2008 Archives Hot Tip of the Week
2008 Provider Tips
- Medicare Advantage (Part C) and MO HealthNet spend down
- Ordering Claim Forms
- Billing for Administering VFC Vaccines
- Psychology Prior Authorization Year End Closing
- Wheelchair Options/Accessories
- Medical Records and Retention
- Hospital Outpatient Facility Charges
- Groups/Clinics — Performing Provider
- Temporary MO HealthNet During Pregnancy
- Prior Authorization Requests [with corrections]
- Billing Proper Medication Quantities
- Level 5 Physician Consultations
- Retrieving An Aged Remittance Advice
- Determining Participant QMB Coverage
- Updating Provider Contact Information
- Provider Information – Hurricane Gustav Evacuees
- Inpatient Hospital Certification – Part C Patients
- School/Athletic Physicals
- Claim Confirmation Report
- Contacting Provider Enrollment Unit
- Hospital Charges – Noncovered Surgical Procedures
- Physician Prior Authorization Requirements
- National Correct Coding Initiative (NCCI)
- NPIS For Hospital Pre-Certifications
- Pre-Certification Requests For DME
- Verifying Participant Eligibility
- Claim Processing Schedule – FY 2009
- Medicare HMO’s (Hot Tip Removed)
- Vaccines For Children Program
- Allowable spend down Medical Expenses
- New MO HealthNet for Kids Web Portal
- Medicare Part B Information – Eastern Missouri
- MO HealthNet Forms
- Provider Practice LocationAddresses
- VFC Information Sources
- Participant Liability
- Contacting the Provider Education Training Unit 573/751-6683
- Vagus Nerve Stimulation
- MO HealthNet Postoperative Care Policy
- Psychology/Counseling Program Documentation Examples
- When can Patients Change Managed Care Health Plans?
- Optical Hot Tip – Replacement of Lens(es) and Frames
- Prior Authorization Requests
- Hospice Election & Revocation
- Chronic Care Improvement Program Update
- Split Claims
- HIPAA-Related Code Lists
- Transfers Within A Hospital
- Clarification To January 14, 2008 Hot Tip
- Optical — Special Frames
- Surgical Field — Hospital Claim Form
- Medical Eligibility Codes Defined
Medicare Advantage (Part C) and MO HealthNet spend down
December 29, 2008
The MO HealthNet liability for dual eligibles is outlined in the following table:
|Group||Medicare Coverage||MO HealthNet Liability|
|Qualified Medicare Beneficiary (QMB) and Dual Eligible (QMB Plus)||Part A||Medicare Deductible & Coinsurance – Part A hospital payments are limited to the lower of the Medicare deductible and coinsurance amounts or the amount the Medicaid payment exceeds the Medicare payment.|
|Part B||Medicare Deductible & Coinsurance – Paid up to the full amount of the Medicare deductible and coinsurance amount.|
Medicare Deductible, Coinsurance & Copayments – Medicare Advantage Part A type hospital claims are limited to the lower of the Medicare Advantage deductible and coinsurance amounts or the amount of Medicaid payment that exceeds the Medicare Advantage payment.
Other Medicare Advantage Part A type claims and Medicare Advantage Part B type claims are paid up to the full amount of the Medicare Advantage deductible, coinsurance and copayment amount.
|Other MO HealthNet Participants||Part A||Medicare Deductible & Coinsurance – Part A hospital payments are limited to the lower of the Medicare deductible and coinsurance amounts or the amount the Medicaid payment exceeds the Medicare payment.|
|Part B||Medicare Deductible & Coinsurance – Paid up to the full amount of the Medicare deductible and coinsurance amount.|
|Part C||Liability for payment is limited to MO HealthNet covered services rendered by MO HealthNet providers in excess of payment made by Medicare Advantage plan. No additional reimbursement is made for deductible, coinsurance or copayment.|
Provider shall accept as payment in full, payment from Medicare/Medicare Advantage Plan and MO HealthNet. Provider shall not balance bill or otherwise charge a MO HealthNet participant except for the normal copay charged by the MO HealthNet agency.
If an enrolled MO HealthNet provider does not want to accept MO HealthNet as payment but instead wants the patient (participant) to be responsible for the payment (be a private pay patient), there must be a written agreement between the patient and the provider in which the patient understands and agrees that MO HealthNet will not be billed for the service(s) and that the patient is fully responsible for the payment for the service(s). The written agreement must be date and service specific and signed and dated both by the patient and the provider. The agreement must be done prior to the service(s) being rendered. A copy of the agreement must be kept in the patient’s medical record.
If there is no evidence of this written agreement, the provider cannot bill the patient and must submit a claim to MO HealthNet for reimbursement for the covered service(s). If MO HealthNet denies payment for a service because all policies, rules and regulations of the MO HealthNet program were not followed (e.g., Prior Authorization, Second Surgical Opinion, etc.), the patient is not responsible and cannot be billed for the item or service.
All commercial insurance benefits must be obtained before MO HealthNet is billed.
In the MO HealthNet program, some individuals are eligible for MO HealthNet benefits only on the basis of meeting a periodic spend down requirement. The MO HealthNet system prevents payment of medical services used to meet an individual’s spend down amount. The MO HealthNet participant may choose to meet their spend down by submitting incurred medical expenses to their Family Support Division (FSD) benefit specialist or paying the monthly spend down amount to the MO HealthNet Division (MHD).
Some Medicare/MO HealthNet dual eligible individuals must meet a spend down amount prior to MO HealthNet considering payment of the Medicare cost-sharing amounts. This may include Medicare beneficiaries enrolled in a Medicare Advantage/Part C plan. On spend down cases, MO HealthNet only reimburses providers for covered medical expenses that exceed a participant’s spend down amount. MO HealthNet does not pay for the portion of a bill used to meet the spend down.
- For QMB Plus MO HealthNet participants with spend down, the Medicare cost-sharing amount will be applied toward the spend down amount. Once the spend down liability is met, MO HealthNet will reimburse the provider for the remaining cost-sharing balance.
- For non-QMB MO HealthNet participants with spend down, MO HealthNet only reimburses providers for covered medical expenses that exceed a participant’s spend down amount.
Refer to Section 1.6.B of the Provider Manual at http://manuals.momed.com/manuals/ and the 2008 Provider Hot Tip of the Week entitled "Allowable spend down Medical Expenses" for detailed information regarding spend down. Refer to the May 5, 2008 provider bulletin for MO HealthNet policy related to Medicare Advantage (Part C) plans.
Ordering Claim Forms
December 22, 2008
Providers continue to place large orders for paper claim forms although claims history show their claims are submitted electronically. All providers are encouraged to submit their claims electronically; however there are situations when claims must be sent on paper claim forms, such as multiple surgery claims that require an operative report attached to the claim.
If an order is received for claim forms, a provider’s claim filing history is reviewed and often the provider is contacted if a large volume is requested. Please note that any forms provided by MO HealthNet are intended solely for MO HealthNet claims filing.
All MO HealthNet forms (including claim forms) can be downloaded and printed from the Web site at http://dss.mo.gov/mhd/providers/. From this page, choose "MO HealthNet forms" option in the left column. They are also available at the MO HealthNet billing Web site at www.emomed.com.
Providers may also order forms, when necessary, by calling the Provider Education Unit at 573/751-6683.
Billing for Administering VFC Vaccines
December 15, 2008
This Hot Tip was first published on October 2, 2006 and is being republished as the result of continued inquires from providers concerning proper billing for the administration of immunizations for children.
MO HealthNet’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 MO HealthNet policy and is improper billing. 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 MO HealthNet Physician Provider Manual clearly gives the MO HealthNet 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.
The MO HealthNet Physician Provider Manual can be accessed through the agency’s public Web site at http://manuals.momed.com/manuals/ .
Psychology Prior Authorization Year End Closing
December 08, 2008
All Psychology prior authorizations (PAs) issued for adults and children in foster care (ME codes 07, 08, 37, and 38) during any calendar year will have an authorized through date of December 31st of that same year. For example, any psychology PA issued during 2008 will close effective December 31, 2008. Any of your unused units on the PA will not carry over to the next year.
If a participant currently in treatment needs ongoing services, a new PA period will begin on January 01, 2009. For adults, providers may begin requesting a new authorization immediately under the guidelines outlined in the Psychology/Counseling manual, Section 13.13B. For children in foster care, providers may begin requesting a new authorization immediately under the guidelines outlined in the Psychology Bulletin Volume 30, Number 27, dated November 30, 2007. The manual and the bulletin may be accessed on-line at dss.mo.gov/mhd/providers/.
Providers who have been paid for services in excess of four (4) hours of therapy for a participant in the last rolling year will not receive four (4) additional non-prior authorized hours for that participant. When psychology services are provided through a group/clinic setting the group/clinic is considered the provider and not each individual.
December 1, 2008
The June 27, 2008 Durable Medical Equipment (DME) bulletin notified MO HealthNet fee-for-service providers of the implementation of changes to billing wheelchair options/accessories. Effective for dates of service August 1, 2008 and after, MO HealthNet requires the use of the item specific HCPCS code for all wheelchairs and wheelchair option/accessories for nursing home participants. The modifier SC must be added to the HCPCS code along with the appropriate NU (purchase), RR (rental) or RP (repair/replacement) modifier. For those options/accessories with an established maximum allowed amount, a manufacturer’s suggested retail price (MSRP) is no longer a necessary attachment regardless if the item requires a prior authorization or options/accessories for a wheelchair approved for a nursing home resident.
For those options/accessories without a specific HCPCS code, prior authorization continues to be a requirement for procedure code K0108. The MSRP will be required for items included in K0108; pricing will be 85% for options/accessories for manual wheelchairs and 90% for power wheelchairs.
Providers must bill MO HealthNet their usual and customary rate (UCR). Reimbursement will be the lesser of MO HealthNet’s maximum allowed amount or the provider’s UCR.
Medical Records and Retention
November 24, 2008
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 on file with the MO HealthNet Division (MHD).
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 MHD, or its authorized agent, providers must make available all records relating to services provided to MO HealthNet participants or records relating to MO HealthNet payments.
All MO HealthNet 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 with MO HealthNet.
A provider’s failure to furnish, reveal and retain adequate documentation for services billed to MO HealthNet can result in the recovery of the payments for those services and can result in sanctions to the provider’s application with the MO HealthNet program.
Hospital Outpatient Facility Charges
November 17, 2008
It is important to remember when it is appropriate to bill MO HealthNet a hospital outpatient facility charge. Inappropriate billing of facility charges will result in recoupment of payments. The following information was obtained from the MO HealthNet hospital provider manual which is available on the Internet at dss.mo.gov/mhd/providers.Please refer to Sections 13.27, 13.44, 13.47 and 15.23 for more information regarding outpatient facility charges.
A facility charge should be shown on the outpatient claim if the patient sees a MO HealthNet enrolled physician, nurse practitioner or podiatrist for evaluation or treatment of the condition that caused the need for hospital services and the person who is registered on the hospital records being in an outpatient status. Services and supplies that may be included in the facility charges include:
- IV Infusion Services, including but not limited to: chemotherapy; antibiotic therapy; hydration therapy; immune globulin therapy; IV rate change; pitocin
- Services such as: venipuncture; specimen collection; taking and monitoring vitals; prepping; positioning; injecting; call-back services; stat charges; routine monitoring (e.g. fetal, cardiac, etc…); after-hours services; claim filing fees; education/instruction (e.g. colostomy care, cardiac care, etc.); handling charge for specimens referred to an independent laboratory; late discharge fee; preparation of special reports sent to insurance companies; psychiatric reports for court evaluation or juvenile court; standby equipment
- The following operational cost elements: administrative costs; basic floor stock supplies; durable, reusable items or medical equipment; fixed building costs; furnishings; insurance; laundry; maintenance; nursing salaries; paramedical salaries; records maintenance; utilities
Services that are not to be added to the facility charge:
- Services performed by hospital staff that are incidental to physician services; and
- Services provided by a physician assistant (PA), including those provided in an outpatient hospital-owned clinic.
If the following services are the only services provided during a visit, without any physician services, a facility charge must not be shown: physical, occupational or speech therapy; renal dialysis; Injections/immunizations; laboratory/pathology; radiology; HCY/EPSDT services. These services can be billed by the hospital using the appropriate HCPCS Level I (CPT), Level II or Level III procedure code. The costs of diagnostic testing and treatment type equipment should be included in the charge for the specific service provided to the patient. The costs of hospital staff who are necessary to the performance of the specific service should be included in the charge for that service.
A facility charge code may not be billed by the hospital on the same date of service as cardiac rehabilitation unless a physician provided services on that day.
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.
Groups/Clinics — Performing Provider
November 10, 2008
Changing from a MO HealthNet legacy provider number to a National Provider Identifier (NPI) did not change the requirement for groups/clinics to show the performing provider NPI in the appropriate field of the claim form. If a claim is submitted using a group/clinic NPI, the individual provider NPI must be shown in the performing provider field; on the paper CMS-1500 form, this is field 24j and electronically, it is the performing provider identifier (NPI) field.
If the claim is filed using the group/clinic NPI and the performing provider field is blank or does not contain the individual performing provider NPI, the claim will deny with Remittance Remark Code N55 (Procedures for billing with group/referring/performing providers were not followed).
Temporary MO HealthNet During Pregnancy (TEMP)
November 3, 2008
As a reminder, TEMP services for pregnant women (Medical Eligibility codes 58 or 59) are limited to ambulatory prenatal services. Services other than ambulatory prenatal may be reimbursed if a Certificate of Medical Necessity is submitted with the claim and it affirms that the pregnancy would have been adversely affected without the service.
The diagnosis on the claim form must be a pregnancy/prenatal diagnosis (V22.0 through V23.9 or V28 through V28.9). Nurse midwives must use diagnosis codes V22.0 through V22.2 or V28 through V28.9.
If the TEMP participant is provided illness care, the illness diagnosis code must appear as the primary diagnosis code on the claim. However, a pregnancy/prenatal diagnosis code must also appear on the claim form.
Inpatient hospital services and deliveries performed either inpatient or outpatient are not covered under the TEMP program. Other non-covered services include postpartum care; contraceptive management; D & C; treatment of spontaneous, missed abortions or other abortions.
Infants born to mothers who are eligible under the TEMP Program are not automatically MO HealthNet eligible under the TEMP program.
For more information on theTEMP Program, please reference Section 13.3 of the MO HealthNet Physician Manual.
Prior Authorization Requests
See Correction below in red
October 27, 2008
Some services covered by the MO HealthNet Program require Prior Authorization (PA). This hot tip is to help you with key fields when completing the PA form and also help you learn how to check the status.
- The PA form can be downloaded from the provider page of the MO HealthNet Web site at /mhd/providers/. Choose the MHD forms option in the left column.
- If you are enrolled as a clinic, you should use your clinic/group name, address and NPI in Section IV of the PA form; otherwise you may not be able to check online the status of the PA or the PA disposition may be sent to another address. The prescribing/performing provider information should be entered in Section V.
- The completed paper PA request form describing those services or items requiring prior authorization and the reason the service or items are needed, along with any supporting documentation, must be submitted to the following address: Infocrossing Healthcare Services, Inc.
PO Box 5700
Jefferson City, MO 65102
- Providers have the ability to check the status of a PA request online at www.emomed.com. In the "Real Time Queries" box at this site, choose the ‘View PA Status’ option. PA status requests are restricted to the MO HealthNet provider NPI the PA was submitted under. This is the NPI you entered in Section IV of the PA form. PAs must be in ‘approved’ status before services can be delivered.
Prior authorization does not guarantee payment, only the medical necessity of the requested service or items.
Whether the PA is approved or denied, a disposition letter will be returned to the provider containing all of the detail information related to the PA request. The disposition letter is mailed to the "Primary" address on the MO HealthNet provider file. If the provider "Primary" address has changed, please send the information in writing to the MHD Provider Enrollment Unit, P. O. Box 6500, Jefferson City, MO 65102
For more information on prior authorizations, you can reference Section 8 of the Mo HealthNet Provider Manuals.
Billing Proper Medication Quantities
October 20, 2008
It is important that MO HealthNet providers understand how to bill the proper quantity for injections and other medications provided to their patients.
On the appropriate claim form, enter the decimal quantity dispensed or used in administration, as follows:
- Number of tablets or patches dispensed;
- Number of grams for ointments or powders (tubes, bottles, etc);
- Number of cc’s (ml’s ) administered for products in solution; (ampule, I.V. bag, bottle, syringe, vial, immunizations);
- Number of vials used containing powder for reconstitution;
- Some products are considered "Kits", these products are to be billed by each "Kit" dispensed (Levonorgestrel Implant 1 kit = 1 unit, Copaxone 1 kit = 1 unit, Diastat 1 kit = 1 unit)
When billing for an injection given from a single dose vial or single dose syringe and only part is administered, the provider can bill for the entire vial or syringe if the balance is not useable for another patient.
There are always exceptions to these rules for certain specialty drugs (Factor, Herceptin). Please call 573-751-6963 with any questions regarding billing NDC units.
October 14, 2008
A Sterilization Consent form is a required attachment for all claims containing the following procedure codes: 55250, 58565, 58600, 58605, 58611, 58615, 58670, and 58671. Without an approved Sterilization Consent form, neither the physician nor the facility can be reimbursed. The MO HealthNet participant must be at least 21 years of age at the time the consent is obtained and be mentally competent. The participant must have given informed consent voluntarily in accordance with federal and state requirements. More information on informed consent is available in Section 10.2.E (2) of the MO HealthNet Provider Manual available from dss.mo.gov/mhd/providers/.
The Sterilization Consent form must be completed and signed by the participant at least 31 days, but not more than 180 days, prior to the date of the sterilization procedure. There must be 30 days between the date of signing and the surgery date. The day after the signing is considered the first day when counting the 30 days. There are provisions for emergency situations which can be referenced in Section 10.2.E (1) of the MO HealthNet Provider Manual available from dss.mo.gov/mhd/providers/.
The Sterilization Consent form can be submitted electronically through the MO HealthNet Internet Web portal at www.emomed.com through the 'Submit Claim Attachments' option. If submitting the Sterilization Consent Form electronically, the provider must still maintain a properly completed paper form in the patient’s file and must provide a copy of the paper form to the hospital if the service was performed in the hospital.
Level 5 Physician Consultations
October 06, 2008
Physician providers are reminded that when billing for level five consultations, CPT codes 99245 (highest level of office/outpatient consultation) or 99255 (highest level of inpatient consultation), the claims must be submitted on the paper CMS-1500 and a copy of the consultation report must be attached to the paper claim. All claims for level five physician consultations are reviewed by the MO HealthNet Physician Consultant. This is specified in Section 13.28.D of the MO HealthNet Physician Provider Manual. The manual can be accessed from the MO HealthNet Provider Home page.
Claims for the lower level consultation codes (99241-99244 – office or other outpatient consultations and 99251-99254 – inpatient consultations) do not require a copy of the consultation report with them and can be filed electronically.
Retrieving An Aged Remittance Advice
September 29, 2008
Provider remittance advices (RAs) are available through the MO HealthNet Web portal at www.emomed.com and remain there for approximately 62 days.
On occasion, a provider may need an older RA. Older RAs can be obtained from the same Web site by choosing the 'Request Aged RA' option. Enter the month (MM), year (CCYY) and cycle (one (1) for the first cycle of the month or two (2) for the second cycle of the month). You can request as many older RAs as you need but can request only one at a time. You are limited to RAs for the past three years based on the date your request is submitted
An aged RA is available the next business day after it is requested. To access the aged RA, choose the 'Printable Aged RA' option from the 'Receive Provider Files' box. This brings up a page that displays the dates of all the RAs you have requested. Clicking on a date brings up the RA in the standard RA format. You then can print it or save it to your computer system. The aged RAs stay on this page for five (5) days following date of the request and then are removed from the page.
Determining Participant QMB Coverage
September 22, 2008
Providers can determine if a MO HealthNet participant is Qualified Medicare Beneficiary (QMB) eligible by checking the MHD eligibility file. Eligibility can be verified by either of the following methods:
- Access the "Verify Participant Eligibility" link through the MO HealthNet Internet Web portal at www.emomed.com. After entering the participant's ID number and date of service, the eligibility screen will show the participant's Plan code (this is the participant's medical eligibility (ME) code). If the participant is QMB only or QMB Plus, the information will be stated on the eligibility screen. A QMB Plus is an individual who meets all the standards for QMB eligibility but who also meets the financial criteria for full MO HealthNet coverage; or
- Access the Interactive Voice Response (IVR) at 573-635-8908. After entering the participant's ID number and date of service, you will hear eligibility information, including QMB coverage, if any.
If the participant's ME code/Plan code is 55, the participant has QMB eligibility only. This means MO HealthNet pays coinsurance, copayment and/or deductible for services covered and paid by Medicare. If Medicare does not make payment, MO HealthNet can not consider the claim for payment.
The ME codes and their descriptions are found in the MO HealthNet Provider Manual, Section 1.1.A, Description of Eligibility Categories.
Updating Provider Contact Information
September 15, 2008
It is often necessary for MO HealthNet Division (MHD) staff to contact enrolled providers for a variety of reasons such as returned checks, claim issues or enrollment information. Individuals who have 'administrator or provider' security access to the MHD Internet Web portal at www.emomed.com can ensure that MHD has the most up-to-date contact information by updating the provider’s contact information.
From this site, providers should select the 'Update Provider Contact Information' link to update certain information. Providers can update 'attention of name' (if other than the provider), 'street address', 'city', 'zip', 'county', 'business phone', 'business fax' and 'contact person’s email address'. The 'state' can be updated if it is a bordering state. A 'Help' feature gives field-by-field directions.
Individual providers may use their personal contact information (i.e., home address and telephone number) if desired. If this option is used, please enter 'home address' or 'home telephone' in the 'attention' field. Any contact information entered is not published; it is for MHD use only.
The following provider types have the ability to update their contact information:
- Advanced Practice Nurse
- Anesthesiology Assistant (AA)
- Certified Registered Nurse Anesthetist (CRNA)
- Clinic/Group (excludes Ambulatory Surgical Centers, FQHC’s and Dialysis Centers)
- Disease Management
- Independent X-ray (excludes portable x-ray and IDTF’s )
- Nurse Midwife
- Occupational Therapist
- Physical Therapist
- Private Duty Nursing
- QMB Only Providers
- Speech/Language Pathologist
For providers not listed above and for all providers to report other changes to the provider master file such as name change, change of ownership, tax ID or payment information, contact the Provider Enrollment Unit via E-mail at email@example.com.
Provider Information – Hurricane Gustav Evacuees
September 8, 2008
Some MO HealthNet enrolled providers may be treating evacuees from Hurricane Gustav who may be Medicaid recipients from the states of Louisiana or Mississippi. In order for providers to receive reimbursement, providers must enroll with the respective state’s Medicaid program. The following links are provided to expedite provider enrollment for the states of Louisiana and Mississippi:
Mississippi – http://www.medicaid.state.ms.us/
As a reminder, the Centers for Medicare & Medicaid Services (CMS) established a modifier and condition code to facilitate claims processing and track services and items provided to victims of disasters in any part of the country. The modifier must be used in addition to the procedure code and any other modifiers, as applicable. The condition code must be used in addition to other required condition codes.
- Professional Claims – Modifier
- CR – Catastrophe/Disaster Related
- Facility Claims – Condition Code
- DR – Disaster Related
Inpatient Hospital Certification – Part C Patients
September 2, 2008
Inpatient hospital claims for deductible and coinsurance for QMB MO HealthNet participants with Medicare Part C benefits are exempt from admission certification. However, if Medicare Part C benefits have been exhausted and a claim is submitted for MO HealthNet only days, admission certification requirements must be met. Pre-admission certification is required also for denied Medicare Part C inpatient hospital claims including exhausted benefits. Before requesting a pre-certification, the provider must exhaust all appeals through the Medicare Advantage/Part C plan appeals process and have a final denial that can be submitted to Health Care Excel (HCE) with the pre-certification request.
For non-QMB MO HealthNet participants enrolled in a Medicare Advantage/Part C Plan, admissions require certification. Additional information regarding inpatient hospital certification reviews is covered in Section 13.31 of the MO HealthNet hospital provider manual available at manuals.momed.com/manuals/
August 25, 2008
With school beginning this month, providers are reminded that MO HealthNet covers school/athletic physicals for MO HealthNet eligible children and youth. Criteria for school/athletic physicals are discussed in Section 13.13.C of the Physician Provider Manual which reads as follows:
"13.13.C SCHOOL/ATHLETIC PHYSICALS A physical examination may be necessary in order to obtain a physician’s certificate stating that a child is physically able to participate in athletic contests at school. When this is necessary, diagnosis code V20.2, should be used. This also applies for other school physicals when required as conditions for entry into or continuance in the educational process. Use the appropriate preventive medicine code (99381—99385 or 99391—99395) with the appropriate modifiers. Reference Section 9.5 of the provider manual for the appropriate modifiers."
The physician manual is available from the MO HealthNet Provider Home page.
Claim Confirmation Report
August 18, 2008
Providers submitting claims to MO HealthNet using Internet applications can learn the status of such claims the day following the submission (Monday-Friday) by going to the MO HealthNet Web site www.emomed.com. At this site in the "Receive Provider Files" box, click on ‘claim confirmation’ to retrieve your report. Claim confirmation reports are generated for each submission and available for approximately 45 days following each submission.
Claim status codes on the confirmation report can be viewed by selecting 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 also be found on the Washington Publishing Company HIPAA-Related Code Lists page
Contacting Provider Enrollment Unit
August 11, 2008
Inquiries for the MO HealthNet Provider Enrollment Unit (PEU) may be sent via E-mail to: firstname.lastname@example.org or by postal mail to the Provider Enrollment Unit, MO HealthNet Division, PO Box 6500, Jefferson City, MO 65102. All inquiries are reviewed and processed in date order as received.
Provider information changes must be reported to the PEU via E-mail or postal mail. With the notice, be sure to include the provider name(s), provider identifier(s), and the contact person’s name, E-mail address, fax number, and telephone number. Once the notice is received and reviewed thoroughly, the Provider Enrollment Unit will determine the action to be taken.
If additional information is needed, the PEU will contact the provider via E-mail, when an E-mail address is available, or by telephone. Provider name change or physical location change may be made from the written notice received by postal mail when the notice contains the original (wet) signature of the provider(s) involved. Other changes require that an update or new application be completed. The provider is notified by mail, E-mail, or telephone if this is necessary.
Possible changes include, but are not limited to:
- Provider name change
- Payment name or address change
- Physical location change
- Change of ownership/operator/merger
- Federal Tax Identification Number change
- Change from Social Security Number to Federal Tax Identification Number
- Change from Federal Tax Identification Number to Social Security Number
- Medicare identifier change
- NPI changes
- Licensure changes
- Certification changes
Emomed users who have provider or administrator access to a provider’s Personal Identification Number (PIN) may add, change, or delete additional practice locations via the Web site at www.emomed.com. Information entered at this site does not change the information on the Provider Enrollment Master File for the fields listed above. The additional practice locations that are published are updated from this site. Written notice is still required for the changes listed above.
Provider Direct Deposit
Electing the direct deposit option, changing routing or account numbers, or ending the direct deposit option requires that an Application for Provider Direct Deposit must be completed. A separate form must be completed for each provider identifier. When changing accounts, DO NOT close an old account until reimbursement is being deposited into the new account. Closing the old account before the new account is established will result in delayed reimbursement. The form must be printed, completed, signed with an original (wet) signature, and mailed to the Provider Enrollment Unit, MO HealthNet Division, P. O. Box 6500, Jefferson City, MO 65102.
Changes are not made without the properly completed form.
Hospital Charges – Noncovered Surgical Procedures
August 4, 2008
MO HealthNet has received many inpatient and outpatient hospital claims containing charges related to noncovered surgical procedures or procedures without an approved Prior Authorization (PA). Section 13.26 of the Hospital manual states "Services related to noncovered procedures are also noncovered. If any noncovered procedure is the chief reason for hospital services, none of the hospital charges are reimbursable." Charges related to surgical procedures without an approved PA are considered noncovered. For example, procedure code 54161 (Circumcision, surgical excision other than clamp, device or dorsal slit; older than 28 days of age) requires a PA to be covered by MO HealthNet. If performed without an approved PA, the procedure is considered noncovered. All noncovered charges reported on an Inpatient claim must be shown in the "Noncovered Charges" field of the UB-04 claim form, the Inpatient claim option on MO HealthNet’s Billing Web site www.emomed.com, and the Institutional ASC X12N 837 Health Care claim transactions. All noncovered outpatient charges should not be reported on the claim to MO HealthNet.
Physician Prior Authorization Requirements
July 28, 2008
Several surgical procedures require a Prior Authorization (PA). MO HealthNet has found that many of the surgical procedures requiring a PA are being performed without obtaining prior approval. Physicians are required to obtain a PA for these procedures before the surgical procedure is performed. If a PA is not obtained for the procedure performed, the surgeon’s charges and any related hospital charges are not payable and the patient cannot be held responsible. Surgical procedures requiring PA can be identified on MO HealthNet’s fee schedule page.
Reference Section 8 of the Physician manual for more information regarding Prior Authorizations.
National Correct Coding Initiative (NCCI)
July 21, 2008
Providers continue to have questions regarding the National Correct Coding Initiative and valid modifiers. MO HealthNet has required providers to follow Medicare’s Physician National Correct Coding Initiative (NCCI) guidelines beginning with dates of service July 1, 2007 and after. 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 Centers for Medicare & Medicaid Services (CMS) Web site at: http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/list.asp
A list of valid modifiers can be found on the MO HealthNet Provider Home page. From this site, you must choose the 'Fee Schedules' option in the column on the left. Read and click on "accept" then scroll down on the page to the "Modifier Information Link". Click on the link to review the list of modifiers. The list will give the modifier; indicate whether it is a pricing, routing or NCCI modifier and a short description.
NPIS For Hospital Pre-Certifications
July 14, 2008
Hospital providers are reminded that when contacting Health Care Excel for an inpatient hospital certification review for an admission, they should use the National Provider Identifier (NPI) assigned to the acute hospital unit. They should not use an NPI assigned to the hospital rehabilitation or psychiatric units.
Pre-Certification Requests For DME
July 07, 2008
In July 2007, the MO HealthNet Division (MHD) initiated a program for pre-certification of specific Durable Medical Equipment (DME) items. The first item to require pre-certification was the small volume nebulizer. Since that time, additional items requiring pre-certification include the following: large volume nebulizers; hospital beds, manual and semi-electric; CPAP and CPAP humidifiers; ultrasonic osteogenesis stimulator; diabetic shoes, inserts and modifications; respiratory assist devices (RAD); and chest wall oscillation devices.
The initiation of the pre-certification of DME is a two-step process. Step one of the pre-certification process must be initiated by an authorized DME prescriber who writes prescriptions for items covered under the DME program. Authorized prescribers include physicians, podiatrists and nurse practitioners who have a collaborative practice agreement with a physician that allows for prescription of such items. The enrolled DME provider will access the pre-certification initiated by the prescriber to complete step two of the pre-certification process. A working relationship between the prescriber and the DME provider is essential. All pre-certification requests must be approved by the MHD.
Providers are encouraged to sign up for the MO HealthNet Web tool CyberAccess which automates the pre-certification process. To become a CyberAccess user, providers should contact the ACS-Heritage help desk at 1-888-581-9797 or 573-632-9797, or send an E-mail to MOHealthNetCyberaccess@heritage-info.com. The CyberAccess tool allows each pre-certification to automatically reference the individual participant’s claim history, including ICD-9-CM diagnosis codes and CPT procedure codes. Requests for pre-certification will also be taken by the MO HealthNet call center at 800-392-8030. The call center is available Monday through Friday, 8:00 am to 5:00 pm, excluding state holidays. Requests for pre-certification must meet medical criteria established by the MHD in order to be approved. The Medical Criteria is published in provider bulletins and posted on the MHD Web site prior to implementation.
An approved pre-certification request does not guarantee payment. Providers must verify participant eligibility on the date of service using the Interactive Voice Response (IVR) at 573-751-2896 or 573-635-8908, or by logging onto the MO HealthNet Billing Web portal.
Please continue to monitor the MHD Web site for updates on this process.
Verifying Participant Eligibility
June 30, 2008
The MO HealthNet Division (MHD) wants providers to be reimbursed for their services the first time their claim is submitted. By far, the top claim denials result from providers failing to check participant eligibility. These denials are:
- Lock-in participant or managed care participant – If a participant is locked-in to a certain provider(s) or enrolled in a MO HealthNet managed care plan, providers are given this information when eligibility is checked. If a participant is locked-in to a provider(s) or enrolled in a managed care plan, services must be obtained through them.
- Medicare coverage – By checking eligibility, providers are informed if the participant has Medicare. The claims must be filed to Medicare first.
- Commercial insurance – A claim must be filed to the commercial insurance plan first if the MO HealthNet eligibility file reflects commercial coverage.
- Participant Name or Number Mismatch – Checking eligibility will verify the patient’s name and MO HealthNet ID number as it appears on the enrollment file. The claim must be filed with the patient’s current file name.
Providers can check eligibility by calling the Interactive Voice Response system at 573-635-8908 or through the Internet at www.emomed.com.
Claim Processing Schedule – FY 2009
June 23, 2008
The provider claim processing schedule has been updated for fiscal year 2009, which begins July 1, 2008. The schedule lists the dates the cycles are run and their corresponding check dates. This updated schedule can be found on the MO HealthNet Web site at http://dss.mo.gov/mhd/providers/ and then choosing the 'Claim processing and payment schedule' link in the left column. This schedule is also displayed at the MO HealthNet billing Web site at www.emomed.com.
Provider reimbursement checks are mailed or directly deposited in to a provider’s account twice each month, the 5th and the 20th. 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.
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 available on the MO HealthNet Provider Manual Web site at http://manuals.momed.com/manuals/ through the 'Forms' option.
Medicare HMO’s (Hot Tip Removed)
June 16, 2008
The Hot Tip titled 'Medicare HMOs and Medicaid' dated January 2, 2007 has been removed from the MHD Web site because the policy is no longer in effect. The hot tip indicated that Missouri Medicaid will not pay any co-payment amounts for Medicare/Medicaid clients that had a Medicare HMO policy.
The new, effective policy was posted in the May 5, 2008 bulletin titled 'MO HealthNet Cost Sharing For Medicare Part C/Medicare Advantage Plans'.
New Policy: For dates of service beginning October 1, 2007, MO HealthNet Division (MHD) will pay 100% of the Medicare Advantage/Part C cost sharing for MO HealthNet participants who are Qualified Medicare Beneficiary (QMB Only) and Qualified Medicare Beneficiary Plus (QMB Plus) participants.
For non-QMB MO HealthNet participants enrolled in a Medicare Advantage/Part C Plan, MHD will process claims in accordance with the established MHD coordination of benefits policy.
If there is no evidence of a written agreement between the patient and the provider in which the patient understands and agrees that MO HealthNet will not be billed for the service(s) and that the patient is fully responsible for the payment for the service(s), the provider cannot bill the patient and must submit a claim to MO HealthNet for reimbursement for the covered service(s).
For specifics and claim filing instructions, please reference the above bulletin.
Vaccines For Children Program
June 9, 2008
Through the Vaccine for Children (VFC) Program, federally provided vaccines are available at no cost to public and private providers for eligible children ages 0 through 18 years of age. MO HealthNet enrolled providers must participate in the VFC Program administered by the Missouri Department of Health and Senior Services (DHSS) and must use the free vaccine when administering vaccine to qualified MO HealthNet eligible children. Providers are required to enroll as VFC providers with DHSS in order to bill MO HealthNet for the administration of the vaccine. For more information regarding the specific guidelines of the VFC Program contact the following:
Missouri Department of Health and Senior Services
930 Wildwood, PO Box 570
Jefferson City, MO 65102
Phone (573) 751-6124
MO HealthNet Managed Care health plan providers must enroll in the VFC Program administered by the DHSS and must use the free vaccine when administering the vaccine to MO HealthNet Managed Care enrollees. The MO HealthNet Managed Care health plans do not receive an additional administration fee as the reimbursement is included in the capitation payment. MO HealthNet Managed Care health plans may have differing payment arrangements with their providers and the VFC administration fee may be included in the capitation payment from the MO HealthNet Managed Care health plan to the provider. However, the MO HealthNet Managed Care health plan’s reimbursement to local public health agencies is $5.00 per vaccine component unless otherwise regulated. Providers should contact the appropriate MO HealthNet Managed Care health plan for correct billing procedures.
For more information, providers can reference Section 13.13A of the MO HealthNet Physician manual.
Allowable spend down Medical Expenses
June 02, 2008
The following information is provided by the Family Support Division, Missouri Department of Social Services.
spend down is similar to a deductible on an insurance policy. Payment for MO HealthNet services begins the date the spend down amount is met. The participant can choose to meet his/her spend down either by:
- Submitting incurred medical expenses (bills) to his/her eligibility specialist
- Paying his/her monthly spend down amount to the MO HealthNet Division. For this option, the participant may send a check or money order to MO HealthNet Division or can opt to have a direct withdrawal from his/her checking account
Expenses that may be used toward meeting a participant’s spend down are incurred expenses that are not subject to payment by a third party, unless the third party is a public program of a state governmental agency.
Medical expenses that can be used to meet spend down include:
- All types of medical expenses covered by MO HealthNet
- All prescribed drugs and dental care
- Health care services rendered in the home including the cost of physical, occupational and speech therapy; services of home health aides; medical supplies such as surgical dressings, splints, casts, syringes, oxygen, braces, catheters, colostomy bags, and other similar medical supplies; and rental durable medical equipment such as oxygen tents, iron lungs, hospital beds, and wheelchairs
- Personal care services not currently being provided for, through other federally-funded programs, i.e. Title XIX (does not include services being provided by a relative)
- Medically related homemaker/chore services and medically related adult day health care or adult day treatment (does not include services provided and paid for through other federally funded programs or non medically related services)
- Independent Living Waiver Services authorized by the Division of Vocational Rehabilitation through a contract with a Center for Independent Living (CIL). The waiver provides services to disabled individuals age 18 through 64. Waiver services include:
- Case Management
- Personal Care Services
- Environmental Accessibility Adaptions
- Specialized medical equipment and supplies
- Private duty nursing services in the home
- Prosthetic devices, hearing aides, and eye glasses
- Services of: optometrist; optician; chiropractor; podiatrist; Christian Science Practitioner
- Residential and day habilitation services prescribed by a physician and authorized by the Department of Mental Health (DMH)
For additional information, please reference the Family Support Division Memo IM-106 dated September 10, 2002 or contact the local Family Support Division office.
New MO HealthNet for Kids Web Portal
May 27, 2008
The Department of Social Services has launched a new MO HealthNet for Kids Web portal page, dss.mo.gov/mhk. This page unites information from various divisions within the Department of Social Services on one convenient page.
Information available on the MO HealthNet for Kids portal page includes how to apply, who is eligible, what benefits are offered and how to find a local provider. It also contains helpful resources such as immunization information and answers to frequently asked questions.
Medicare Part B Information – Eastern Missouri
May 19, 2008
MO HealthNet is helping to disseminate information to Medicare Part B providers in the eastern region of the state of Missouri as to specific instructions on filing claims to the new Medicare Part B Contractor effective June 1, 2008.
Please reference the following link: http://www.wpsmedicare.com/mac/transition/moe_cutover.pdf
Counties in eastern Missouri affected by the change in billing from Pinnacle Business Solutions to Wisconsin Physicians Service (the new Medicare Administrative Contractor for Iowa, Kansas, Missouri and Nebraska) include: Adair, Audrain, Barry, Barton, Bollinger, Boone, Butler, Callaway, Camden, Cape Girardeau, Carter, Cedar, Chariton, Christian, Clark, Cole, Cooper, Crawford, Dade, Dallas, Dent, Douglas, Dunklin, Franklin, Gasconade, Greene, Hickory, Howard, Howell, Iron, Jasper, Jefferson, Knox, Laclede, Lawrence, Lewis, Lincoln, Linn, McDonald, Macon, Madison, Maries, Marion, Miller, Mississippi, Moniteau, Monroe, Montgomery, Morgan, New Madrid, Newton, Oregon, Osage, Ozark, Pemiscot, Perry, Phelps, Pike, Polk, Pulaski, Putnam, Ralls, Randolph, Reynolds, Ripley, St. Charles, Ste. Genevieve, St. Francois, St. Louis City, St. Louis County, Schuyler, Scotland, Scott, Shannon, Shelby, Stoddard, Stone, Sullivan, Taney, Texas, Warren, Washington, Wayne, Webster and Wright.
The remaining counties (western Missouri) transitioned to Wisconsin Physician Service on March 1, 2008.
MO HealthNet Forms
May 12, 2008
Obtaining forms for service documentation or necessary claim filing is quick and simple. All forms, including Sterilization Consent, HCY Screening, Hospice Election and Second Surgical Opinion can be easily downloaded from the Mo HealthNet Web site at http://dss.mo.gov/mhd/providers/. At this site, click on the 'MO HealthNet Forms' option in the left hand column.
Once completed, information from the forms such as the Sterilization Consent, Medical Necessity, Hysterectomy and Second Surgical Opinion can be entered on-line through the MO HealthNet Billing Web site at www.emomed.com; however, the paper forms must be retained in the patient’s file and be available upon request by MO HealthNet.
Provider Practice LocationAddresses
May 5, 2008
Providers have control over which of their practice addresses are viewed by participants and other providers when the search is made for a practicing provider in a particular area or for a specific service.
With consolidation of provider identifiers, you can maintain the listing of your practice addresses. For example, you have only one National Provider Identifier (NPI), but you may want others to be aware of the different locations at which you practice. Or you may need to update or delete practice location information. You can update the information at the MO HealthNet Billing Web site at www.emomed.com. You must be the enrolled provider or the provider administrator to access the option to maintain addresses.
At www.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. Please be sure to select your specialty for each location.
Changing your address at www.emomed.com does not change your enrollment address on the MO HealthNet Provider Master Record. Changes to the Master Record must still be done by contacting the Provider Enrollment Unit via E-mail at email@example.com.
If you are unsure if your provider practice location(s) is/are shown correctly, you can query the provider information through the MO HealthNet Provider Search link at: https://apps.dss.mo.gov/fmsMedicaidProviderSearch/. After reviewing, if practice locations need to be added or updated, please follow the process above to change.
VFC Information Sources
April 28, 2008
MO HealthNet often receives inquiries from providers regarding Vaccines for Children (VFC) program guidelines and policies. Information specific to MO HealthNet VFC policies is found in Section 13.13.A of the MO HealthNet Physician Provider Manual.
The Bureau of Immunization Assessment and Assurance in the Missouri Department of Health and Senior Services (DHSS) administers the Missouri VFC program. The Bureau uses the following sources of information.
- Epidemiology and Prevention of Vaccine-Preventable Diseases (Pink Book). This book provides the latest information concerning vaccines and vaccine-preventable diseases. The publication can be accessed at the following Web site: http://www.cdc.gov/vaccines/pubs/pinkbook/pink-chapters.htm
- Centers for Disease Control (CDC) frequently asked questions. http://www.cdc.gov/vaccines/vpd-vac/faqs-nipinfo-list.htm
- "Ask the Experts", Immunization Action Coalition http://www.immunize.org/askexperts
- The Advisory Committee on Immunization Practices (ACIP) http://www.cdc.gov/vaccines/pubs/ACIP-list.htm
Providers can use the above resources or may call the Bureau of Immunization Assessment and Assurance VFC program at 573/526-5349 or 800/219/3224 regarding specific immunization policies and guidelines. Additional DHSS VFC program information is available at the following Web site: http://www.dhss.mo.gov/Immunizations/VFC-Providers.html. Questions regarding VFC billing and coverage for MO HealthNet participants should be directed to MO HealthNet Provider Communications, 573/751-2896.
April 21, 2008
Enrolled MO HealthNet providers often ask about certain situations that would make the MO HealthNet participant 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 titled “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 MO HealthNet reimbursement based on the participant’s MO HealthNet benefits unless the MO HealthNet participant agrees in writing, prior to receiving the service, that MO HealthNet will not be billed and the participant accepts financial responsibility for the service. The statement must include the date of service, the service for which the participant has accepted financial responsibility, the participant’s signature and the date signed. This should be maintained by the provider in the patient record.
A participant 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 MO HealthNet denies payment for a service because all the policies, rules and regulations of the MO HealthNet program were not followed by the enrolled provider, (such as Prior Authorization or Sterilization Consent Form), the participant is not responsible and cannot be billed for the item or service.
Contacting the Provider Education Training Unit 573/751-6683
April 14, 2008
General claim billing, claim denials, and participant eligibility questions should be directed to the
With the increased use of group provider numbers and the impending use of National Provider Identifier (NPI) numbers, providers should be aware of which Provider Education representative to contact to receive training. When calling the Provider Education Training Unit, ask for the appropriate representative (shown below). If you need to leave a message be sure to include your name, the provider name, provider/NPI number, telephone number, extension number if necessary and the type of training needed. It is not possible to list all the MO HealthNet programs below, but by providing the pertinent information above, your request for assistance can easily be directed to the appropriate staff.
The names of the Provider Education representatives and some of their training programs are listed below:
Becky — personal care/homemaker-chore, home health, private duty nursing, psychology/counseling, speech/occupational/physical therapy, including these providers within a group or clinic;
Dawn — durable medical equipment, ambulance, adult day care, nursing homes, dental, optical (optometrists), including these providers within a group or clinic;
Roger — nurse practitioners, podiatrists, hospitals, physician/clinics, professional medical billing concerning Federally Qualified Health Centers and Rural Health Clinics;
Carol — Medicare/MO HealthNet crossover claim filing.
Requests for training can be made by E-mail to MHD.ProvTrain@dss.mo.gov or by telephone at 573/751-6683. All information, including a provider/NPI number must be readily available.
Vagus Nerve Stimulation
April 7, 2008
MO HealthNet’s Program Integrity Unit recently discovered instances where physicians and hospitals have improperly billed for vagus nerve stimulation services for medical conditions other than those allowed by MO HealthNet policy.
Vagus nerve stimulation is covered for patients with medically refractory partial onset epileptic seizures for whom surgery is not recommended or for whom surgery has failed.
At this time MO HealthNet does not cover vagus nerve stimulation therapy for treatment resistant depression.
The device is included in the hospital per diem if the surgery is performed in an inpatient hospital setting. If the surgery is performed in an outpatient hospital setting, the device is billable under the outpatient supply code.
More information on vagus nerve stimulation can be referenced in Section 13.75 of the Physician Provider Manual.
MO HealthNet Postoperative Care Policy
March 31, 2008
This Hot Tip was first published on November 28, 2005 but recent inquiries indicate providers continue to have problems regarding billing for postoperative care. Therefore, it is being republished. The postoperative policy is covered in Section 13.41 of the Physician Provider Manual:
Postoperative care includes 30 days of routine follow-up care for those surgical or diagnostic procedures having a MO HealthNet reimbursement amount of $75.00 or more. For counting purposes, the date of surgery is the first day. This policy applies whether the procedure was performed in the hospital, an ambulatory surgical center or an office setting, and applies to subsequent physician visits in any setting (e.g., inpatient and outpatient hospital, office, home, nursing home, etc.). Pain management is considered part of postoperative care. Visits for the purpose of postoperative pain control are not separately reimbursable. Physician [surgeon or physician other than the surgeon] services are audited against claims that have already been paid as well as against those claims currently in process. Supplies necessary for providing the follow-up care in the office, such as splints, casts and surgical dressings in connection with covered surgical procedures that meet the postoperative care policy, may be billed under the appropriate supply code. Attach an invoice if applicable.
Procedures subject to postoperative editing are covered in Section 13.41.B of the Physician Provider Manual.
Sometimes providers fail to use the appropriate modifier when billing for surgical care only or post operative management only. Use modifier 54 with the surgical procedure code to indicate surgical care only. Use modifier 55 with the surgical procedure code to indicate postoperative management only with the date of service being the date of the actual surgery.
Psychology/Counseling Program Documentation Examples
March 24, 2008
MO HealthNet Division (MHD) has developed examples of documentation for the Psychology/Counseling program. The examples address treatment of a fictional patient and include a Diagnostic Assessment, Diagnostic Assessment Update, Treatment Plan, Treatment Plan Update, an Individual Therapy Progress Note, and a Family Therapy Progress Note. Though the MHD does not require a specific format for documentation, the examples depict the required content defined by policy in Section 13.6.A through 13.6.A(5) of the Psychology/Counseling Manual. A link to the provider manual can be found at: dss.mo.gov/mhd/providers/. This is the provider page. Scroll to the bottom and click on provider manuals. You will find instructions on this page to direct you to Section 13.
These documentation requirements pertain to all providers rendering psychology/counseling services to any MHD eligible participant regardless of placement, setting, or provider credential. These requirements do not replace or negate documentation or reports required by the Children’s Division (CD) for individuals in their care and custody, or those required by other authoritative entities. Providers are expected to comply with the policies and procedures established by CD and those other entities.
For provider and policy issues regarding MHD Clinical Services Program, including Psychology, Pharmacy, The Missouri Rx Plan (MoRX), Exceptions, Chronic Care Improvement (CCIP), and Medical Precertification, E-mail us at: firstname.lastname@example.org.
Questions and comments regarding any other issues should be directed to: ask.MHD@dss.mo.gov.
When can Patients Change Managed Care Health Plans?
March 17, 2008
A MO HealthNet participant newly enrolled in a MO HealthNet Managed Care health plan can change health plans, for any reason, during the first 90 days of becoming a Managed Care health plan member.
The participant may also be able to change MO HealthNet Managed Care health plans after 90 days. Some reasons for changing after 90 days include: the participant moved out of the MO HealthNet Managed Care area; the participant’s primary care provider is no longer with the person’s MO HealthNet Managed Care health plan and is in another MO HealthNet Managed Care health plan; or the participant’s specialist or other health care provider from whom the person currently is obtaining services is no longer with the health plan and is in another MO HealthNet Managed Care health plan.
Participants have a 30–day open enrollment period once a year. Members may change MO HealthNet Managed Care health plans during their annual open enrollment period and children in Category of Aid 04 (state care and custody) may change MO HealthNet Managed Care health plans as often as circumstances necessitate.
Participants also have a right to change the primary care provider (PCP) within their MO HealthNet Managed Care health plan at least two times each year. Some MO HealthNet Managed Care health plans may allow more. Children in state custody may change their primary care provider as often as necessary.
Optical Hot Tip – Replacement of Lens(es) and Frames
March 10, 2008
MO HealthNet covers one pair of lens(es) and frames per participant every two years (during any 24-month period). The date of service for lens(es) and frames is the date they were dispensed, not the date the lens(es) and frames were ordered.
Replacement of a lens(es) is not covered within the 24 months following the date of service of the MO HealthNet purchase unless medically necessary due to a prescription change of at least 0.50 diopters for one eye or 0.50 diopters for each eye. If there is a 0.50 diopter change in one eye, MO HealthNet only replaces the lens for the eye with the 0.50 diopter change, not both eyes. Replacement of frames is not covered during the 24 months following the date of service of the MO HealthNet purchased frames.
In order to bill for replacement lens(es) due to a prescription change, a completed Certificate of Medical Necessity is required. The Certificate of Medical Necessity can be entered as an electronic attachment to the Medical (CMS-1500) claim form at the MO HealthNet billing Web site, www.emomed.com by clicking on the “Medical Nec” link on the claim form. Most of the fields are automatically populated, but the fields for the description of the item or service, reason for the service, provider name and number, and the date prescribed must be completed. Both the old and new prescriptions must be included in the reason field for each replacement lens(es). The participant’s new prescription must still be entered in the “Add/View Optical” link on the claim form.
Replacement of lost or broken glasses, frames, or lens(es) is a covered service for participants under the age of 21 with an approved prior authorization for procedure code V2799. The lens(es) prescription and the procedure code(s) of the items being requested must be written on the Prior Authorization Request form in the “Description of Service/Item” field.
Prior Authorization Requests
March 3, 2008
The Durable Medical Equipment (DME) Bulletin dated June 5, 2007, Volume 29, Number 57, informed DME providers they may submit Prior Authorization (PA) Requests by facsimile (fax) to 573/659-0207. At this time, only DME providers are allowed to fax PA requests. All other providers who dispense or provide services which require prior authorization must continue to submit a paper PA request form.
The completed paper PA request form describing those services or items requiring prior authorization and the reason the services or items are needed, along with any supporting documentation, must be submitted to the following address:Infocrossing Healthcare Services
PO Box 5700
Jefferson City, MO 65102
PA requests received at the DME fax number above from non-DME providers will be returned via the fax number through which the request was sent.
Providers may confirm if a procedure code requires prior authorization by using the Fee Schedules link on the MO HealthNet Division Provider page.
Hospice Election & Revocation
February 25, 2008
To be eligible to elect hospice care under MO HealthNet, participants must be certified by a physician as being terminally ill. Participants are considered terminally ill if they have a medical prognosis that their life expectancy is six months or less. Hospice services must be reasonable and necessary for the palliation or management of the terminal illness and related conditions. Participants must elect hospice care and agree to seek only palliative care for the duration of the hospice enrollment. Care may be provided in the home, a nursing facility or in a hospital.
Participants must be made aware that by electing hospice services they waive all rights to MO HealthNet services related to the treatment of the terminal condition and any related conditions for which hospice care was elected, or for services that are equivalent to hospice care, except for services:
- provided by the designated hospice;
- provided by another hospice under arrangements made by the designated hospice; and
- provided by the participant’s attending physician if that physician is not an employee of the designated hospice or receiving compensation from the hospice for those services.
A participant or their representative may revoke the election of hospice care at any time by filing a Notification of Termination of Hospice Benefits form with the hospice that includes a signed statement the participant revokes the election for MO HealthNet coverage of hospice care. The effective date of the revocation is the date of the signature unless a subsequent date is designated. The revocation of hospice services is always the participant’s choice. A hospice may not revoke an election because the participant is admitted to a hospital or chooses other curative care. The participant must understand when he/she signs the Hospice Election Statement he/she can be financially liable for curative treatment not arranged by the hospice or provided by the attending physician.
The hospice provider is reimbursed for the date of revocation. The MO HealthNet participant resumes MO HealthNet coverage for services related to the terminal illness the day following the day of revocation. Reimbursement for services related to the terminal illness provided on the day of revocation to another entity will be reviewed by the MO HealthNet Division on a case-by-case basis. MO HealthNet providers should direct their claim concerns to the following:Provider Communications Unit
PO Box 5500
Jefferson City, MO 65102-5500
Chronic Care Improvement Program Update
February 18, 2008 Updated 2/20/08
The correct telephone number for the Chronic Care Improvement Program (CCIP) Update is 1-866-464-7147.
The Chronic Care Improvement Program (CCIP) is an enhanced primary care case management program that incorporates the principles of disease management, care coordination and case management to serve fee-for-service patients identified through a risk assessment and disease stratification model. APS Healthcare administers the program on behalf of the MO HealthNet Division.
The CCIP works to improve the health status and decrease complications for patients with chronic illness including asthma, chronic obstructive pulmonary disease (COPD), diabetes, cardiovascular disease and gastroesophageal reflux disease (GERD) and Sickle Cell Disease (SCD). Key CCIP goals include establishment of a health care home, patient empowerment through education and increased self-management of their health status, and utilization of existing community resources and health infrastructures through the coordination of care.
CCIP participants benefit from access to telephonic support from a registered nurse health coach, assistance with social barriers to care, and easy to understand educational materials.
Provider benefits include reinforcing medical treatment plans; assistance with locating community resources; access to an online interactive tool, APS Care Connection®, for pharmacy information, claims history and diagnosis history financial incentives for participation and performance and a link to access Cyber Access sm directly from Care Connection.
CCIP is available to MO HealthNet participants in most areas of the state, including the counties along the I-70 corridor and the northeast and southeast regions of the state.
Enrollment is open continuously for new participants at any time. To refer a participant to CCIP, or to learn more about CCIP or to schedule a visit from a CCIP representative, please call the APS help desk toll free: 1-866-464-7147 or visit http://www.moccip.com/ or http://dss.mo.gov/mhd/cs/cci/.
For additional program information, please reference the following MO HealthNet Provider Bulletin: Volume 29 Number 22 – January 16, 2007
February 11, 2008
Claims submitted to MO HealthNet may, due to the adjudication system requirements, have service lines separated from the original claim. This is commonly referred to as a split claim. Each portion of a claim that has been split is assigned a separate internal control number and the sum of the service line(s) charge submitted on each split claim becomes the split claim total charge. Currently, a maximum of 28 service lines per claim are processed. All detail lines that exceed the size allowed are split into a separate claim. If a claim denies for more than 25 edits, the claim must be split into multiple claims.
Timely filing, duplicate claim submission, third party liability and spend down all post an edit for each line and can cause a claim to deny for more edits than the system can process. Providers can avoid this type of claim denial by submitting smaller claims with fewer line details.
MO HealthNet applies editing to Medicare/MO HealthNet crossover claims very similar to that used to process MO HealthNet only claims. The system can only process 25 edits or less on one claim. If the claim denies for more than 25 edits, the crossover claim must be split into multiple claims. When splitting the claim into multiple claims, the claim header charge will be different than the one sent to Medicare because the claim header charge must reflect the total charge of the service lines on the smaller split claim.
Providers can also bill smaller claims to Medicare so that the claim can crossover correctly without being manually split to address more than 25 edits.
Additional information regarding split claims can be found in Section 17.6 of the provider manual located on the Internet at http://dss.mo.gov/mhd/providers/. Information regarding Medicare/MO HealthNet crossover claims can be found in the Crossover Claim Editing Bulletin, Volume 29, Number 8 dated August 21, 2006.
HIPAA-Related Code Lists
February 4, 2008
Providers continue to question the explanation of the codes shown on their claim confirmation report as well as their remittance advices.
MO HealthNet no longer reports MO HealthNet-specific explanation of benefits and exception message codes on any type of remittance advice. As required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) national standards, administrative code sets such as Claim Adjustment Reason Codes, Remittance Advice Remark Codes and NCPDP Version 5.0 Reject Codes for Telecommunication Standard are used.
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. A listing of the NCPDP Version 5.0 Reject Codes for Telecommunication Standard can be found in the NCPDP Version 5.Ø Reject Codes For Telecommunication Standard appendix.
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/.
Transfers Within A Hospital
January 28, 2008
Section 13.30.E of the MO HealthNet Hospital Provider Manual addresses the matter of transfers within a hospital.
13.30.E Transfers Within A Hospital
It is improper to submit two claims when a patient is transferred from one part of a hospital to another. The counting of days that are allowable under the length-of-stay (LOS) schedule or Health Care Excel (HCE) approved days is from the date of initial admission for a continuous period of hospitalization. Only one claim may be submitted which covers the full continuous length of stay at the one hospital. This policy includes the following situations:
When post payment review shows evidence that the LOS limitation or HCE approved days has been exceeded because two claims where submitted for one continuous stay at the same hospital, recoupments are made.
- Movement from one level of room accommodation to another level.
- Movement from the acute area of the hospital to another area, such as a psychiatric or rehabilitation unit.
- Written discharge from one unit and admission to another unit of the hospital.
Note - If the patient is on spend down and the hospital stay spans from one month to the next, the hospital must submit a separate claim for each month since spend down medical expenses are incurred by the patient on a monthly basis.
Clarification To January 14, 2008 Hot Tip
January 29, 2008
The information below is to provide clarification to the hot tip dated January 14, 2008 regarding information to enter in the surgical field of the hospital claim form.
Inpatient Claim Form
If it is necessary to use the operating room to perform a procedure during an inpatient hospital stay, the principal procedure field 74 on the UB-04 Claim form must be completed. If more than one procedure is performed, list the other procedures and dates in fields 74a-74e using ICD-9 Surgical Procedure Codes on the inpatient claim form.
If a procedure is performed in the patient’s room, in a treatment room, or in another area of the hospital that is not an operating room, do not complete field 74 on the UB-04 inpatient claim form.
If a procedure is entered in field 74 of the inpatient claim form, there must be a revenue code shown for the operating room or labor/delivery room.
Outpatient Claim Form
For surgical procedures performed in the outpatient/emergency room setting of the hospital, the principal procedure field 74 on the UB-04 Claim form must be completed. If more than one procedure is performed, list the other procedures and dates in fields 74a-74e using CPT Surgical Procedure Codes.
Optical — Special Frames
January 21, 2008
Special frames, procedure code V2020-22, are covered under the MO HealthNet Optical Program if medically necessary. Special frames are covered if one or more of the following circumstances apply:
- if the participant requires special lens(es) over 4.00 diopters for one eye, or over 4.00 diopters for each eye and are extra thick or heavy, or;
- if the structure of the participant’s face requires special frames (a very large face or wide-set eyes), or;
- if the participant needs glasses with pads because of nose surgery.
A Certificate of Medical Necessity form is not a required attachment; however documentation of the medical necessity for a special frame must be retained in the participant’s file.
Surgical Field — Hospital Claim Form See January 29 above for clarification
January 14, 2008
If it is necessary to use the operating room to perform a surgical procedure, the principal procedure code (field 74) on the UB-04 claim form must be completed or the corresponding field on the electronic layout if billing electronically. If more than one procedure is performed, list the other procedures and dates in fields 74a-74e using CPT-Surgical Procedure Codes.
If a procedure is performed in any area of the hospital that is not an operating room, do not complete field 74 on the UB-04 claim form.
If a procedure is entered in field 74, there must be a revenue code shown for the operating or labor/delivery room.
Medical Eligibility Codes Defined
January 7, 2008
At the request of providers, this hot tip regarding medical eligibility (ME) codes is a duplicate to the one dated December 26, 2006.
MO HealthNet 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 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 MO HealthNet Provider Manuals, Section 1.1.A, Description of Eligibility Categories.