, Jefferson City, MO 65101
The MO HealthNet Division mailing address is: MO HealthNet Division, PO Box 6500, Jefferson City, MO 65102
Frequently Asked Questions
June 11, 2007
There are many resources such as manuals, bulletins, fee schedules, etc. available on the Medicaid Web site at http://dss.mo.gov/mhd/providers/ to assist providers. However, one resource that is often overlooked is the Frequently Asked Questions option.
At this option, providers can view commonly asked questions and answers to general, enrollment, nursing home and drug information. Utilizing this option reduces the need to contact the Medicaid Provider Communications Unit. Please click on the Frequently Asked Questions link above to review.
Nursing Home Room & Board/Crossover Claims
June 4, 2007
When a patient has both Medicare Part A and Medicaid coverage, the Medicare Part A benefit must be utilized until it has been exhausted. During a Medicare Part A coverage period, only claims reflecting Medicare days, revenue code 0189, are to be submitted. Nursing facilities are not to submit claims for room and board charges, revenue codes 0110, 0119, 0120, 0129, 0190, 0191, 0192, 0193, 0194 and 0199 during Part A coverage periods. Such charges are subject to post-payment review which may result in recoupments of payments made.
Codes Reported on Remittance Advice
May 28, 2007 Updated 5/29
Claim Group Codes
To aid providers in identifying the most common payment reductions or cutbacks by Missouri Medicaid on Remittance Advices (RAs), claim group codes and claim adjustment reason codes are reported to providers on all RA formats when the following claim payment reduction or cutback occurs:
- CO = Contractual Obligation
- OA = Other Adjustment
- PR = Patient Responsibility
|Payment reimbursed at the maximum allowed||CO||45||Charges exceed our fee schedule maximum allowable amount.|
|Payment reduced by other insurance amount||OA||23||Payment adjusted because charges have been paid by another payer.|
|Medicare Part A Repricing||OA||45||Charges exceed our fee schedule or maximum allowable amount.|
|Payment cut back to federal percentage (IEP therapy services)||OA||A2||Contractual adjustment.|
|Payment reduced by co-payment amount||PR||3||Co-Payment amount.|
|Payment reduced by patient spend down amount||PR||178||Payment adjusted because patient has not met the required spend down.|
|Payment reduced by patient liability amount||PR||142||Claim adjusted by monthly Medicaid patient liability amount.|
Billing for Multiple Surgical Procedures
May 21, 2007
A continual reason for surgical claim denials is that providers are not following Medicaid policy regarding multiple surgeries for procedures on the same patient on the same date of service.
The following information is taken from Section 13.40.F of the Medicaid Physician Provider Manual available from the MHD Web site.
When multiple surgical procedures are performed for the same body system through the same incision, the major procedure is considered for payment at 100% of the Medicaid allowable fee for the procedure. (No reimbursement is made for incidental procedures.)
Multiple surgical procedures performed on the same recipient, on the same date of service, by the same provider, for the same or separate body systems through separate incisions must be billed in accordance with the following guidelines:
- The major, secondary and tertiary procedures should be indicated on the claim form using appropriate CPT codes.
- A copy of the Operative Report may be attached to claims for multiple surgeries to provide additional information. If not attached, a copy may be requested to assist with the claim processing.
Claims for multiple surgeries are allowed according to the following:
- 100% of the allowable fee for the major procedure.
- 50% of the allowable fee for the secondary procedure.
- 25% of the allowable fee for the tertiary procedure(s).
National Correct Coding Initiative
May 14, 2007
As a reminder to providers, Missouri Medicaid will require providers to follow Medicare’s Physician National Correct Coding Initiative (NCCI) guidelines effective for dates of service on or after July 1, 2007. This information was posted in the NCCI Bulletin dated January 23, 2007. The purpose of the NCCI edits is to ensure the most comprehensive groups of codes are billed rather than the component parts.
Providers can find the current Physician NCCI edits and the current Mutually Exclusive Code edits on the CMS Web site at http://www.cms.hhs.gov/NationalCorrectCodInitEd/.
Services of Physician Assistants
May 7, 2007
Missouri Medicaid does not allow Physician Assistants (PA) to enroll individually. However, PA services can be billed using the supervising physician’s Missouri Medicaid provider number when there is direct personal supervision. Direct personal supervision in the office, clinic or hospital setting does not mean that the physician must be present in the same room with the PA. However, the physician must be present in the office suite (if office or clinic services) or hospital premises (if hospital services) and immediately available to provide assistance and direction throughout the time the PA is performing services.
PA’s providing services in a Rural Health Clinic setting can bill services under the Rural Health Clinic Medicaid provider number. PA’s in a Federally Qualified Health Center must bill using the supervising physician’s Missouri Medicaid provider number when there is direct personal supervision.
Eligibility Verification for Hospice Lock-in
April 30, 2007
When a Medicaid patient elects the hospice benefit, the hospice provider assumes the responsibility for managing the patient’s medical care related to the terminal illness. The hospice provides or arranges for services reasonable and necessary for the palliation or management of the terminal illness and related conditions. This includes all care, supplies, equipment and medicines.
Any provider, other than the attending physician, who provides care related to the terminal illness for a hospice patient must contact the hospice provider to arrange for approval of the service and for payment prior to providing care to the hospice patient. Medicaid reimburses the hospice provider for covered services and the hospice reimburses the provider of the service(s).
Providers must verify recipient eligibility prior to rendering services. Recipients who elect hospice care are identified under the eligibility lock-in information. Hospice providers are identified by provider lock-in numbers that begin with an “82”. Eligibility can be verified in one of two ways:
- Through the Medicaid billing Web site at www.emomed.com; or
- By calling the Interactive Voice Response system at 573/635-8908 and then accessing the lock-in option.
Adjusting Claims Electronically
April 23, 2007
Providers are urged to adjust their claims electronically. Whether you are replacing a paid claim or voiding a claim, claims can be adjusted electronically through the Medicaid billing Web site at www.emomed.com. Even if your claim was submitted by paper, any adjustment can be done electronically.
With the new automated retrieval process in place at www.emomed.com, you can bring up the claim you want to adjust through the ‘View Claim Status’ option or the ‘Claim Confirmation’ option. The claim is automatically populated with the information you originally submitted. To void a claim, you merely change your claim frequency type code to ‘8’ (void) and click on ‘Continue’ or ‘Resubmit’. To replace a claim that has been paid, you retrieve your claim through the same process stated above, however, you change your claim frequency type code to ‘7’ (replacement) and correct or change the information in error and then resubmit.
For more information on retrieving and resubmitting claims through the Medicaid billing Web site, please reference the Medicaid Bulletin dated March 20, 2007.
Provider Fee Schedule
April 16, 2007
Providers have access to the Medicaid fee schedule online at http://dss.mo.gov/mhd/providers/. The fee schedule is updated quarterly. The Web site is dated to show when the fee schedule was last updated. Any procedure codes added to the fee schedule or updated during a quarter will not appear until the next quarterly update. Until codes are updated, providers should refer to provider bulletins.
To access the fee schedule online from the link above, click on the ‘fee schedules’ option in the left column. From that point you will be prompted to read and accept the “License For Use of Physicians' Current Procedural Terminology”. Then follow directions to download individual files or search for a specific fee schedule.
The online fee schedules will identify covered and non-covered procedure codes, restrictions, allowed units and the Medicaid allowable fee for each unit. The fee schedule is intended as a reference and not a guarantee of payment. Please refer to program specific Medicaid provider manuals and bulletins for benefit and limitations.
RHC and FQHC Injection Administrations
April 9, 2007
Rural Health Clinics (RHCs) (provider based) and Federally Qualified Health Centers (FQHCs) may not separately bill for the administration of an injection regardless of whether or not there is an encounter with a core service provider. For example, RHCs and FQHCs may not separately bill CPT procedure codes 95115 (professional services for allergen immunotherapy not including the provision of allergenic extracts; single injection), 95117 (professional services for allergen immunotherapy not including provision of allergenic extracts; two or more injections), or 95165 (professional services for the supervision of the preparation and provision of antigens for allergen immunotherapy; single or multiple antigens).
The costs for these services are to be included in the RHC and FQHC cost reports.
April 2, 2007
Missouri Medicaid covers adult physicals. Criteria for adult physicals are discussed in Section 13.31 of the Physician Manual as indicated below. Manuals can be accessed from the MHD Provider home page.
13.31 Adult Physicals
One adult "preventive" examination/physical, including a well woman exam (ages 21 and older) per 12 months is covered by Medicaid. Physicals are also covered when required as a condition of employment. Diagnosis code V70.0, "routine general medical examination at a health care facility", or diagnosis code V72.31, "gynecological examination", should be used and billed under the appropriate preventative medicine procedure code (99385-99387 or 99395-99397).
Tips on NPI
March 26, 2007
Prior to April 1, 2007, all active Missouri Medicaid providers are required to submit their National Provider Identifiers (NPIs) to Missouri Medicaid for use in processing all health care transactions. Failure to submit your NPI(s) to Missouri Medicaid will result in denied claims. Please reference the NPI Transition Plan Bulletin dated February 2, 2007.
Following are some helpful tips to facilitate the application for and reporting your NPI to Missouri Medicaid:
- Decide how you will apply for your NPIs, if multiple NPIs are needed, or if multiple NPIs would benefit your organization.
- Does your billing system allow for using an NPI and taxonomy code on claims? If not, you may want to consider obtaining separate NPIs for each subpart.
- In order to apply for an NPI for one or more subparts, the applicant is required to provide the appropriate taxonomy code on each NPI application. Select your health care provider taxonomy code from a list available at http://www.wpc-edi.com/codes/taxonomy .
The taxonomy code is comprised of provider type, specialty, and sub-specialty classification. The Health Care Provider Taxonomy Code Set is sorted by individual or groups (of individuals) and non-individuals. All provider types are listed.
- If you have already received one NPI for multiple Medicare and/or Medicaid provider numbers and decide you want separate NPIs for your subparts, you must update your main NPI record with the NPI enumerator at: https://nppes.cms.hhs.gov. Include ONLY the taxonomy code for that specific NPI. Then you must apply for the subpart NPI(s) using the correct taxonomy code for each subpart.
- If you plan to use one NPI for multiple organization provider numbers, you must bill using the single NPI along with the appropriate taxonomy code for the type of services you are providing so the Medicaid claims will process correctly.
- If you receive an NPI for each subpart, only the NPI for each specific subpart must be used when billing Missouri Medicaid and the taxonomy code is not required.
Services Exempt from Hospital Admission Certification
March 19, 2007
The following services do not require hospital admission certification. Claims with a principal diagnosis that is one of the exempt diagnosis codes do not require a certification number in field 63 on the UB-92. Health Care Excel (HCE), the review authority for Medicaid, does not need to be contacted under these circumstances.
Certain Pregnancy-Related Diagnosis Codes
- 633 range
- 640-649 range with a fifth digit of 0, 1, 2 or 3
- 651-676 range with a fifth digit of 0, 1, 2 or 3
NOTE: Diagnoses for missed abortion, pregnancy with abortive outcome, and postpartum care continue to require certification.
Admissions for Deliveries
Delivery diagnosis codes are:
- 640-649 range with a fifth digit of 0, 1, 2 or 3
- 651-676 range with a fifth digit of 0, 1, 2 or 3
NOTE: Providers are cautioned to refer to the ICD-9-CM diagnosis coding book because a fifth digit of 0, 1, 2 or 3 is not valid with every diagnosis within the ranges listed above.
Admissions for Newborns
Newborn diagnosis codes are:
- V30.00-V39.1 (If the fourth digit is 0, a fifth digit of 0 or 1 is required)
Admissions of Patients Enrolled in MC+ Health Plans
The health plan is responsible for certifying the hospital admission for MC+ enrollees. A transplant candidate may choose the Medicaid approved transplant facility and may choose a Medicaid approved transplant facility outside of the health plan’s network and MHD will prior authorize the transplant. The health plan is responsible for pre-transplant and post-transplant follow-up at both the in-network and the out-of-network transplant facilities.
Admissions Covered By Medicare Part A
Claims for deductible and coinsurance for Medicaid patients with Medicare Part A benefits are exempt from admission certification. However, if Medicare Part A benefits have been exhausted and a claim is submitted for Medicaid only days, admission certification requirements must be met. Pre-admission certification is required also for denied Medicare Part A inpatient hospital claims. Before requesting a pre-certification, the provider must exhaust all appeals through the Medicare appeals process and have a final denial that can be submitted to HCE with the pre-certification request.
Admissions for Medicaid patients with Medicare Part B only require certification.
More information on inpatient hospital certification can be found in Section 13.31 of the hospital manual. Provider Manuals are linked from the Provider home page.
Timely Filing Updates to Regulation
March 12, 2007
Missouri Medicaid timely filing regulation 13 CSR 70-3.100 for claims and adjustments was recently updated. Section 4 of the Medicaid Provider Manuals has been updated to reflect the current policy. Some of the highlights include:
- Original claims must be filed by the provider and received by the state agency within 12 months from the date of service. 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 the Medicare provider’s notice of the allowed claim. Claims denied by Medicare must be filed by the provider and received by the state agency within 12 months from the date of service.
- Medicaid claims with third party liability must first be submitted to the insurance company in most instances. However, the claim to Medicaid must still meet the Medicaid timely filing guidelines outlined above. Claim disposition by the insurance company after 1 year from the date of service does not serve to extend the filing requirement. However, the 12-month filing rule may be extended if a third-party payer, later reverses the payment determination sometime after 12 months from the date of service has elapsed and requests the provider return the payment. In this case, the provider may file a claim with Missouri Medicaid later than 12 months from the date of service by submitting the claim to the Third Party Liability Unit, PO Box 6500, Jefferson City, MO 65102 for special handling.
- Adjustments to a paid claim must be filed within 24 months from the date of the remittance advice on which payment was made. If the processing of an adjustment necessitates filing a new claim, the timely limits for resubmitting the new, corrected claim is limited to 90 days from the date of the remittance advice indicating recoupment or 12 months from the date of service, whichever is longer.
Provider manuals can be accessed from the MO HealthNet Division Web site.
Prior Authorization — Request For Change Durable Medical Equipment
March 5, 2007
To request a change to an approved Prior Authorization (PA) request, providers are required to make the applicable changes on the Missouri Medicaid Authorization Determination letter, the letter that is sent to the provider with any stipulations for approval or reason for denial of a PA request. When changes to an approved PA request are made on the Missouri Medicaid Authorization Determination, the Missouri Medicaid Authorization Determination is referred to as a Request For Change (RFC). Requests for reconsideration of items that reflect a “D” (denied) or “I” (incomplete) status must not be included on a RFC; providers must submit a new PA request.
Missouri Medicaid is receiving large amounts of duplicate requests for changes to approved wheelchairs and wheelchair accessories. Please keep the following in mind before submitting a RFC:
- Do not submit a RFC if a MO Medicaid Authorization Determination letter has not been received from the initial PA request;
- Do not submit a RFC if a MO Medicaid Authorization Determination letter has not been received on a previous RFC for the same item;
- For patients who have or need both a power and manual wheelchair, the RFC for accessories must state which wheelchair the accessories are for. This becomes especially important when some of the accessories have been combined in to procedure code K0108 on both wheelchairs;
- A RFC may be submitted to correct a procedure code and/or modifier, but providers need to explain the reason a different procedure code is being requested and supply additional documentation as necessary.
PA requests and a RFC for the same patient, for the same or similar items, will be denied as duplicate requests.
February 26, 2007
All enrolled Medicaid providers must keep their mailing address current with the Missouri Medicaid Program. The Missouri Code of State Regulation at 13 CSR 70-3.020 (7) requires providers to advise the MO HealthNet Division (MHD), in writing, of any changes affecting the provider’s enrollment records. Failure to do so is a program violation found in 13 CSR 70-3.030.
The on-lineProvider Enrollment Guide states that all Missouri Medicaid providers must notify the Provider Enrollment Unit by mail of any changes to their enrollment record. The provider’s name, Medicaid/NPI number, and original signature must be included with the written notification. The address in the provider’s enrollment record is the location to which all official correspondence is mailed. Indication of a change of address on a claim form is insufficient notice. Providers enrolled as a performing provider are not exempt from keeping their provider enrollment record current. The Program Integrity Unit of MHD has seen instances in which performing providers have failed to properly notify the agency of address changes.
Practice locations, as modified by the provider on the Missouri Medicaid billing Web site, eMomed, do not change a provider’s enrollment record. The practice locations entered by the provider on eMomed are used to enable recipients and others to locate a provider in a particular area or for a specific service through the provider search function on the Division’s Web site. For more information about updating practice locations on eMomed read Provider Bulletin, Volume 28, Number 50 dated May 18, 2006.
Electronic Medical Necessity Form
February 19, 2007
The Missouri Medicaid Program requires that a Certificate of Medical Necessity form accompany claims for reimbursement of certain procedures, services or circumstances. Some examples include:
- Claims for concurrent care when more than one provider is treating a seriously ill patient that requires the skills of more than one physician; each physician must document the necessity for concurrent care;
- Claims for procedures that require prior authorization which were performed on an emergency basis.
This hot tip is to remind you that certificates of medical necessity can be entered electronically as an attachment to the medical, inpatient or outpatient claim form at the Medicaid billing Web site at www.emomed.com by clicking on the medical necessity link on the claim form. Most fields are automatically populated on the medical necessity form taken from information on the claim such as the patient name, Medicaid ID number and procedure and diagnosis codes. You must complete the fields for the description of the item or service, reason for the service, provider name and number and date of service. You can access field-by-field instructions by clicking on the “Help” option at the bottom of the form.
Entering the medical necessity form electronically as an attachment to your claim can greatly speed the claim processing time in lieu of sending a paper claim with the medical necessity form attached.
Please Note: A Durable Medical Equipment (DME) medical necessity form is not completed from the claim form as described above. Instead, it must be completed separately by utilizing the DME Certificate of Medical Necessity from the “Submit Claim Attachments” option at www.emomed.com. Certificates of Medical Necessity for DME can only be submitted electronically.
Daily Claims Summary
February 12, 2007
A feature on the Medicaid billing Web site at www.emomed.com 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'.
February 5, 2007
The 2007 Current Procedural Terminology (CPT) manual added text clarification to the office/outpatient and inpatient consultation codes (99241-99245 and 99251-99255) that Missouri Medicaid follows. Keep in mind the following tips when billing a consultation to Missouri Medicaid:
- A consultation is the evaluation of a patient provided by a physician at the request of another physician or appropriate source.
- The consulting physician must provide a written report to the physician requesting the consultation.
- If the consulting physician assumes responsibility for all or a portion of the patient’s care, the initial visit can be billed as a consultation as long as you have documented the consultation requirements. Subsequent visits should be billed using the established patient evaluation and management codes.
- For the inpatient consultation codes, CPT 2007 added text that clarifies "Only one consultation code should be reported by a consultant per admission. Subsequent services during the same admission are reported using Subsequent Hospital Care codes (99231-99233) or Subsequent Nursing Facility Care codes (99307-99310)," whichever setting is appropriate.
- If a patient presents to your office and requests a second opinion, you should bill using the appropriate E/M code (99201-99215).
- The two highest levels of consultations (99245 and 99255) require a consultation report attached to the claim.
HIPAA-Related Code Lists
January 29, 2007
Providers continue to question the explanation of the codes shown on their claim confirmation report as well as their remittances advices.
Explanations for claim status codes, remittance advice remark codes and claim adjustment reason codes can be found on the Internet at www.wpc-edi.com/codes under the HIPAA-Related Code Lists.
More information on HIPAA-Related Code Lists can be referenced in Section 17 (Claims Disposition) of your provider manuals located on the Internet at http://dss.mo.gov/mhd/providers/.
What Is Your NPI Number
January 22, 2007
What is your National Provider Identifier (NPI) number?
May 23, 2007, the deadline for NPI implementation is quickly approaching. Beginning on that date, the NPI is the mandatory identifier to process all electronic and paper claims submitted to Missouri Medicaid.
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 for each active provider number to the Missouri Medicaid Provider Master Record by using the option titled "Add/View NPI". If you need assistance in submitting NPIs for multiple providers, please contact the Infocrossing Help Desk at 573/635-3559. If you have one NPI for multiple provider types or any other NPI questions, please E-mail the Provider Enrollment Unit.
After a NPI has been entered on EMOMED, it cannot be changed. If the NPI is entered incorrectly or in error, a copy of the correct NPI approval notice, an explanation of the error and the provider number(s) involved must be submitted to the Provider Enrollment Unit. The notice may be faxed to 573-526-2054.
Dentists and Dental Hygienists may submit their NPIs to Missouri Medicaid starting March 1, 2007.
If you are a health care provider and have not applied for an NPI, you must contact the National Plan and Provider Enumeration System (NPPES) as soon as possible.
Checking Medicaid Eligibility
January 16, 2007
Many claim denials can be avoided if providers check Medicaid eligibility prior to services being rendered. In fact, four of the top ten reasons claims deny each month result from failing to check eligibility. These denials are:
- Medicare coverage — By checking eligibility, providers are informed if the recipient has Medicare. The claims must be filed to Medicare first.
- Recipient Name or Number Mismatch — Checking eligibility will determine the patient’s name and Medicaid number as it appears on the enrollment file. The claim must be filed with the patient’s current file name.
- Lock-in recipient or managed care recipient — If a recipient is locked-in to a certain provider(s) or enrolled in a Medicaid MC+ managed care plan, providers are given this information when eligibility is checked. If a recipient is locked-in to a provider(s) or enrolled in a managed care plan, services must be obtained through them.
- Commercial insurance — A claim must be filed to the commercial insurance plan first if the Medicaid eligibility file reflects commercial coverage.
Providers can check eligibility 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.
* Registration by completing an online application is required to utilize Missouri Medicaid electronic services at emomed.com.
Dually Eligible Hospice Patients
January 08, 2007
Any time a hospice patient is eligible for both Medicare and Medicaid at the time of election, the hospice election for both programs must be made simultaneously. If the patient’s Medicaid eligibility begins or the hospice agency becomes aware of the Medicaid eligibility after Medicare Hospice benefits have been elected, a completed Medicaid Hospice Election Statement must be sent to the MO HealthNet Division' Hospice Unit with a copy of the Medicare election form attached. The signature and dates on the Medicare election may be used as verification of the patient’s election date when attached to the Medicaid Hospice Election Statement.
Hospice revocations are to be handled in the same manner by completing the required forms for each agency. The Medicaid Notification of Termination of Hospice Benefits form is designed for Medicaid clients and not intended to be used for Medicare revocations.
Medicare HMOs and Medicaid
January 2, 2007
Medicaid patients with Medicare may have the option to enroll in a Medicare Health Maintenance Organization (HMO) for their Medicare benefits.
Because the patient has chosen to obtain his/her Medicare benefits through a Medicare HMO, Missouri Medicaid will not pay any co-payment amounts for claims for Medicare/Medicaid clients. The provider can bill the client for these amounts.
Charges denied by the HMO can be submitted to Medicaid and reimbursed if they are for covered services for the patient. The provider is responsible for making every effort to obtain referrals or other required HMO documentation before Medicaid is billed. A denied Medicare HMO claim must be submitted as a Medicaid claim, not as a crossover claim. Documentation from the HMO explaining the denial must be submitted with a paper claim. An electronic claim must include the basic HMO information along with the group code and reason code detailing why the claim was denied.
Medicaid currently does not have the ability to provide Medicare HMO enrollment information when a provider checks eligibility. The provider must rely on the patient, the patient’s family or care giver for the Medicare HMO enrollment information.