2009 Provider Tips

Dental Prior Authorizations

December 28, 2009

The treating or performing dentist is responsible for submitting a Prior Authorization Request form as required by the MO HealthNet Division for those procedure codes requiring a prior authorization (PA). In situations when dentists are employed by or under contract with a dental clinic, the clinic may submit the PA request form; however the treating or performing dentist’s name must be stated in field 25 of the PA Request form and their individual National Provider Identifier (NPI) must be stated in field 27. The PA Request form is not to be submitted under the name of a dental clinic or under the NPI of the dental clinic.

For the purpose of submitting claims for approved prior authorized services, the NPI of the billing provider should be the same NPI the PA was approved under. In the case of the dental clinic, the billing NPI will be the NPI of the clinic and the treating or performing dentist should be the NPI the PA was approved under.

For more information on completion of the Prior Authorization Request form, providers can reference sections 8 and 14 of the dental provider manual.

Multiple Surgical Procedure Billing Policy

December 21, 2009

Each month, MO HealthNet generates a report on major claim denial reasons for the various provider types. One of the continuing reasons for medical claim denials pertains to claims filed for multiple surgical procedures performed by a physician on the same patient on the same day. Claims for multiple surgeries on the same patient on the same day by the same provider must be submitted on paper and the operative report must be included with the paper claim. The claims cannot be filed electronically.

The two major reasons for the denials are: 1) the claim was filed electronically which means an operative report could not be submitted with the claim; or, 2) the claim was filed on paper but no operative report was submitted with the claim.

The following information is taken from Section 13.40.F of the MO HealthNet Physician Provider Manual :

“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 MO HealthNet allowable fee for the procedure. (No reimbursement is made for incidental procedures.)

Multiple surgical procedures performed on the same participant, 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 from the provider 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). “

Evaluation and Management (E&M) Services

December 14, 2009

Providers often inquire about the level of service to bill for office visit evaluation and management (E&M) services, CPT codes 9920199205 and 99211-99215. Section 13.21 of the MO HealthNet Physician Provider Manual gives guidance on billing services to MO HealthNet.

13.21 OFFICE OR OTHER OUTPATIENT SERVICES

The procedure codes to be used to report evaluation and management services provided in the physician’s office, an outpatient hospital facility, or other ambulatory facilities are found in the CPT book. A patient is considered an outpatient until inpatient admission to a health care facility occurs. Non-emergency services provided in an emergency room should be considered clinic (outpatient) place of service (POS) for billing purposes.

13.21.A LIMITATIONS TO OFFICE/OUTPATIENT SERVICES

  • Office/outpatient services are to be used for “illness” care and are limited to one visit per participant per provider per day. Additional medically necessary visits on the same day may be covered if a properly completed Certificate of Medical Necessity form is attached to the claim and approved by the medical consultant. (See Section 7 for instructions on completion of the Certificate of Medical Necessity form.)
  • An office/outpatient physician visit includes, but is not limited to, the following:
    • Examining the patient and obtaining a medical history for symptoms or indications of an illness or medical condition. For children’s examinations as required for school education purposes, reference Section 13.13. Reference Section 9 for information on Healthy Children and Youth (HCY) screenings;
    • Administering injections;
    • Preparing bacterial, fungal and cytopathology smear(s) and cultures;
    • Obtaining specimens (urine, blood, etc.);
    • Using any instrument to examine and/or diagnose the illness or condition;
    • Fitting a diaphragm;
    • Removing an IUD;
    • Furnishing supplies (e.g., gowns, drapes, gloves, urine cups, swabs, etc.)
      (Reference Section 19.5 for billable supplies);
    • Preparing medical records and all required forms.
  • An office/outpatient service may not be billed on the same date of service as a home visit, subsequent hospital visit, consultation, preventive medicine services, HCY screening or nursing home visit. (An office visit may be billed on the same date of service as a hospital admission.)
  • An office/outpatient visit may not be billed on the same date of service as any of the psychotherapy visits. (Reference Section 13.57 for information on psychiatric services)
  • An office visit is not covered if the only service is to obtain a prescription, the need for which has been determined previously.
  • An office/outpatient visit may only be billed on the same date of service as a physical medicine modality or procedure when an office/outpatient visit service is provided. (If planned therapy is the only service received, an office/outpatient visit should not be billed in addition to the therapy procedure.)
  • Procedure code 99201 (new patient) or 99211 (established patient) may be billed in addition to an injection if the injection does not have an administration procedure code.
  • “New patient” office/outpatient services are limited to one per provider for each participant. Visits subsequent to the “new patient” office/outpatient services must be coded as “established patient” office/outpatient services as defined in the CPT procedural coding book.
  • Healthy Children and Youth (HCY), also known as Early Periodic Screening, Diagnosis and Treatment (EPSDT), full and partial screenings are covered in accordance with the periodicity schedule and procedures outlined in Section 9 of this manual.
  • A “new patient,” office/outpatient, for a physician in a group or clinic is defined as one that has not been seen by another member of the group who has the same specialty. Subsequent services must be coded as “established patient” services.

13.21.B HISTORY AND EXAMINATION (OUTPATIENT) PRIOR TO OUTPATIENT SURGERY

Procedure code 99218, 99219 or 99220 may be used in the outpatient setting (POS 22) for the initial history and physical workup prior to outpatient surgery.

NOTE: These procedure codes are not to be used for any other service provided in the outpatient setting. (Reference Office/Outpatient Evaluation and Management codes 99201-99215 for other physician services provided in an outpatient setting.)

Finding Pre-certification Codes/Requirements

December 7, 2009

Many providers contact the Provider Communications Unit at 573/751-2896 and often hold in a queue to talk to a phone specialist to determine if certain codes require pre-certification. This information is readily available through the MO HealthNet Web site and providers can save time by checking themselves.

  • http://dss.mo.gov/mhd/cs/ — From this page, choose from the Clinical Services Programs headings (Medical Pre-certification, DME Pre-certification, Optical Pre-certification, etc.). In the left-hand column of each respective program, select the ‘Pre-certification Criteria Documents’. This will bring up a list of services. Then you can choose the service/item to see the procedure code(s) that requires pre-certification.
  • http://dss.mo.gov/mhd/providers/ — This is the MO HealthNet provider home page. Providers have the ability to check limitations on specific codes by viewing the on-line fee schedule. In the left-hand column, choose ‘fee schedule’. The fee schedule 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 (such as pre-certification), the maximum quantity and reimbursement fee.

Essure Product Reimbursement

November 30,2009

The MO HealthNet Division has updated reimbursement for the family planning product Essure, CPT procedure code 58565, to both office and outpatient settings. This is to encourage offering of the procedure in the office setting and to account for the separate facility charge billed by the outpatient hospital. The updated reimbursement closely mirrors Medicare and other state Medicaid agencies’ reimbursement policies for the procedure.

For the professional services performed in an outpatient setting, providers must bill using CPT procedure code 58565 with a 52 modifier. Providers must use the correct place of service code to ensure proper payment.

The MO HealthNet fee schedule is available online

Timely Filing Guidelines

November 23, 2009

MO HealthNet timely filing guidelines can be found in Section 4 of Provider Manuals and are as follows for claims and adjustments:

  • 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/MO HealthNet 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.
  • MO HealthNet claims with third party liability must first be submitted to the insurance company in most instances. However, the claim to MO HealthNet must still meet the 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 MO HealthNet 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.

MO HealthNet provider manuals can be referenced through the following link: http://manuals.momed.com/manuals/.

Adult Dental – Physician Referral

November 16, 2009

Dental services for adults age 21 and over related to a medical condition will be covered when a written referral from the participant’s physician states the absence of dental treatment would adversely affect the stated pre-existing medical condition. This referral must be maintained in the participant’s record and made available to the MO HealthNet Division or its agent upon request. It is not necessary to attach a copy of the referral when submitting a paper claim form.

The referral by the participant’s physician must include the following:

  • Referring physician’s name
  • Referring physician’s NPI
  • Type of dental services the participant needs
  • The pre-existing medical condition that would be adversely affected without the dental care

For a list of covered procedure codes, providers can reference Section 19.1 of the dental provider manual.

Pre-Certification of Durable Medical Equipment

November 9, 2009

Pre-certification of Durable Medical Equipment (DME) is a two-step process. Requests for pre-certification must be initiated by an authorized DME prescriber who writes prescriptions for items covered under the DME Program. Authorized prescribers include physicians, podiatrists, as well as nurse practitioners who have a collaborative practice agreement with a physician that allows for prescription of such items. The DME provider will access the pre-certification initiated by the prescriber to complete the second step of the pre-certification process.

Authorized prescribers cannot delegate the responsibility to complete Step 1 of the pre-certification process to a DME provider. Likewise, a DME provider must not complete Step 1 of the pre-certification process. Any activity through which a provider misrepresents themself to accomplish approval at any step of the pre-certification process is considered fraudulent activity. Any potential fraudulent activity may result in provider sanctions as specified under 13 CSR 70-3.030 including recoupment of reimbursement made to a provider as a result of fraudulent activity.

Durable Medical Equipment Enrollment Guidelines

November 2, 2009

A Durable Medical Equipment (DME) provider must be an approved Medicare DME provider to enroll in the MO HealthNet DME program. If a DME provider is terminated by Medicare, participation in the MO HealthNet DME program is also terminated. MO HealthNet services must not be billed for dates of service effective the date of Medicare termination. MO HealthNet providers being terminated are notified in writing by MO HealthNet.

If a provider is later re-enrolled with Medicare, the provider will need to contact Provider Enrollment regarding re-enrollment in the MO HealthNet DME program. MO HealthNet re-enrollment will not be made effective prior to the new Medicare approval effective date.

Provider Enrollment may be contacted by E-mail at providerenrollment@dss.mo.gov or by mail at:

MO HealthNet Division
ATTN: Provider Enrollment Unit
PO Box 6500
Jefferson City, MO 65102

Services provided to participants who have dual coverage through Medicare/Medicaid during a period of Medicare termination will be denied by both Medicare and MO HealthNet. These services cannot be billed to the participant.

End Stage Renal Disease

October 26, 2009

Effective for services January 1, 2009 and after, the Current Procedural Codes (CPT) for the monthly ESRD services has been updated. For reporting purposes, each month is considered 30 days.

Monthly End Stage Renal Disease

Current Procedural Terminology codes (CPT) 90951 through 90962 (based on the patient’s age and physician visits) are used for the monthly supervision of ESRD patients. The appropriate code should be used for ongoing monitoring of the patient, regardless of whether a service is rendered on every day of the month. When billing for monthly supervision, identify only the first date of the month as the date of service and "1" for the number of units.

  • For services prior to January 1, 2009, the monthly ESRD procedure codes are reported ONCE per month and should not be used if the patient is hospitalized during the month.
  • For services on and after January 1, 2009, the monthly ESRD procedure codes are reported once per month. In the circumstances where the patient has had a complete assessment visit during the month and services are provided over a period of less than a month, bill according to the visits performed. If the assessment was not completed during the month or was a transient or dialysis was stopped due to recovery or death, the appropriate daily code (90967-90970) should be reported.

Daily End Stage Renal Disease

If the physician is not involved in continuous supervision of the patient, or becomes involved late in the month, daily visits must be billed. When billing supervision for less than a full month (procedure code 90967-90970, based on the patient’s age), identify the first day of dialysis to the last day of dialysis. The number of units must equal the number of days within the range of dates. If treatment periods within a month are interrupted (i.e., hospitalization), bill on separate lines for each continuous period using these same guidelines.

Medicare Part C Using the Correct Claim Form

October 19, 2009

Confusion exists among providers in determining which MO HealthNet Division (MHD) claim form to complete to be reimbursed for co-insurance and deductible amounts for those Medicare/MO HealthNet participants with Part C coverage. Claims for participants with Part C coverage do not cross over automatically from the Medicare Part C Plans. As a result, providers must file claims through the MO HealthNet Web portal. Choose from the appropriate claim options shown below.

If the participant is enrolled in a Medicare Advantage/Part C Plan and is Qualified Medicare Beneficiary (QMB) eligible, use one of the following:

  • The Medicare UB-04 Part C Institutional Crossover to file for inpatient room and board. The header screen must be completed. Choose filing indicator '16' (Medicare Part C Institutional); or
  • The Medicare UB-04 Part C Professional Crossover to file for outpatient professional services. The header screen and line detail screens must be completed. Choose filing indicator '16' (Medicare Part C Professional) on the header screen; or
  • The Medicare CMS-1500 Part C Professional Crossover to file for professional services. The header and line detail screens must be completed. Choose filing indicator '16' (Medicare Part C Professional) on the header screen.

If the participant is enrolled in a Medicare Advantage/Part C Plan and is not QMB eligible, you must submit your claim on one of the following:

  • The Inpatient UB-04 for room and board. You must show the Part C information on the header screen. Choose filing indicator '16' (Health Maint Org Medicare Risk). Inpatient claims require pre-certification through Health Care Excel; or
  • The Outpatient UB-04 for outpatient professional services. Show the Part C information on the header and line detail screens. Choose filing indicator '16' (Health Maint Org Medicare Risk); or
  • The Medical (CMS-1500) claim form for professional services. Show the Part C information on the header and line detail. Choose filing indicator '16' (Health Maint Org Medicare Risk).

Reminder – For non QMB participants enrolled in a Medicare Advantage/Part C Plan, MHD will process claims in accordance with the established MHD coordination of benefits policy. The policy can be viewed in Section 5.1.A of the MHD provider manuals. In accordance with this policy, the amount paid by MHD is the difference between the MHD allowable amount and the amount paid by the third party resource.

MHD guidelines and policies regarding attachments and prior authorization must be followed for participants, including Medicare Part C non-QMB participants. If the procedure billed requires an attachment (Certificate of Medical Necessity, Second Surgical Opinion, Sterilization Consent, etc.), you must have a completed, approved form on file. If the procedure requires prior authorization, you must have an approved prior authorization from MHD on file.

Crossover Claims That Require Special Handling

October 13, 2009

Some Medicare/MO HealthNet crossover claims require special handling by MO HealthNet Division (MHD) staff for proper adjudication and payment. Some reasons include:

  • The claim was billed by the provider as a medical claim, but should have been billed as a crossover claim. The MHD system is not able to link the claims to document timely filing;
  • The provider billed the claim as a Part C (Medicare Advantage Plan) when it should have been filed as a regular crossover claim; the MHD system is not able to link the claims to document timely filing;
  • If a program integrity audit reveals claims that should have been filed as crossover claims; these may require special handling for timely filing; and
  • If, to no fault of the provider, an error occurred in the enrollment records.

When situations like those suggested above occur, claims must be special handled by MO HealthNet staff. Please follow the instructions below to send your claims for special handling.

  • Go to www.emomed.com and log in.
  • Select and complete the appropriate crossover claim type.
  • Each claim should not exceed six detail lines.
  • Instead of submitting the claim, select Ctrl P to print each page of the claim.
  • Once the claim and attachments (Header and Other Payer Screens) are printed, number the pages i.e. 1 of 4, 2 of 4, etc.
  • On each page, on the solid line across the top of the page, handwrite the participant’s MO HealthNet ID number, name and from and through dates of service.
  • Staple the claim, attachments, the Medicare EOMB and other applicable documentation together.

The claim and documentation should be mailed to:

Provider Communications Unit
PO Box 6500
Jefferson City, MO 65102

Ambulance Modifiers

October 5, 2009

The MO HealthNet Ambulance Program does not recognize all modifiers Medicare utilizes in their program. Modifiers used in conjunction with covered procedure codes not recognized by MO HealthNet will result in claim denials. The following are the only modifiers currently used in the MO HealthNet Ambulance Program:

HH —
Ground ambulance for hospital to hospital transfers.
HD —
Ground ambulance transport from one hospital to another hospital or medical facility for specialized testing and/or treatment.
EP —
Transport by ambulance for patients under 21 years of age through the Healthy Children and Youth (HCY) Program if it is medically necessary, and any other method of transportation would endanger the child’s health. This modifier should not be used if the transport meets the definition of emergency services.
GM —
To be used with an appropriate ground ambulance base code when additional patients are transported.
SC —
To be used with fixed wing transport codes when the flight is medically necessary and not related to weather.

For more information, providers can reference Sections 13 and 19 of the MO HealthNet Ambulance manual.

Suspended Claims

September 28, 2009

A suspended MO HealthNet Claim is a claim that, although being in the fiscal agent’s system, is in suspense and has not processed to pay or deny during the current payment cycle.

A claim can be suspended for various reasons. Examples include the following.

  • The claim is attempting to link to an approved attachment such as a Sterilization Consent form, an Acknowledgment of Hysterectomy Information form or a Medical Referral of Restricted Participant (Lock-in) form.
  • Records, such as an operative report, were sent with the claim and are being reviewed.
  • The claim is being reviewed as a possible duplicate.
  • The claim is being processed for participant spend down.
  • The claim is being reviewed because it is for an office visit possibly related to a surgical procedure done within the previous 30 days.

If the provider refiles the same claim while there is a corresponding suspended claim, the refiled claim will deny as a duplicate because the suspended claim has not been finalized. Providers should always check the status of a suspended claim before refiling using the agency’s Web portal.

Questions regarding a suspended claim should be directed to the Provider Communications Unit at 573/751-2896. Providers can also submit E-mail claims inquiries through the MO HealthNet Web portal.

Participant Inquiries

September 21, 2009

Occasionally, providers may have MO HealthNet patients ask questions about specific benefits, non-covered services, administrative lock-in or other matters regarding the MO HealthNet program.

The MO HealthNet Division maintains a Participant Services Unit to which providers can direct participants for assistance with these questions and others regarding such things as MO HealthNet covered services, the denial or payment of claims filed with the MO HealthNet Program, and the location of participating providers in their area of the state. This unit can be helpful, for example, when a participant moves to a new area of the state and needs the names of all physicians who are active MO HealthNet providers in the new area.

Participants who have problems or questions concerning MO HealthNet should be directed to call (800) 392-2161 or to write:

MO HealthNet Division
Participant Services Unit
PO Box 3535
Jefferson City, MO 65102

All calls or correspondence from providers are referred to the Provider Relations Communication Unit. Please do not give participants the Provider Relations telephone number.

After Hours and Holiday Physician Services

September 14, 2009

On occasion, a physician may be called to see participants after normal office/clinic hours or on holidays. Billing requirements for these services is covered in sections 13.22A and 13.22B in the MO HealthNet Physician Provider Manual.

13.22.A PHYSICIAN SERVICES—AFTER HOURS

Procedure code 99050, "Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed," may be billed in addition to the appropriate procedure code for the service, for those services provided before or after the physician’s designated office hours. "Designated office hours" are defined as those hours known and understood by the public as times the office is regularly open for business.

"After hours" designation may only be applied to those unusual circumstances occurring outside the regular/designated office hours as represented to the public, and during which the physician is not normally on-site. This policy is applicable only to physician office/clinic services and RHC/FQHC services.

13.22.B PHYSICIAN SERVICES—SUNDAYS/HOLIDAYS

For those physician office/clinic services requested on Sundays or on one of the following specified holidays, the physician may bill procedure code 99051 "Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours", in addition to the appropriate procedure code for the service performed.

The following holidays are recognized:

  • Memorial Day
  • Independence Day
  • Labor Day
  • Thanksgiving Day
  • Christmas Day
  • New Year’s Day

Ambulatory Surgical Center Services

September 08, 2009

The services and procedures that can be performed in an ambulatory surgical center (ASC) are limited to those listed in Section 19 of the MO HealthNet Ambulatory Surgical Center Manual and are limited to an ASC (place of service 24) as a medically appropriate alternative to inpatient hospitalization. The MO HealthNet list of allowable procedures is based on the corresponding list published by the Centers for Medicare and Medicaid and is updated accordingly. The surgical procedures listed may only be performed in an ASC facility by a currently licensed physician (medical or osteopathic), dentist, or podiatrist.

Physicians and other providers performing services in an ambulatory surgical center facility are not required to be MO HealthNet enrolled providers as a condition of coverage of the ASC facility service. However, no MO HealthNet payment can be made to non-enrolled MO HealthNet providers for the professional services.

For more information, see sections 13.6, 13.7 and 19 of the Ambulatory Surgical Center Manual.

Adult Preventive Medicine Codes

August 31, 2009

All adult preventive medicine/physicals including well-woman examinations are to be billed using the preventive medicine codes (CPT codes 99385-99387 and 99395-99397). Diagnosis codes V70.0 or V72.3 should be used as the primary diagnosis. MHD covers one adult preventive examination/physical per 12 months.

Office visit codes (CPT codes 99201-99205 and 99211-99215) are to be used for "illness" care only and are limited to one visit per participant, per day, per provider in accordance with Section 13.21.A of the MO HealthNet Physician Provider Manual. Additional medically necessary visits for the same day may be covered with a properly completed Certificate of Medical Necessity form for each service which must be submitted with the claim. It is improper to use preventive diagnosis codes with office visit procedure codes or illness diagnosis codes with the preventive medicine CPT codes.

Since some services and CPT codes are diagnosis code specific, providers should use care when assigning diagnosis codes. Generally, the main reason for the encounter should be listed as the primary diagnosis.

Hospital Outpatient Laboratory Fees

August 24, 2009

The hospital outpatient laboratory fee schedule is not available through the MO HealthNet Internet on-line fee schedule resource. Information on these fees is available by calling Provider Communications at 573/751-2896 or by sending an E-mail inquiry through the MO HealthNet Web portal page.

The fee schedule also is available either on paper or CD (computer disk). The cost for producing either the paper list or the CD is $20 per item. Providers wanting a copy of the schedule should send a check or money order made payable to Infocrossing Healthcare Services, Inc. along with a written request including the name and address (no post office boxes) of where the information is to be sent. The request and the check must be sent to the following address.

Infocrossing Healthcare Services, Inc.
Attn: Carla Klebba
905 Weathered Rock Road
Jefferson City, MO 65101

Infocrossing does not invoice or accept credit cards or purchase orders. Payment must be received with the request before the pricing file will be produced and sent via FedEx. Please allow a two week turn around time.

The pricing file the provider will receive is the most current and has history for up to four changes per procedure code.

For technical assistance, contact the Infocrossing help desk at 573-635-3559.

Wheelchair Option/Accessory Replacement and Repair

August 17, 2009

Submission of claims by durable medical equipment (DME) providers are being incorrectly billed with procedure code Z0160 (Repair of wheelchair equipment replace or repair minor parts). Claims with procedure codes Z0160RB and Z0160RBSC are being received when there is an existing item-specific HCPCS code available for the item(s) being billed. Additionally, claims are being submitted in excess of the $500.00 maximum.

DME providers should bill the appropriate HCPCS codes for wheelchair replacement items. For those items not having an item-specific HCPCS code, procedure codes Z0160RB or Z0160RBSC may be used if the manufacturers’ suggested retail price (MSRP) is $500.00 or less. Items with a MSRP greater than $500.00 must be prior authorized utilizing procedure codes K0108RB and K0108RBSC.

The information above can be referenced in Section 13.29F of the DME MO HealthNet provider manuals

HCY Screens and Immunizations

August 10, 2009

Missouri schools are back in session and providers should be considering the required immunizations for their MO HealthNet children and youth patients. MO HealthNet providers are reminded that when they do a Healthy Children and Youth (HCY) screening, they are to give all appropriate Vaccine for Children (VFC) immunizations as a part of either a full, partial or interperiodic screening.

Section 9.10 of the provider manual details MO HealthNet policy on immunizations as part of an HCY screen.

9.10 IMMUNIZATIONS

Immunizations must be provided during a full medical HCY screening unless medically contraindicated or refused by the parent or guardian of the patient. When an appropriate immunization is not provided, the patient’s medical record must document why the appropriate immunization was not provided. Immunization against polio, measles, mumps, rubella, pertussis, chicken pox, diphtheria, tetanus, haemophilus influenza type b, and hepatitis B must be provided according to the Recommended Childhood Immunization Schedule found on the Department of Health and Senior Services' Web site at: http://www.dhss.mo.gov/Immunizations/l.

More information regarding the HCY program, including the VFC program, is available in Section 9 of the provider manuals.

CMS PERM Project

August 03, 2009

The MO HealthNet Division (MHD) participates in the Centers for Medicare and Medicaid Services (CMS) Payment Error Rate Measurement (PERM) project. The purpose of the project is for CMS to measure the accuracy of payments for Medicaid services at the state and national levels. The PERM project is designed to comply with the Improper Payments Information Act of 2002 (IPIA; Public Law 107-300).

The PERM project includes a random claim sample for medical record review. Those providers selected will be directed to submit medical records to Livanta, LLC, the CMS contractor responsible for obtaining medical records. Requests for medical records will be in writing. Livanta, LLC will contact the provider to determine how the provider wants to receive the requests for medical records, either facsimile or mail. The provider must have the records to Livanta, LLC within 60 days of the request. Livanta, LLC and MHD Program Integrity Unit will follow up to ensure that providers submit the documentation before the 60 days has expired.

It is important that providers cooperate and send in all requested documentation to Livanta, LLC. Failure to provide Livanta, LLC with the requested documentation or provision of incomplete documentation will result in an error. Such an error may result in recovery of the Medicaid payment. Please be reminded records must be made available upon request to authorized state or federal Title XIX agents. Be advised that a release of information signed by the patient is not required for you to provide the requested medical records to Livanta, LLC.

If a provider has a question about the validity of a request for medical records from Livanta, LLC, the provider may contact the Program Integrity Unit at 573-751-3399.

Commercial Health Plans and Co-Pays

July 27, 2009

Providers often see MO HealthNet participants who have commercial insurance benefits in addition to MO HealthNet. The following information, taken from Section 5, of the MO HealthNet provider manuals, addresses some of the issues regarding commercial managed care health plan insurance including plan co-pays. Note – this information also pertains to a participant with a Medicare Part C/Advantage plan but who is not QMB (Qualified Medicare Beneficiary) eligible.

5.4 COMMERCIAL MANAGED HEALTH CARE PLANS

Employers frequently offer commercial managed health care plans to their employees in an effort to keep insurance costs more reasonable. Most of these policies require the patient to use the plan’s designated health care providers. Other providers are considered “out-of-plan” and those services are not reimbursed by the commercial managed health care plan unless a referral was made by the commercial managed health care plan provider or, in the case of emergencies, the plan authorized the services (usually within 48 hours after the service was provided). Some commercial managed-care policies pay an out-of-plan provider at a reduced rate.

MO HealthNet reimburses providers who are not affiliated with the commercial managed health care plan. The provider must attach a denial from the commercial managed-care plan to the MO HealthNet claim form for MO HealthNet to consider the claim for payment.

Frequently, commercial managed health care plans require a copayment from the patient in addition to the amounts paid by the insurance plan. MO HealthNet does not reimburse copayments. This copayment may not be billed to the MO HealthNet participant or the participant’s guardian caretaker. In order for a copayment to be collected, the parent, guardian or responsible party must also be the subscriber or policyholder on the insurance policy and not a MO HealthNet participant.

Authorized Nurse Visits

July 20, 2009

The authorized nurse visit, procedure codes T1001 and T1001 EP, are covered services under the MO HealthNet Personal Care Program. The nursing services that may be authorized in the participant’s home include services of a maintenance or preventive nature provided to participants with stable, chronic conditions. The participant must have a documented need for the authorized nurse visit and have no adequate support system that could provide these services.

Authorized nurse visits are limited to 26 within a six-month time frame per participant, calculated on a rolling basis. MO HealthNet has found instances where more than 26 visits are being billed within a six-month time frame. This is incorrect billing and authorized nurse visits in excess of the limits will not be paid.

Reimbursement is made for visits by a nurse to participants with special needs when such visits are prior authorized by the Department of Health and Senior Services' Division of Senior and Disability Services or the Bureau of Special Health Care Needs. Providers are cautioned that an approved prior authorization approves only the medical necessity of the service and does not guarantee payment. Services must be provided within policy limitations and services billed outside of program restrictions will be denied.

Authorized nurse visits under the Personal Care Program are not intended as treatment for an acute health condition and may not include services that are reimbursable as skilled nursing care under either the Medicare or MO HealthNet Home Health Programs. If there is a need for more than 26 visits in a six month period, the need for home health services must be evaluated.

More information about authorized nurse visits is available in Section 13.8 of the Personal Care Provider Manual.

Dental Coverage for Vendor Facility Residents

July 13, 2009

MO HealthNet eligible adults receiving a limited benefit package are eligible for full comprehensive dental services if they reside in a vendor nursing facility. Their benefit package includes, but is not limited to, preventive care, restorations, extractions, and dentures. Section 19 of the MO HealthNet Dental Manual provides procedure codes, allowed amounts, and reimbursement limitations. The following limited benefit medical eligibility (ME) codes included for nursing home residents are: 01, 04, 05, 10, 11, 13, 14, 16, 19, 21, 24, 26, 83, 84, 85, and 86.

MO HealthNet eligible participants with ME codes 55, 58, 59, 80, 89 and 82 are also restrictive in the services they receive. Participants residing in a vendor nursing facility with these ME codes do not receive dental services if they do not meet the basic coverage criteria as described in Section 1 of all provider manuals located on the Internet at http://manuals.momed.com/manuals/.

Participant Administrative Lock-In

July 6, 2009

Some MO HealthNet participants are restricted (or locked-in) to a provider or providers, such as a certain physician, hospital and pharmacy where they can receive treatment or services. This is to help the participant use the MO HealthNet program properly. A provider checking patient eligibility is given the names and phone numbers of the lock-in providers. Payment of services for a locked-in participant cannot be made to other providers except for emergency services or authorized referral services.

Claims for emergency services must have an attached Certificate of Medical Necessity and/or medical records documenting the emergency circumstances.

When a physician is the designated/authorized provider, they are responsible for the participant’s primary care and for making necessary referrals to other providers as medically indicated. When a referral is necessary to other providers, the lock-in provider must complete a Medical Referral Form of Restricted Recipient (PI-118) and send it to each provider to whom the participant is referred.

The referral form must contain the NPI (and taxonomy code if appropriate) for the provider to whom the patient was restricted on the date of service. For example, if the participant is locked into a clinic, you must use the clinic’s NPI (and taxonomy code if appropriate) on either the paper form or the electronic form. Do not put the physician’s individual NPI on the referral form as the information will not match the MO HealthNet lock-in file. The NPI on the claim from the provider who received the referral must match the NPI on the referral form.

The information from the form can then be submitted by the treating provider(s) via the Internet at www.emomed.com or the form can be mailed to Infocrossing Healthcare Services, PO Box 5900, Jefferson City, MO 65102.

The referral form is good for 30 days from the date of service or appointment. A new referral form must be submitted if additional care is required after the 30 days.

Claim Processing Schedule – FY 2010

June 29, 2009

The provider claim processing schedule has been updated for state fiscal year 2010, which begins July 1, 2009. The schedule lists the dates the cycles are run and their corresponding check dates.

Provider reimbursement checks are mailed or directly deposited into a provider’s account twice each month, the 5th and the 20th. If either date falls on a Saturday, Sunday or state holiday, the check will be mailed or directly deposited the following working day.

MO HealthNet Division encourages providers who receive paper checks to apply for 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.

Provider Audio/Visual Presentations

June 22, 2009

A new training feature, audio/visual presentations, has been added to the Provider Education section of the MO HealthNet Web site. Providers and others can view and listen to short audio/visual billing tips and presentations at their own pace. The trainings are PowerPoint presentations with a voice to explain each slide. All you need is a computer with Internet access, PowerPoint or PowerPoint Viewer and a sound card.

The first four audio/visual presentations made available, train on the proper completion of these forms: Hysterectomy Consent Form; PI-118 Form; Sterilization Consent Form; and Second Surgical Opinion Form.

Additional trainings will be added as they are developed.

Releasing Billing or Medical Record Information

June 15, 2009

Sometimes MO HealthNet providers receive requests from MO HealthNet participants for copies of medical and/or billing records. MO HealthNet policy on releasing this information is detailed in Section 5.10 of the provider manuals.

5.10 Release of Billing or Medical Records Information

The following procedures should be followed when a MO HealthNet participant requests a copy of the provider’s billing or medical records for a claim paid by or to be filed with MO HealthNet.

  • If an attorney is involved, the provider should obtain the full name of the attorney.
  • In addition, the provider should obtain the name of any liable party, the liable insurance company name, address and policy number.
  • Prior to releasing bills or medical records to the participant, the provider must either contact the MO HealthNet Division, Third Party Liability Unit, PO Box 6500, Jefferson City, MO 65102-6500, (573) 751-2005, or complete a MO HealthNet Accident Report or MO HealthNet Insurance Resource Report as applicable. If the participant requires copies of bills or medical records for a reason other than third party liability, it is not necessary to contact the Third Party Liability Unit or complete the forms referenced above.
  • Prior to releasing bills or medical records to the participant, the provider must stamp or write across the bill, "Paid by MO HealthNet" or "Filed with MO HealthNet" in compliance with 13 CSR 70–3.040.

Incarcerated Participants

June 8, 2009

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

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

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

Claim Documentation

June 1, 2009

Reminder — If your claim should deny for lack of required documentation (eg. trip ticket, operative report, medical records, etc.), attach the required documentation to a new claim form and mail the claim and supporting documentation to Infocrossing Healthcare Services at one of the appropriate mailing addresses shown below. Providers have mailed medical records/documentation without a supporting claim form attached. The claim was not able to be processed as a result.

If you need to mail a claim to the Provider Communications Unit for review or special handling, please attach the requested supporting documentation to a new claim form and mail to Provider Communications Unit, PO Box 5500, Jefferson City, MO 65102-5500. Medical records/documentation mailed without an accompanying claim form can not be processed.

Mail claim forms and required supporting documentation to one of the following addresses:

Infocrossing Healthcare Services
PO Box (see below)
Jefferson City, MO 65102

  • Inpatient Claims: Box 5100
  • Outpatient Claims: Box 5200
  • CMS-1500 Claims: Box 5600

Adjusting Claims Electronically

May 26, 2009

Providers are urged to adjust their claims electronically. Some claims such as Medicare crossover claims must be adjusted electronically. Whether you are replacing a paid claim or voiding a claim, claims can be adjusted electronically through the MO HealthNet Web portal 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 choose claim frequency type code '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 choose claim frequency type code '7' (replacement) and correct or change the information in error and then resubmit.

For more information on retrieving and resubmitting claims, please reference the provider bulletin (Retrieval and Resubmitting Claims On Emomed) dated March 20, 2007.

NOTE: Medicare/MO HealthNet crossover claims must be voided/replaced electronically if you are able to view the claim online. Paper adjustment forms will not be accepted or processed.

Women’s Health Coverage

May 18, 2009

The MO HealthNet Division notified providers of the expansion of women’s health services for family planning and sexually transmitted disease (STD) testing and treatment services in the provider bulletin dated February 9, 2009. This hot tip is to address some of the questions providers have asked.

Women qualify to receive family planning and/or STD services if they lose MO HealthNet eligibility after the birth of their child or if they are uninsured, 18 to 55 years of age, net family income of at or below 185% of the Federal Poverty Level and have assets totaling no more than $250,000. The qualifying medical eligibility (ME) codes are 80 and 89. These ME codes will be given when you check participant eligibility. When you see these ME codes, please be aware MO HealthNet coverage is limited to family planning and STD services. A description of all ME codes can be found in Section 1 of all provider manuals, which are located on the Internet at http://manuals.momed.com/manuals/.

The important thing for providers to be aware of when treating these women is that individuals must present with family planning diagnosis in order for any STD disease testing and treatment to be covered or any routine pap tests and pelvic exams to be covered. Primary diagnosis codes are V25-V25.9. Per CMS requirements, an appointment for STD services or routine check-ups alone is not covered without a family planning encounter.

If an STD is identified during a family planning encounter, treatment can be provided. Any follow-up care for STD alone is not covered unless it is during a family planning encounter.

If an individual has been sterilized, they do not qualify for family planning services.

MO HealthNet E-mail News

May 11, 2009

By subscribing to MO HealthNet News, providers and others are notified via E-mail any time the MO HealthNet Web site is updated. Each person subscribed to the MO HealthNet E-mail news service receives every message sent regardless of the program or provider type. The subscriber chooses which E-mail notices to read and keep. Only one mailing list is maintained because a number of subscribers represent multiple provider types.

To subscribe or unsubscribe, go to the MO HealthNet provider Web site at http://dss.mo.gov/mhd/providers/. From here, click on the 'Subscribe to MO HealthNet News' in column on the left.

From the same Web site, you can also access any past notifications by clicking on the 'MO HealthNet List Archive'.

To change an E-mail address, you first must unsubscribe; then subscribe using your new E-mail address.

Medicare Part C Non-QMB Claims

May 4, 2009

Reminder – For non-Qualified Medicare Beneficiary (QMB) participants enrolled in a Medicare Advantage/Part C Plan, MO HealthNet Division (MHD) will process claims in accordance with the established MHD coordination of benefits policy. The policy can be viewed in Section 5.1.A of the MHD provider manual at http://manuals.momed.com/manuals/. In accordance with this policy, the amount paid by MHD is the difference between the MHD allowable amount and the amount paid by the third party resource. Claims should be filed using the appropriate claim format (i.e. CMS-1500, UB-04). Do not use a crossover claim.

MHD guidelines and policies regarding attachments and prior authorization must be followed for participants, including Medicare Part C Non-QMB participants. If the procedure billed requires an attachment (Certificate of Medical Necessity, Second Surgical Opinion, Sterilization Consent, etc.), you must have a completed, approved form on file. If the procedure requires prior authorization, you must have an approved prior authorization from MHD on file.

NEMT – Where’s My Ride?

April 27, 2009

Non-emergency medical transportation (NEMT) is available to eligible MO HealthNet participants who do not have access to free appropriate transportation to and from scheduled MO HealthNet covered services. NEMT services are arranged through LogistiCare Solutions L.L.C., the NEMT broker for MO HealthNet.

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 1-866-269-5944.

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.

Using Locum Tenens

April 20, 2009

The MO HealthNet Division (MHD) occasionally receives inquiries regarding the use of "locum tenens" for physician offices and clinics.

A locum tenen is a physician who substitutes temporarily for another physician. MHD does not reimburse for locum tenens who submit claims using the absent physician’s National Provider Identifier (NPI). It is a violation of MHD policy to submit claims for services not personally rendered by the individually enrolled provider, except for services rendered under provisions specified in the MO HealthNet dental, physician, or nurse midwife programs. In accordance with these provisions, such claims may be submitted only if the individually enrolled provider directly supervised the person who actually performed the service and the person was employed by the enrolled provider at the time the service was rendered. Information regarding Conditions of Provider Participation, Reimbursement and Procedure of General Accountability can be found in the Missouri Code of State Regulations, Section 13 CSR 70-3.030.

If the locum tenen is already a currently enrolled MHD provider or enrolls as an MHD provider, then the services can be billed to MHD using the provider’s NPI.

IM-62 Form

April 13, 2009

The Notice of Eligibility for Nursing Facility and Other Vendor Services form, most commonly referred to as the IM-62, is a nursing home’s authorization to submit claims for MO HealthNet payment on behalf of the participant named on the form. A claim for MO HealthNet payment must not be submitted until the provider has a copy of an IM-62 for the resident. If an IM-62 is not received within a reasonable time, providers need to contact the participant’s Family Support Division (FSD) Eligibility Specialist (formerly referred to as caseworkers). If a participant transfers from one nursing home to another, the receiving facility must have a new IM-62 from FSD before billing MO HealthNet.

The FSD Eligibility Specialist completes an IM-62 form for each eligible resident after financial and medical eligibility has been determined. The IM-62 is sent to the participant with a copy to the facility. The IM-62 form is important to the provider as it establishes three items:

  1. the earliest date of service for which MO HealthNet vendor payment is made;
  2. the participant’s level of care; and
  3. the patient liability (surplus) amount to be collected from the participant or the participant’s representative and the effective date the surplus amount is first due.

When a nursing home resident elects the hospice benefit, the hospice agency should request from the nursing home, the participant or the participant’s representative, a copy of the IM-62 and any subsequent IM-62s. Just as a nursing home is not to submit a claim to MO HealthNet for payment until they have received a copy of an IM-62 for the resident, the hospice agency should not submit a claim to MO HealthNet for nursing home room and board charges until they receive a copy of the IM-62.

Emergency Ambulance vs. NEMT Transports

April 06, 2009

Emergency ambulance services are covered if they are emergency services and transportation is made to the nearest appropriate hospital, 13 CSR 70-6.010(5). MO HealthNet ambulance providers are only to bill MO HealthNet for those transports emergent in nature through the Emergency Ambulance Program. Reimbursement is made for emergent transports provided all other claim filing guidelines have been met.

When individuals are transported by ambulance to an emergency room for treatment and then released without admission to the hospital, the return trip is not covered under the MO HealthNet Emergency Ambulance Program. The same holds true for a nursing home resident who is discharged from a hospital stay. Return trips to a nursing home are not covered under the Emergency Ambulance Program, 13 CSR 70-6.010(6).

Additional transports not covered in the Emergency Ambulance Program include:

  • transportation to a physician or dentist’s office, or a participant’s home;
  • ambulance services to a hospital for the first stage of labor; or,
  • transport of a participant pronounced dead before the ambulance is called.

Transport by ambulance may be covered under the Non-Emergency Medical Transportation (NEMT) program for eligible participants if it is the most appropriate mode of transportation based on the participant’s medical needs. Hospital staff, nursing home staff, social workers, case managers, family members and other related parties may call LogistiCare Solutions, L.L.C., the NEMT broker for MO HealthNet, toll-free at (866)269-5927 to arrange NEMT to and from medical providers for eligible participants. NEMT services are available 24 hours per day, 7 days per week. To provide adequate time for NEMT services to be arranged, a participant or someone calling on their behalf should call at least three (3) days in advance. For hospital discharges, it may require up to three (3) hours to arrange the appropriate mode of transportation.

LogistiCare Solutions, L.L.C will provide the most appropriate mode of transportation based on the patient’s medical needs. For information on the available modes of transport, please refer to Section 22.8 of any provider manual. If patients are confined to a bed, but do not require any medical equipment or medical attention en route, a stretcher van may be authorized. If patients require medical attention or equipment en route, an ambulance will be authorized. Be sure to tell LogistiCare when arranging transportation whether the patient is bed confined and whether or not medical attention or equipment is needed.

Neither the participant nor MO HealthNet are responsible for payment if physicians, hospital staff or others arrange ambulance transports for non-emergency trips that are covered under the NEMT program without authorization from LogistiCare Solutions, L.L.C. Missouri Code of State Regulations 13 CSR 70-4.030 (2) states a "service will not be the liability of the participant if the service would have been otherwise payable by the MO HealthNet agency at the MO HealthNet allowable amount had the provider followed all of the policies, procedures and rules applicable to the service as of the date provided."

For more information, providers can reference Sections 13.3 of the MO HealthNet ambulance manual located on the Internet at http://manuals.momed.com/manuals/.

For more information on NEMT and all the modes of transportation under NEMT, providers can reference Section 22 of any provider manual located on the Internet at http://manuals.momed.com/manuals/.

Registering for On-line Training Sessions

March 30, 2009

The MO HealthNet Division (MHD) provider education staff can provide interactive training to providers at their office location to help with billing, using the Internet and telephone conference lines. The presentations are relatively short and are usually limited to 60 to 90 minutes in length.

To register for training:

  • Log on to the Internet Web site at http://dss.mo.gov/mhd/providers/.
  • Scroll down on the page to Education and Billing under Provider Options.
  • Click on 'On-line LiveLOOK Training'.
  • You can ask to be included in a session by clicking onto the date of session you wish to participate or by sending an E-mail to mhd.provtrain@dss.mo.gov. In either E-mail, please include the name of the meeting participant(s), name of provider, National Provider Identifier (NPI), the date and time of the session, a phone number where we can reach you on the day of the session and your E-mail address.
  • You will be notified by E-mail of confirmation with special instructions prior to the date of the session. You will also be notified if space is not available.

The provider must have access to the Internet and must be using a current browser program (Internet Explorer 5/6/7 or Netscape 5 or higher, that is Windows Vista compatible).

"21" Modifier No Longer Used

March 23, 2009

The "21" modifier (prolonged evaluation and management service) was deleted in the 2009 edition of the Current Procedural Terminology (CPT) code set and is no longer to be used for any services billed on or after January 1, 2009.

The MO HealthNet Division (MHD) previously used the "21" modifier in the agency’s Early Periodic Screening, Diagnosis and Treatment (EPSDT) program (also known as Missouri’s Healthy Children and Youth program) to identify a full HCY screen. Effective for dates of service on and after January 1, 2009, the "21" modifier is no longer to be used to bill for these services. The new codes to be used for a full screening are: 99381EP-99385EP (new patient) and 99391EP-99395EP (established patient)

Details on the termination of the use of the "21" modifier and the revised codes to be used to bill full and partial HCY screenings as well as inter-periodic screenings are found in the February 5, 2009 Healthy Children and Youth (HCY) Bulletin, Volume 31, Number 49.

Participant Liability Services at the Hospital

March 16, 2009

If a hospital is a MO HealthNet participating hospital, the hospital is responsible for arranging for all medically necessary services and make sure there are medical professionals available who will accept MO HealthNet reimbursement and not bill the participant.

A participant could elect to be treated by a non-participating provider, but must have the option of one that is enrolled as a MO HealthNet provider. If the participant chooses to be treated by a non-participating provider, the participant must agree 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.

If the hospital assigns a non-participating provider to a participant that is not elected by the participant, the hospital must absorb the provider’s bill for services or risk losing certification as governed under 42 CFR 482.12, 21 & 22.

Pre-Certification for Specific Codes

March 9, 2009

The MO HealthNet Division (MHD) has implemented a pre-certification process for specific radiological and durable medical equipment items/services. Pre-certification serves as a utilization management tool allowing payment for services that are medically necessary, appropriate and cost-effective without compromising the quality of care to MO HealthNet participants.

As a reminder when calling the Provider Communications Unit at 573/751-2896 to check pre-certification requirements for specific codes, please be sure to have the actual CPT or HCPCS code that will be billed. If you do not ask for requirements for the correct code, it could result in receiving information on another code that does not require pre-certification and your claim will deny.

Providers themselves have the ability to check limitations on specific codes by viewing the MO HealthNet provider fee schedule. This online site will show 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 (such as pre-certification), the maximum quantity and reimbursement fee.

Additional information regarding how to access the fee schedule can be found in the recent Hot Tip dated February 2, 2009.

Billing Anesthesia Services

March 2, 2009

Anesthesia services are covered when performed by an Anesthesiologist, Certified Registered Nurse Anesthetist (CRNA) or Anesthesiologist Assistant (AA). Medical direction of anesthetists by an anesthesiologist is also a covered service.

Services involving administration of anesthesia are reported by the use of the anesthesia CPT procedure codes (00100-01999) plus one of the following modifier codes:

  • AA - Anesthesia service performed personally by anesthesiologist
  • QX - CRNA/AA service with medical direction by a physician
  • QZ - CRNA service without medical direction by a physician
  • QK - Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals.

Anesthesia time begins with participant preparation for anesthesia and ends when the patient leaves the operating room and is safely under customary postoperative supervision in the recovery room. One unit, 15 minutes, is allowed for anesthesia induction time prior to surgery. No allowance is made after the surgery ends and the participant is transferred to the recovery room.

Anesthesia providers may only bill for one procedure per operative setting using the appropriate anesthesia modifier. When anesthesia is administered for multiple surgical procedures for the same participant (same operative setting/date of service), only the major surgical procedure may be billed. Anesthesia time for all of the procedures should be calculated into total minutes and billed using the major procedure code only. Services may not be billed separately for the other procedures performed.

When the anesthesiologist personally performs a service, the procedure should be billed using modifier AA. No separate payment is allowed for supervision by the anesthesiologist.

An AA and a CRNA are not allowed to bill for the same anesthesia service.

The professional claim must reflect the appropriate anesthesia procedure code and modifier and the actual anesthesia time in minutes. Each 15-minute unit of anesthesia is equal to a time unit of 1.

Detailed information regarding anesthesia services is found in Section 13.39 of the MO HealthNet Physician Provider Manual available on the Internet at: http://manuals.momed.com/manuals/.

Denture Coverage

February 23, 2009

Dentures are not covered for MO HealthNet participants with a limited benefit package. For those participants receiving dental care meeting the criteria established for individuals with a limited benefit package, even when that care may include full mouth extractions, dentures are still a non-covered service. A complete list of ME (medical eligibility) codes for participants receiving limited benefits can be found in the MO HealthNet Guide – Puzzled by the Terminology online at http://dss.mo.gov/mhd/providers/pdf/puzzledterm.pdf.

Dentures are a covered service for participants residing in a vendor nursing facility regardless of their ME code. Verification of participants residing in a vendor nursing facility can be determined by checking the participant’s eligibility for "Nursing Home Information".

Dentures are a covered service for pregnant participants enrolled in the regular fee-for-service program as well as MO HealthNet managed care health plans if they have one of the following ME codes: 18, 43, 44, 45 and 61. Reimbursement for dentures for eligible participants in one of the MO HealthNet managed care plans is the responsibility of the health plan.

Dentures for eligible MO HealthNet fee-for-service participants do not require prior authorization.

Hospice Election & Revocation

February 16, 2009

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 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 by the election of 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; or
  • 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. This form can be found at http://manuals.momed.com/manuals/presentation/forms.jsp. 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 he/she can be financially liable for curative treatment not arranged by the hospice or provided by the attending physician. If the participant chooses to disregard this and is admitted to the hospital, the hospice cannot automatically remove the participant from hospice care. This information may be found online in section 13 of the MO HealthNet Hospice Provider Manual.

The hospice provider is reimbursed for the date of revocation except in cases when the participant expires in a nursing home or the participant is discharged from a nursing home setting. The MO HealthNet participant resumes MO HealthNet coverage for services related to the terminal illness the day following the date of revocation. Reimbursement for services related to the terminal illness provided on the date 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
(573) 751-2896

Provider Initiated Self Disclosures

February 09, 2009

MO HealthNet would like to encourage providers to continue sending in Provider Initiated Self Disclosures as referenced in the November 19, 2007 Hot Tip – Reporting Suspected MO HealthNet Benefits Fraud. It states in part:

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 below:

MO HealthNet Division
Program Integrity Unit – SELF DISCLOSURE
PO Box 6500
Jefferson City, MO 65102-6500.

In an effort to assure Provider Initiated Self Disclosures are processed quickly and efficiently please reference the Provider Initiated Self Disclosure Report Form. Providers can direct questions regarding Self Disclosures to the MO HealthNet Division’s Program Integrity Unit at 573-751-3399.

MO HealthNet Provider Fee Schedule

February 2, 2009

Providers have access to the MO HealthNet provider fee schedule online at http://dss.mo.gov/mhd/providers/pages/cptagree.htm. At this site, 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.

The fee schedule is updated quarterly on a calendar year basis. 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.

The fee schedule is intended as a reference and not a guarantee of payment. Please refer to program specific MO HealthNet provider manuals and bulletins for benefit and limitations.

Paper Medicare/Medicaid Crossover Claims

January 26, 2009

Effective January 30, 2009, any paper Medicare/Medicaid crossover claims received by the MO HealthNet Division will not be returned to the provider, nor will the paper billings be retained by the MO HealthNet Division or its contractors. This information is published in the December 31, 2008 edition of the Missouri Register under 13 CSR 70-3.100.

In a provider bulletin dated July 1, 2005, enrolled providers were instructed to bill all Medicare/Medicaid crossover claims electronically. It also stated paper claims received by MO HealthNet would be returned to providers. Again, effective January 30, 2009, paper Medicare/Medicaid crossover claims will not be returned to the provider nor retained by the MO HealthNet Division or its contractors.

Medicare claims that have been initially filed with Medicare and which require separate filing to the MO HealthNet Division, must be filed electronically using a HIPAA 837 claim or the MO HealthNet Division Web portal at www.emomed.com.

Inpatient Hospital Claim Value Codes and Amounts

January 19, 2009

The November 5, 2007 Hot Tip entitled "UB-04 Inpatient Claim Form" explained how hospital providers are to complete fields 39-41 on the paper UB-04 claim form for inpatient hospital claims. The agency is still seeing many claim denials for invalid information in these fields.

As a reminder, the instructions for fields 39-41 are as follows.

"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.

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."

The covered days' information must be shown in field 39. Value Code 80 should be listed in the "Code" column and the number of covered days listed in the "Amount" column. Do not list any other data in field 39 such as rates, etc., as this can result in the claim denials.

The non-covered days' information should be listed in field 40. Value Code 81 must be listed in the "Code" Column and the number of non-covered days listed in the "Amount" column.

ICD-9 Diagnosis Code V708 Usage

January 12, 2009

MO HealthNet’s Transplant Program has been encountering instances where medical providers are inadvertently billing claims as transplant donor claims instead of general exams. Diagnosis code V708 is to be used only for patients who are being examined as a "potential donor of organ or tissue". If a provider is billing for a general exam, the guidelines for choosing the appropriate diagnosis code are found in the ICD.9.CM manual (diagnosis code manual).

Claims submitted with ICD-9 diagnosis code V708 will only be considered for payment in situations where the patient is being considered as a donor and an approved transplant agreement is on file with the MO HealthNet Division’s Transplant Section for the transplant recipient.

Please review the MO HealthNet Transplant Provider manual, Section 13, for more information on transplant services.

Should providers have additional questions regarding transplant services or coverage through MO HealthNet Division, you may contact the Transplant Section within the Clinical Services Unit at (573) 751-6963.

Give Us Your Suggestions!

January 5, 2009

The Provider Education Unit of the MO HealthNet Division (MHD) wants to provide you weekly hot tips that are clear, concise, brief and beneficial to you as providers. Hot tips are usually developed when MHD observations and reports indicate trends regarding billing errors or areas of misunderstandings surrounding benefits and limitations.

Each year you are asked to provide input to the topics you would like to see as a hot tip and that you believe would benefit other providers. Now is that time. If you have suggestions, please send them by E-mail to: MHD.provtrain@dss.mo.gov.