2010 Archives Hot Tip of the Week
2010 Provider Tips
- Retrieving an Aged/Older Remittance Advice
- Timely Filing Guidelines
- Billing for Contrast Materials (Revised)
- Correctly Reporting Value Amounts on the UB-04 Inpatient Claim Form
- Delivery and Placement Dates versus Date of Service
- MHD Request for a Paper Claim
- How to Retrieve Your Remittance Advice Electronically
- Adult and Children Flu Shot Reminders
- EMOMED—Choosing the Right Claim Form
- Non-Emergency Medical Transportation
- Custom-Made Items
- TPL and Patient Responsibility
- Hospital Observation Beyond 24 Hours
- Using the Correct Claim Form
- When Can Patients Change Managed Care Health Plans?
- No More Paper Checks or RAs!
- Billing Policy for CPT Code 90862
- MO HealthNet News Email Subscription
- Billing for Bilateral Procedures
- Requesting Provider Assistance
- Case Management
- ER Surgery and Post-Op Care
- Supervision of Auxiliary Personnel in Medical Offices/Clinics
- Updating Provider Location Information
- In-Home Service Billing Reminders
- spend down and Eligibility
- Global Prenatal and Global OB Billing Policies
- Claim Processing Schedule - FY 2011
- Concurrent Dates of Hospital Services
- We Need Your Suggestions!
- Sending Claims For Special Handling
- Billing for Contrast Materials
- Re-Pricing Medicare Inpatient Hospital Claims
- Optical Claims - Date of Service Requirement
- Hospital Outpatient Charges Assessment vs. Triage Services
- Does a Code Require Prior Authorization?
- Using Correct/Valid Performing Provider NPI
- Presumptive Eligibility Programs
- Claim Documentation
- Orthodontia Records
- Nursing Home Reimbursement
- Part C Crossover Claim Form
- Hospital Discharge - Emergency Ambulance VS. NEMT Transports
- Contacting the Provider Education Training Unit (573) 751-6683
- Manually Priced Procedures
- Contacting Provider Communications
- Hospital Inpatient Pre-Certification Transition
- Registering for On-line Training Sessions
- MO HealthNet is the Last Payer
- MRIs/CAT Scans and Eligibility
- Postoperative Care
- Pregnancy Related Ultrasounds
Retrieving an Aged/Older Remittance Advice
December 27, 2010
Occasionally, a provider may find need for an older Remittance Advice (RA). Older RAs are available through the MO HealthNet Internet billing Web site at www.emomed.com. A provider can request multiple older RAs per day but only one can be requested at a time. Access to older RAs is limited to the past three years based on the date the request is submitted.
On the new Welcome to eProvider Home Page, click on File Management and make sure to choose the appropriate NPI for the Remittance Advice to be requested. On the File Management page, click on “Request Aged RA”. 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. Click on Save and then on Finished.
The requested aged RA is available the next business day following the day the request is submitted. To obtain an aged RA, go to the www.emomed.com Home Page and under File Management, choose "Printable Aged RA". The dates of all the RAs requested will be displayed in the Results box. Clicking on the Adobe icon on the right side of the date brings up the RA in the standard RA Adobe format. To print it, click on the printer icon or select print from “File” on the tool bar at the top of the page. Additionally, it can be saved it to your computer system for future reference. The aged RAs stay on this page for five (5) working days following the date of the request and then are deleted from the page.
Timely Filing Guidelines
December 20, 2010
MO HealthNet timely filing guidelines for claims and adjustments can be found in Section 4 of Provider Manuals and are outlined below:
- Original claims must be filed by the provider and received by the state agency within twelve (12) months from the date of service. Any claims that originally were submitted and received within twelve (12) months from the date of service, but were denied or returned to the provider, must be resubmitted and received within twenty-four (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 twelve (12) months from the date of service or six (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 twelve (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 one (1) year from the date of service does not serve to extend the filing requirement. However, the twelve (12) month filing rule may be extended if a third-party payer, later reverses the payment determination sometime after twelve (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 twelve (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 twenty-four (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 time limit for resubmitting the new, corrected claim is ninety (90) days from the date of the remittance advice indicating recoupment or twelve (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/.
Billing for Contrast Materials (Revised)
December 13, 2010
A Hot Tip published on May 24, 2010 regarding billing for contrast materials contained an error. A provider cannot submit an invoice for one of the listed “A” codes on the electronic institutional 837 HIPPA claim transaction. Following is the corrected Hot Tip.
MO HealthNet regularly receives inquiries from hospitals regarding the correct codes to use for billing contrast materials such as those used for MRI and CAT scans performed in the hospital outpatient setting.
If the contrast material has a valid National Drug Code (NDC) associated with it, the hospital can bill the material either on the electronic outpatient UB-04 or the www.emomed.com Web site or the electronic institutional 837. The material can be billed also on the Pharmacy Claim Form on www.emomed.com.
If the material does not have a valid NDC or the NDC is alphanumeric, it can be billed with an appropriate HCPCS “A” code. Following is a list of the covered HCPCS “A” codes. These codes must be submitted either on a paper UB-04 or the electronic outpatient UB-04 on www.emomed.com. Regardless of which method is used to submit the claim, it must include an invoice of cost as the codes are manually priced.
Correctly Reporting Value Amounts on the UB-04 Inpatient Claim Form
December 6, 2010
Hospitals sometimes fail to report the correct information in fields 39-41, Value Codes and Amounts, when filing an inpatient claim on the paper UB-04 claim form. Following are the MO HealthNet program instructions for completing these fields. The value code is entered in the left (Code) column and the number of days (units) are listed in right column.
Field 39-41 Value Codes and Amounts
Enter the appropriate code(s) and unit amount(s) to identify the information necessary for the processing of this claim.
- 80 - Covered Days
- Enter the number of days shown in field 6 minus the date of discharge. The discharge date is not a covered day and should not be included in the calculation of this field.
- The through date of service in field 6 is included in the covered days if the patient status is field 17 is “30 - still a patient”
Note - The units entered in this field must be equal to the number of days in “Statement Covers Period”, less the day of discharge. If the patient status is “30 - still a patient”, the units entered include the through day.
- 81 - Non-Covered Days
- If applicable, enter the number of non-covered days. Examples of non-covered days are those days for which the participant is ineligible for MO HealthNet benefits.
Note - The total units entered in this field must be equal to the total accommodation units listed in field 46.
Delivery and Placement Dates versus Date of Service
November 29, 2010
Reminder - The date of service, for items such as the placement of dentures, hearing aids, eyeglasses, or durable medical equipment, should be the date of delivery or placement of the device or item. The date of service is not the date an item or device is ordered, fabricated, or shipped. Providers should reference Missouri State Regulation 13 CSR 70-3.100(7)(D)(7).
MHD Request for a Paper Claim
November 22, 2010
On occasion, MO HealthNet may request or require a provider submit a paper claim to the agency instead of an electronic claim to assist the provider in receiving reimbursement for the services rendered. If a paper claim is requested or required, the provider must complete the appropriate paper claim form (CMS-1500 or UB-04) and submit it along with any requested documentation.
However, instead of sending the proper paper claim form, some providers are sending screen prints of the www.emomed.com version of the CMS-1500 or UB-04. These screen prints are not acceptable as replacements for the requested paper claim form and cannot be processed as claims.
An exception is a Medicare crossover claim when there is a request that it be special processed for timely filing. In this instance, the provider will be requested to complete one of the following claim types from the “New X-Over Claim” drop down menu on the www.emomed.com Claim Management screen: the Medicare CMS-1500 Part B Professional, Medicare CMS-1500 Part C Professional, Medicare UB-04 Part A institutional, Medicare UB-04 Part C Institutional, the Medicare UB-04 Part B Professional or the Medicare UB-04 Part C Professional. The provider should select the appropriate claim type and complete all required fields on the form. Instead of submitting the claim, the provider must click on the “Printer Friendly Button” to print the completed form. Once the form is printed, list the participant’s name and MO HealthNet identification number (DCN), the date of service and the number of pages at the top of the printed page(s).
The completed screen print page(s), along with the Medicare explanation of benefits for the claim, should be mailed to:
MO HealthNet Division
PO Box 6500
Jefferson City, MO 65102.
How to Retrieve Your Remittance Advice Electronically
November 15, 2010
Effective with the October 22, 2010 remittance advice (RA), MO HealthNet is no longer producing paper RA’s. Providers must now obtain RA’s through the agency’s Internet billing Web portal www.emomed.com or through the 835 RA. Details were announced in an August 2, 2010 MO HealthNet Provider Bulletin.
RA files are accessible by National Provider Identifier (NPI) and are available automatically following each financial cycle. Each RA remains available for approximately 62 days; the oldest drops off the list when a new RA becomes available.
MO HealthNet has received a number of calls from providers asking how to retrieve their electronic RA through www.emomed.com. If the provider has a www.emomed.com account, this Hot Tip provides instructions on how to find and download the RA. If the provider does not have a www.emomed.com account, one must be obtained. To begin the application process go to: http://manuals.momed.com/Application.html.
To retrieve an RA, go to www.emomed.com and log-in with your user ID and password. This opens the “Welcome to e-Provider” screen.
- Click on “File Management”.
- In “Search Scope”, check “Selected NPI”. Be sure the correct NPI is displayed in the NPI box.
- Select “Printable RAs” in the “File Type” section and click on “Search”. This brings up a list of your four most recent RAs in the “Results” section. The RAs are in chronological order from the newest to the oldest.
- Click on the Adobe icon on the right side of the RA you want to open.
- This opens the RA as an Adobe PDF document.
- To print the RA, click on the printer icon or select print from “File” on the tool bar at the top of the page.
- You can also save the document to your computer system by clicking on the computer disk icon or by selecting the “Save” option from “File” and selecting a location on your computer where you want to save the document.
Adult and Children Flu Shot Reminders
November 8, 2010
It’s that time of year again for the flu and flu shots. MO HealthNet covers both adult flu vaccines and their administrations unless the individual is enrolled in a managed care health plan. Providers should contact the managed care health plan regarding reimbursement of the administration of the vaccine.
Note - the HIN1 vaccine is included in the flu vaccines this year and is not a separate immunization.
MO HealthNet Fee-For-Service Participants
For participants not enrolled in a managed care health plan, the vaccine is billed on the MO HealthNet pharmacy claim form on www.emomed.com. The administration is billed separately either on the paper CMS-1500 claim form, through a clearing house on the 837 HIPAA professional transaction or through www.emomed.com on the medical claim form. Administrations are billed with CPT code 90471 for a single immunization or CPT code 90472 for multiple immunizations. Provider Based Rural Health Clinics and Federally Qualified Health Centers cannot bill administration but can bill for the vaccine. For independent Rural Health Clinics, the administration and vaccine are included in the per diem reimbursement for a medically necessary encounter and are not separately billable.
MO HealthNet Managed Care Health Plan Participants
For participants enrolled in a managed care health plan, the vaccine is billed to MO HealthNet on the www.emomed.com pharmacy claim form. Contact the managed care health plan for information regarding reimbursement of administration of the vaccine.
Vaccines for Children Program
Flu vaccine for children is available for free from the Missouri Department of Health and Senior Services under the Vaccines for Children (VFC) program. VFC administration codes for children not enrolled in a managed care health plan are billed to MO HealthNet with the appropriate CPT code and the SL modifier. Rural Health Clinics and Federally Qualified Health Centers cannot bill the VFC administration code as it is considered included in the reimbursement for a visit.Contact the appropriate managed care health plan for information regarding reimbursement of administration of the vaccine.
EMOMED - Choosing the Right Claim Form
November 1, 2010
By now, many of you have experienced billing through the redesigned billing Web Site at www.emomed.com.
A common error that results in a claim denial is choosing the wrong claim form to bill for the provider’s services. For example, some physicians/clinics are selecting the ‘inpatient’ form when billing for their hospital inpatient services. When submitting a new claim, you have the option to bill on a medical (CMS-1500), outpatient (UB-04), inpatient (UB-04), dental (ADA 2002, 2004) or pharmacy claim form. Providers should choose the claim form appropriate to their profession not based on where the services were provided. For instance, a physician should bill on a medical claim form; an outpatient hospital facility or a rural health clinic should bill using the outpatient form; a dentist should use the dental form, etc. A physician’s office would not use the outpatient form simply because services were rendered at the outpatient hospital facility.
All questions should be directed to the Provider Communication Unit at 573/751-2896.
Non-Emergency Medical Transportation
October 25, 2010
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 Medical Transportation Management, Inc. (MTM), the NEMT broker for MO HealthNet beginning October 1, 2010.
Effective October 1, 2010, participants under the age of 17 will require the presence of a parent/guardian or another adult while being transported to a MO HealthNet covered service. Transportation will not be provided for a child under the age of 17 who is unaccompanied unless they are an emancipated minor.
To schedule a ride, participants or their representative can contact MTM toll-free at 1-866-269-5927. The following information is necessary when scheduling a ride:
- Participant’s full name, current address, telephone number, and date of birth
- MO HealthNet ID
- Date of the medical appointment
- Name, address and telephone number of the medical provider
- Medical reason for the request
- Type of MO HealthNet covered service
October 18, 2010
MO HealthNet payment may be made for custom-made items when the participant becomes ineligible (either through complete loss of MO HealthNet eligibility or change of assistance category for which the particular service is not covered) or dies after the item is ordered or fabricated and prior to the date of delivery or placement of the item. MO HealthNet considers the following to be custom-made items: dentures, hearing aids, prosthetic eye(s), len(es), complete eyeglasses, custom wheelchairs, orthotics, prosthetics, and custom HCY (Healthy Children and Youth) equipment.
The following prerequisites apply to all such payments:
- The participant must have been eligible when the service was first initiated (and following the approval through the CyberAccess process or Prior Authorization Request if required) and at the time of any subsequent service, preparatory and prior to the actual ordering or fabrication of the device or item;
- The custom-made device or item must have been fitted and fabricated to the specific medical needs of the participant in such a manner so as to preclude its use for medical purpose by any other eligible; and
- The custom-made device or item must have been delivered or placed if the participant is still living.
If the provider determines the participant has lost eligibility after the service is first initiated and before the custom-made item or device is actually ordered or fabricated, the participant must be immediately advised that completion of the work and delivery or placement of the item or device is not covered by MO HealthNet. It is then the participant’s choice whether to request completion of the work on a private pay basis. If the participant’s death is the reason for loss of eligibility, the provider can, of course, proceed no further and there is no claim for the non-provided item or device.
If a participant refuses to accept the item or device, MO HealthNet does not reimburse the provider.
MO HealthNet policy and billing instructions for custom-made items is detailed in section 13 of the Durable Medical Equipment, Dental, Optical, and Hearing Aid Provider Manuals.
TPL and Patient Responsibility
October 12, 2010
The MO HealthNet Provider Communications staff frequently receives inquiries concerning situations where the provider is attempting to obtain commercial insurance information from the participant or the policy holder and the person is not cooperating in providing the requested information.
There are collection alternatives for providers in these situations. Missouri regulation allows the provider of the services to bill participants for MO HealthNet covered services if due to the participant’s action or inaction, the provider cannot be reimbursed by the state agency for the services. Missouri Regulation 13 CSR 70-4.030 states in part:
“…if the item or service is not otherwise payable for reasons unrelated to actions of the provider, the participant is liable to the provider for payment of the item or service.”
It’s the provider’s responsibility to document reasonable efforts to obtain the required information so that the agency can make a fair and accurate determination of responsibility. The documentation should include a record of phone calls and/or copies of letters to the participant or the policyholder.
In those instances when someone other than the participant is not cooperating with the provider’s request for information (e.g., an absent or non-cooperative parent or a policyholder that is not the participant), the provider must document failed efforts to collect a payment and/or the information.
The commercial insurance carrier will occasionally send the check to the patient instead of sending it to the provider. When this information becomes known to the provider, the provider must make a reasonable effort to obtain the payment from the patient prior to submitting the claim to MO HealthNet. Again, the provider must document the efforts to collect the payment. Note - once the provider submits a claim and receives payment for it from MO HealthNet, the provider cannot undertake additional collection efforts from the patient or policy holder.
For each of the above situations, once the provider can provide adequate documentation of failed efforts to obtain the information, the provider can submit the documentation (copies of letters, records of phone calls, etc.) along with a claim to the Third Party Liability Unit for determination and possible special handling. The information should be sent to:
Third Party Liability Unit
MO HealthNet Division
PO Box 6500
Jefferson City, MO 65102
Questions regarding third party liability should be directed to the Third Party Liability Unit at 573/751-2005.
Hospital Observation Beyond 24 Hours
October 4, 2010
Section 13.45.B of the MO HealthNet Hospital Provider Manual states that outpatient hospital observation room charges beyond 24 hours cannot be billed to MO HealthNet or the patient. It further states that diagnostic and procedural services, performed after the initial 24 hour period has expired, may be billed to MO HealthNet and the date of service is the date the services were provided.
Recently, MO HealthNet has discovered that some hospitals are billing an outpatient facility charge for additional services performed while the patient is still in observation beyond the initial 24 hour period. It is improper for a hospital to bill an additional facility charge while the patient is still in observation for any diagnostic and/or procedural services performed after the 24 hour limit. Only one observation code is billed per stay.
Using the Correct Claim Form
September 27, 2010
Confusion exists among providers in determining which MO HealthNet Division (MHD) claim form to complete for reimbursement of co-insurance and deductible amounts for those Medicare/MO HealthNet participants with Medicare Part C coverage. Claims for participants with Medicare 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. Providers should 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 ACS; 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 all MO HealthNet 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.
When Can Patients Change Managed Care Health Plans?
September 20, 2010
A MO HealthNet participant newly enrolled in a MO HealthNet Managed Care health plan can change MO HealthNet Managed Care 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 at other times for just cause. Some reasons for changing after the 90 day period include: the participant moved out of the MO HealthNet Managed Care area; the participant’s primary care provider is no longer with the individual’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 is no longer with the individual’s MO HealthNet Managed Care health plan and the transfer is necessary to ensure continuity of care.
Participants have a 30-day annual open enrollment period. Members may change MO HealthNet Managed Care health plans during their annual open enrollment period for any reason. 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 their primary care provider (PCP) within the MO HealthNet Managed Care health plan at least two (2) times each year. Some MO HealthNet Managed Care health plans may allow a PCP change more frequently. Children in state custody may change their primary care provider as often as necessary.
No More Paper Checks or RAs!
September 13, 2010
MO HealthNet will cease sending providers paper checks effective with the October 22, 2010 financial cycle. Future MO HealthNet payments will be by direct deposit only. If you are not on direct deposit by this cycle date, you will not receive a paper check. There are no exceptions.
Providers who are not on direct deposit for their provider checks must immediately complete an Application for Provider Direct Deposit form to have their reimbursements deposited directly to their bank or savings account. Instructions for completing the form are on page two.
The application must be downloaded, printed, completed and mailed along with a voided check or letter from your bank to:
MO HealthNet Division
Provider Enrollment Unit
P. O. Box 6500
Jefferson City, MO 65102
If you wait until October 22 to submit the form, the agency will not have enough time to process your application and you will not receive the October 22 cycle check. Again, there are no exceptions.
Individual providers whose services are billed only as a performing provider are not required to participate in direct deposit since reimbursement for their services is already sent to the billing provider. Individual providers who bill using their own NPI and who currently are not on direct deposit must enroll for direct deposit.
The last paper remittance advice will be for the October 22, 2010 financial cycle. Unless you are utilizing the electronic HIPAA 835 transaction to receive your RA, future remittance advices will be available only by using the MO HealthNet Web portal at www.emomed.com. If you are not already an emomed.com user, you must apply on-line for access by completing the Application for MO HealthNet Internet Access Account form.
Questions regarding either of these items should be directed to the Provider Communications Unit at 573-751-2896.
Billing Policy for CPT Code 90862
September 7, 2010
MO HealthNet has recently received several inquiries concerning which physician specialties can be reimbursed for CPT code 90862. According to the CPT code book, “Other Psychiatric Services or Procedures”, code 90862 is “Pharmacologic management, including prescription, use and review of medication with no more than minimal medical psychotherapy”. MO HealthNet reimbursement for this service is restricted to only psychiatrists and clinical nurse practitioners with a psychiatric specialty. Non-psychiatric physician services that might include medical pharmacologic management should be billed with the appropriate level evaluation and management service CPT code.
MO HealthNet News Email Subscription
August 30, 2010
It is important that enrolled MO HealthNet providers and their staff are signed up to be notified when news is posted to the MO HealthNet Web site. Each person subscribed to the MO HealthNet email news service receives every message sent regardless of the program or provider type. The subscriber chooses which email notices to read and keep.
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’ from the column on the left. Follow the instructions on this page to subscribe or unsubscribe.
When you receive notification of news posted to the MO HealthNet Web site, please note you cannot respond as this is a one-way notice to you. If you have questions regarding the information in the notice, you can contact the Provider Communications Unit at 573/751-2896.
Billing for Bilateral Procedures
August 23, 2010
The MO HealthNet agency recently has observed that some providers are incorrectly filing claims for bilateral procedures. This is resulting in delays in processing either the claims or denials.
A bilateral procedure is when the same procedure is performed on both sides of the body. To correctly bill this claim, a 50 modifier must be used along with the procedure code. The 50 modifier allows the system to identify the service as a bilateral procedure. It is to be billed with a quantity of one. The provider’s billed amount should represent the cost for the whole service.
The problems are occurring because the providers are billing one line with the surgical procedure code and a second line with the same surgical code along with the 50 modifier. Consequently, this gives the appearance that the provider is billing for three procedures when in reality only two were performed. In these instances, the claims suspend for manual review which can take several weeks. The reviewer can either allow payment for one line of the claim or can deny it.
MO HealthNet policy on bilateral procedures is detailed in Section 13.81 of the Physician Provider Manual and below:
13.81 BILATERAL PROCEDURES (50 MODIFIER)
MO HealthNet covered procedures that are performed bilaterally and are identified by Medicare Services as appropriate bilateral procedures, must be billed using the 50 modifier and quantity of 1. For bilateral procedures identified by Medicare Services, please reference the Medicare Physician Fee Schedule Relative Value File (MPFSRVU) (Medicare Physician Fee Schedule Database). The MPFSRVU indicators in the bilateral surgery column of the database instruct carriers how to reimburse for services. The fee schedule can be found at: http://www.cms.hhs.gov/PhysicianFeeSched/PFSRVF/list.asp.
Note: Not all codes in the listing are covered by MO HealthNet. Refer to the MO HealthNet fee schedule for more information.
Requesting Provider Assistance
August 16, 2010
The Provider Education and Provider Communication Units within the MO HealthNet Division (MHD) provide education and assistance for the provider community. These units strive to provide accurate and timely responses to provider inquiries and concerns regarding MO HealthNet policies and procedures. On occasion, an issue is more complex in nature and may require further research by MHD staff which could delay the response time. If multiple requests are received from the same provider for the same issue, this could also further delay the response time. Therefore, providers are encouraged to direct all follow-up communication regarding the same issue to the same MHD staff member. This will allow for the most efficient and timely resolution of the issue.
Inquiries, concerns or questions regarding claim filing, claims resolution, and participant eligibility and verification should be directed to Provider Communications at 573/751-2896.
Provider Education can be contacted at 573/751-6683 to schedule training in claim filing and program policies.
August 9, 2010
Case management services are available for MO HealthNet eligible pregnant women who are “at risk” of poor pregnancy outcomes. Case Management Services are intended to reduce infant mortality and low birth weight by encouraging adequate prenatal care and adherence to the recommendations of the prenatal caregiver.
Completion of the “Risk Appraisal for Pregnant Women” by an appropriate MO HealthNet provider is mandatory in order to establish the “at risk” status of the patient. Completion of the “Risk Appraisal for Pregnant Women” is also mandatory in order to be reimbursed for the global prenatal or global delivery procedure code. A Risk Appraisal may be completed by a registered nurse, a social worker, a certified nurse practitioner, a physician, or a team of these professionals. A copy of the Risk Appraisal must remain in the patient’s medical record.
The Risk Appraisal form is available on our website. On the left side of the screen, choose “MO HealthNet Forms” and scroll down to the Risk Appraisal for Pregnant Women form. These forms may be printed directly and copied.
If a woman qualifies for case management, the risk appraisal must be sent directly to the enrolled Case Management Provider of the patient’s choice. Please do not forward these forms to the MO HealthNet office. Providers who are interested in becoming case managers should contact the Provider Enrollment Unit for more information at email@example.com.
Refer to Section 13.66 of the Physician’s Manual located on our website at http://manuals.momed.com/manuals/ for further information regarding Case Management for Pregnant Women.
ER Surgery and Post-Op Care
August 2, 2010
MO HealthNet has received an increased number of inquiries from providers whose claims for post-operative care are being denied. The majority of the inquiries pertain to situations where a surgery was performed in a hospital emergency department and the participant was directed to go to their personal physician or clinic for follow-up/post-op care.
In these situations, the post-op care claims generally deny if the emergency department physician billed the surgery CPT code without the 54 modifier. This modifier indicates that the provider is billing only for the surgery and is not providing follow-up care. A surgery claim filed without the 54 modifier results in the provider being reimbursed for both the surgery and the post-op care.
If a provider has billed claims incorrectly as described above, the paid claims must be adjusted to add the 54 modifier and if appropriate, correct the billed amount. Otherwise, the provider has been reimbursed for post-op services which were not rendered.
MO HealthNet policy regarding post-op care is detailed in Section13.41 of the MO HealthNet Physician Provider Manual. If the reimbursement for a surgical procedure is more than $75, the reimbursement includes 30 days post-op service.
Supervision of Auxiliary Personnel in Medical Offices/Clinics
July 26, 2010
MO HealthNet regularly receives inquiries regarding supervision and employment of auxiliary personnel in medical offices. A recent inquiry requested clarification for situations where the personnel
- might be from a temporary staffing agency;
- considered independent contractors;
- employees of a non-physician corporate practice owner (e.g. hospital, medical school, etc); or
- are under some other form of employment.
According to the Missouri Board of Registration for the Healing Arts, an auxiliary employee is defined as anyone who works for and provides services for a physician. How that physician pays or employs this person is up to the physician employer. In accordance with the information from the Board, the agency believes that the employment scenarios referenced in the first paragraph meet the definition of employed auxiliary personnel.
Section 13.18.A of the MO HealthNet Physician Provider Manual states that a provider may bill for the services of auxiliary personnel employed by the physician only when the person is working under direct physician supervision. Direct supervision in the office/clinic setting does not mean the physician must be present in the same room with the auxiliary personnel. However, the supervising physician must be in the office suite and immediately available to provide assistance and direction throughout the time the auxiliary personnel are performing services.
Updating Provider Location Information
July 19, 2010
Providers, or provider administrators, are responsible for notifying MO HealthNet of the provider’s practice locations and to update practice location information when changes occur. The location information is used as the official mailing address for agency documents such as prior authorization forms, determination letters, and correspondence from the Program Integrity Unit. Unless the mail is forwarded to a new address, it is returned to the MO HealthNet Division (MHD) and your provider enrollment can be inactivated. The information is also used to populate the ‘MO HealthNet Provider Search’ feature on the agency’s general information Web page so participants, providers, and others can locate MO HealthNet providers in a particular area or for a specific specialty.
Practice location information can be updated via the MO HealthNet Internet billing Web site, www.emomed.com. Click on 'Add/Update/Delete Provider Practice Locations' to make additions or changes. Click on the 'Help' button at the bottom of the page to guide you step-by-step through the process of adding or updating provider practice locations. Only the enrolled provider or the provider administrator has access to add or update provider practice locations.
Adding or changing practice locations at www.emomed.com only updates the MO HealthNet Provider Search; it does not update the MO HealthNet Provider Master Record. You still must report your address change as well as other changes such as tax identification number and change of ownership by contacting the Provider Enrollment Unit via E-mail at firstname.lastname@example.org for specific instructions.
If you are unsure if your provider practice location(s) is/are shown correctly, you can query the provider practice location information through the MO HealthNet Provider Search link at: https://apps.dss.mo.gov/fmsMedicaidProviderSearch/. If the practice location(s) need to be updated or added, please follow the process as outlined above to change practice location information.
In-Home Service Billing Reminders
July 12, 2010
In-home services provided in an assisted living/residential care facility or the participant’s home must be authorized by the Department of Health and Senior Services (DHSS). DHSS may authorize personal care, advanced personal care and nurse visits under the Personal Care program. For those participants 63 years of age and older, respite services may be authorized under the Aged and Disabled waiver program. This program includes Homemaker/Chores services for those residing in their own home.
Services are billed on the CMS-1500 claim form and use a Place of Service (POS) code of 12 - home. Most services must be provided and billed in full 15 minute increments with the exception of the nurse visits and the block respite services. These services are billed as one (1) unit for the entire time the nurse or worker is in the home. The DHSS plan of care includes a list of medical conditions pertaining to the participant and the provider must determine the appropriate diagnosis code using the ICD-9 diagnosis code book. There is no list of commonly used diagnosis codes. While most agencies can bill a from/through range of dates, consumer directed services must be billed daily and some services must also be billed using the specific date. Providers must ensure they do not include dates the participant was not in the home, such as a hospital inpatient stay.
When a participant moves they should inform the local Family Support Division office of the change in address. As DHSS authorizes services to a specific provider NPI, the provider needs to immediately notify the DHSS Regional Evaluation Team of the move. This allows for the authorization to be updated and if necessary, the services transferred to the appropriate provider NPI.
Many in-home services deny for eligibility, no prior authorization, or exceeding the authorized units. Providers should always verify eligibility prior to rendering services and have a valid authorization on file. The Adjustment Reason and Remark codes will assist the provider in understanding why a claim denied. These code lists may be found on the MHD Web site under HIPAA Related Code Lists.
MHD runs financial cycles twice a month. Approximately 2-3 weeks after the financial cycle, checks are mailed or direct deposited. The Claims Processing and Payment Schedule are also located on the MHD Web site.
spend down and Eligibility
July 5, 2010
Providers frequently call MO HealthNet Provider Communications with questions regarding participant spend down requirements and policies.
spend down is a MO HealthNet program in which participants have an amount they must pay or reach each month before they can have MO HealthNet coverage. It is similar to an insurance premium. The spend down amount is determined by the Family Support Division (FSD) and can range from as little as $1 to more than $1,000 a month depending on the participant’s monthly income. There are several ways a participant can meet their required spend down amount.
- Incurred Expenses - The spend down amount can be met by incurred and reported allowable medical expenses. A June 2, 2008 Hot Tip details what are considered allowable medical expenses. In order to be eligible for the month, the participant must report their incurred medical expenses to their FSD eligibility specialist, preferably each month. The expenses then are entered into the system and the date of service the reported expenses meet the spend down amount, is the effective date of the participant’s eligibility.
- Participants commonly believe that once they have met their spend down amount, eligibility is backdated to the first of the month. Eligibility is not necessarily retro-active back to the first of the month unless that is the date the reported expenses meet the spend down amount.
- Monthly Payment – The spend down amount can also be met by a monthly payment by the participant to the MO HealthNet program. The payment must be equal to the required spend down amount. Under this option, the participant can send a check or money order to the MO HealthNet Division before the start of the month and is automatically eligible the first of that month. Or, the participant can opt to have a direct withdrawal from his/her checking account.
spend down is one of the major reasons a provider must check a participant’s eligibility prior to each service date. When eligibility is checked and it indicates the participant is not eligible on the date of service, the provider can make the participant responsible for the cost of services even if eligibility is made retro-active when the incurred expenses are reported and entered into the system at a later date.
Global Prenatal and Global OB Billing Policies
June 28, 2010
Audits by the Program Integrity Unit have determined that some MO HealthNet providers are billing for global OB services but are not following agency policy especially on the number of prenatal visits required in order to bill global services. The unit has found numerous instances where providers are unbundling services that are considered a part of the global service and not separately billable. Recoupment of payments will be made in instances where providers are found not to be following agency policy, which is incorporated in regulation 13 CSR 70 - 3.030
Global prenatal care (CPT codes 59425 and 59426) includes all prenatal visits performed at medically appropriate intervals up to the date of delivery, urinalysis testing during the prenatal period, care for all pregnancy-related condition; e.g., nausea, vomiting, cystitis, vaginitis, and a “Risk Appraisal for Pregnant Women”. The provider must have seen the MO HealthNet eligible participant for four or more prenatal visits and performed all the “prenatal visit” services at each visit as defined in Section 13.67.F of the MO HealthNet Physician Provider Manual. If a provider sees the participant for more than three visits but she goes to another provider for the remainder of her pregnancy, all visits by both providers must be billed using the appropriate procedure codes for each date of service, except for the exempted visits/consultations for complications.
Global prenatal/delivery/postpartum (CPT codes 59400, 59510, 59610, and 59618) includes all prenatal visits, urinalysis, care for all pregnancy -related conditions and a Risk Appraisal for Pregnant Women. The fee also includes the initial hospital visit, the delivery and postpartum care. Again, the provider must have seen the participant for four or more prenatal visits and performed and documented all the prenatal visits during each visit.
Global codes are designed to be used for uncomplicated pregnancies. Global billing is optional for providers but if the global codes are billed, the payment includes all pregnancy related care and visits deemed “non-routine”, e.g. observation, preterm labor, etc., and are not separately billable.
Providers managing high risk pregnancies should consider billing each service separately in these instances and not billing global codes.
Full details on MO HealthNet polices on obstetrical care are found in reference Section 13.67 of the Physician Provider Manual.
Claim Processing Schedule - FY 2011
June 21, 2010
The provider claim processing schedule has been updated for state fiscal year 2011, which begins July 1, 2010. The new schedule lists the ending dates for claim capture, Remittance Advice (RA) dates and their corresponding check dates. It is important that you make a copy of the claim processing schedule and refer to it often.
Please Note: In the past, claims were received up to 5PM of the financial cycle RA date. That will not always be the case with the new schedule. There is now a column of dates that shows the last date claims will be accepted for the next RA. This new schedule is posted below and can also be accessed through the link above.
Provider reimbursement checks are mailed or directly deposited into a provider’s account twice each month, usually around the 5th and the 20th days. If either date falls on a Saturday, Sunday or state holiday, the check will be mailed or directly deposited the following working day.
If you still receive your reimbursement in the form of a paper check, you are urged 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.
The 2011 Claim Processing Schedule is shown below:
For Fiscal Year 2011 July 1, 2010 thru June 30, 2011
|ENDING CLAIM CAPTURE DATE 1||FINANCIAL CYCLE RA DATE||PROVIDER CHECK DATE|
|Note 1: Closeout is 5:00 p.m. on the date shown|
|Friday 06/25/2010||Friday 06/25/2010||Tuesday 07/06/2010|
|Friday 07/09/2010||Friday 07/09/2010||Tuesday 07/20/2010|
|Friday 07/23/2010||Friday 07/23/2010||Thursday 08/05/2010|
|Thursday 08/05/2010||Friday 08/06/2010||Friday 08/20/2010|
|Thursday 08/19/2010||Friday 08/20/2010||Friday 09/03/2010|
|Friday 09/10/2010||Friday 09/10/2010||Friday 09/17/2010|
|Wednesday 09/22/2010||Friday 09/24/2010||Tuesday 10/05/2010|
|Friday 10/08/2010||Friday 10/08/2010||Wednesday 10/20/2010|
|Friday 10/22/2010||Friday 10/22/2010||Friday 11/05/2010|
|Wednesday 11/10/2010||Friday 11/12/2010||Friday 11/19/2010|
|Tuesday 11/23/2010||Friday 11/26/2010||Monday 12/06/2010|
|Wednesday 12/08/2010||Friday 12/10/2010||Monday 12/20/2010|
|Thursday 12/23/2010||Friday 12/24/2010||Wednesday 01/05/2011|
|Thursday 01/06/2011||Friday 01/07/2011||Thursday 01/20/2011|
|Friday 01/21/2011||Friday 01/21/2011||Friday 02/04/2011|
|Friday 02/11/2011||Friday 02/11/2011||Friday 02/18/2011|
|Friday 02/25/2011||Friday 02/25/2011||Monday 03/07/2011|
|Friday 03/11/2011||Friday 03/11/2011||Monday 03/21/2011|
|Friday 03/25/2011||Friday 03/25/2011||Tuesday 04/05/2011|
|Wednesday 04/06/2011||Friday 04/08/2011||Wednesday 04/20/2011|
|Wednesday 04/20/2011||Friday 04/22/2011||Thursday 05/05/2011|
|Tuesday 05/10/2011||Friday 05/13/2011||Friday 05/20/2011|
|Tuesday 05/24/2011||Friday 05/27/2011||Tuesday 06/07/2011|
|Sunday 06/05/2011||Friday 06/10/2011||Monday 06/20/2011|
Concurrent Dates of Hospital Services
June 14, 2010
Because of a number of recent inquiries, a December 31, 2007 Hot Tip discussing MO HealthNet policy on concurrent dates of hospital services is being republished.
Section 13.22 of the Hospital Provider Manual discusses billing for outpatient/emergency room/observation services that occur on the same day that a participant is admitted for inpatient services but prior to the actual admission. The section reads in part:
“Any outpatient service performed after a recipient has been admitted as an inpatient must be shown as ancillary charges on the inpatient claim. It is an improper billing procedure for a provider to submit an inpatient claim and the same or a different provider to submit an outpatient claim for concurrent dates of service for the same recipient. Outpatient services provided on the day of admission, but prior to admission, or on the day of discharge, but following discharge, are not considered concurrent care for the purpose of this policy. Such outpatient services provided on the day of admission or the day of discharge are reimbursable as outpatient services.
Outpatient/emergency department/observation room services provided prior to and on the same date as an admission should be billed as an outpatient claim while the inpatient services are to be billed on a separate inpatient claim. Do not bill both types of services on the same claim.”
For more information regarding concurrent dates of service, you can reference Section 13.22 of the hospital provider manual.
We Need Your Suggestions!
June 7, 2010
The Provider Education Unit of the MO HealthNet Division (MHD) wants to provide weekly hot tips that are beneficial to you, the provider. Hot tips are often developed when MHD observations and reports indicate trends in billing errors or areas of misunderstandings regarding program policies and procedures.
Provider Education encourages and welcomes your input to the topics you would like to see as hot tips you believe would benefit the provider community. If you have suggestions, please send them by E-mail to: MHD.email@example.com.
Sending Claims For Special Handling
June 1, 2010
When an enrolled MO HealthNet Division (MHD) provider sends claims directly to MHD for special handling of any kind, a cover sheet that includes the directions for the special handling must be attached. A provider contact person and telephone number must be included in the event there are questions regarding the request or additional documentation is needed for processing. If the required information is not included with your claim, the request will not be processed and will be returned.
If the patient has private commercial insurance, please attach the insurance Explanation of Benefit Notice to the claim form along with any other pertinent documentation.
When a Medicare Part A, B or C claim requires special handling by MHD staff, please follow the instructions below to send your claims for special handling.
- Log onto the MHD web portal for billing at www.emomed.com.
- Select and complete the appropriate crossover claim type.
- Each claim must not exceed six detail lines.
- Do not submit the claim electronically. Instead, select Ctrl P to print each page of the claim.
- After printing the claim screens, select the ‘Home’ button to return to the Home page. From this point you may logout or access other features available from the Home page.
- Number the pages you have printed, 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 and/or Medicare Part C EOMB and other applicable documentation together.
- If you have discussed your claim issue with a particular MHD staff person, please address and send to them at:
MO HealthNet Division
P. O. Box 6500
Jefferson City, MO 65102
Billing for Contrast Materials
May 24, 2010
MO HealthNet regularly receives inquiries from hospitals regarding the correct codes to use for billing contrast materials such as those used for MRI and CAT scans performed in the hospital outpatient setting.
If the contrast material has a valid National Drug Code (NDC) associated with it, the hospital can bill the material either on the electronic outpatient UB-04 on www.emomed.com Web site or the electronic institutional 837. The material can be billed also on the Pharmacy Claim Form on the www.emomed.com.
If the material does not have a valid NDC or the NDC is alphanumeric, it can be billed with an appropriate HCPCS ‘A’ code. The following chart lists the covered HCPCS ‘A’ codes. These codes can be submitted either on a paper UB-04, the electronic outpatient UB-04 on www.emomed.com or an electronic institutional 837. Regardless of the method used to submit the claim, it must include an invoice of cost as the codes are manually priced.
Re-Pricing Medicare Inpatient Hospital Claims
May 17, 2010
Since July 1, 1991, the MO HealthNet Division (MHD) has been re-pricing Medicare Part A inpatient hospital crossover claims for the possible payment of Medicare deductible and co-insurance amounts. This Hot Tip is a reminder that the re-pricing policy also applies to Medicare Part C/Advantage plans for inpatient hospital services for deductible, co-insurance and co-pay amounts for participants who are QMB eligible. The following information is taken from Section 12.5.A of the Hospital Provider Manual.
MO HealthNet is responsible for deductible and coinsurance amounts for Medicare Part A crossover claims only when the MO HealthNet applicable payment schedule exceeds the amount paid by Medicare. In those situations where MO HealthNet has an obligation to pay a crossover claim, the amount of MO HealthNet’s payment is limited to the lower of the actual crossover amount or the amount the MO HealthNet fee exceeds the Medicare payment. The hospital’s remittance advice will show the amount to be paid for each re-priced Part A/Part C crossover claim. The system will post claim adjustment reason code OA-045 (charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement) and remittance advice remark code N-59 (please refer to your provider manual for additional program and provider information) for those claims where Medicare has paid more than MO HealthNet would.
Amounts not reimbursed by MO HealthNet for allowable crossover claims may not be billed to the MO HealthNet participant.
The Part A Medicare deductible for inpatient services is always applied to the day of admission or the first day in the hospital stay that the individual becomes Medicare eligible. If the patient is not MO HealthNet eligible on the day the deductible is applied, MO HealthNet does not pay the deductible and it becomes the responsibility of the patient to pay for the deductible.
Optical Claims - Date of Service Requirement
May 10, 2010
Reminder - The date of service on optical claims filed to MO HealthNet must be submitted with the date the service is rendered to the participant.
The date of service for a participant’s eye examination must be the date they have their eye exam. The date of service for frames, lenses, and any other optical material must be the date dispensed, not the date the materials are ordered or the date the precertification is obtained.
Hospital Outpatient Charges Assessment vs. Triage Services
May 3, 2010
To clarify the possible confusion between “assessment” and “triage” services in the outpatient hospital, MO HealthNet defines them as follows:
Assessment is an examination by a medical professional (physician or other person who is authorized by State licensure law to order hospital services for diagnosis or treatment of a patient) in an outpatient or emergency department setting to determine the best course of treatment for the patient.
Triage is a preliminary medical screening of patients to determine their relative priority for treatment prior to being seen by a medical professional as defined above.
Sections 13.44, 13.45 and 15.23 of the Hospital manual state that outpatient hospital facility charges can only be billed when the patient is seen by a medical professional. A medical professional is a physician or other person authorized by State licensure law to order hospital services for diagnosis or treatment of a patient. For example: A MO HealthNet participant presents to the emergency department at a participating hospital, is seen by the triage nurse then decides to leave without seeing a physician or other medical professional. Since the participant was not assessed and/or seen by a physician or other medical professional, a facility charge cannot be submitted.
Does a Code Require Prior Authorization?
April 26, 2010
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 Prior Authorization (PA). This information is readily available through the MO HealthNet Web site and providers can save time by checking themselves.
- 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 PA), the maximum quantity and reimbursement fee.
- 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 which 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.
Using Correct/Valid Performing Provider NPI
April 19, 2010
When a clinic enrolls with MO HealthNet, it is imperative that all the providers within that clinic who intend to bill for services provided to MO HealthNet participants be enrolled with MO HealthNet. The clinic must submit claims to MO HealthNet with the NPI of the provider of service as the performing provider. It is against MO HealthNet regulation to bill for clinic services under the NPI of only one enrolled provider when the services were performed by other providers. If the agency encounters a situation like this, it can recoup all the improperly billed claims.
It is the responsibility of MO HealthNet hospitals and clinics to ensure that all the providers for whom they bill have a current Missouri license. A provider who does not have a current valid license is not eligible for continued enrollment/participation with the MO HealthNet program. The agency’s Provider Enrollment Unit strives to keep current on provider licensure. It is not always possible to know when there is official action against a provider’s license including suspension, expiration or revocation. Billing services under the NPI of a provider who is no longer licensed is against MO HealthNet regulation and will result in a recoupment of all the improperly filed claims. It is imperative that the enrolled provider’s credentialing person or department regularly check on the licensure of enrolled providers and to share any licensure information with their billing staff and with the MO HealthNet Provider Enrollment Unit.
Inquiries regarding the enrollment status of a provider should be directed to the provider enrollment unit at firstname.lastname@example.org.
Go to the following Web site to enroll as a MO HealthNet provider.
Presumptive Eligibility Programs
April 12, 2010
Some MO HealthNet participants are eligible for “presumptive eligibility” programs. Unfortunately, providers sometimes don’t understand what this means and are reluctant to provide services to these persons even when the participant provides official Family Support Division (FSD) documents supporting their presumptive eligibility for MO HealthNet services. There are two MO HealthNet Division (MHD) programs that give presumptive eligibility to eligible persons.
The first is Temporary Assistance for Pregnant Women (TEMP) and is a period of presumptive eligibility while an official MO HealthNet for Pregnant Women (MPW) application eligibility determination is made. Eligibility for TEMP is indicated on a TEMP form, the QP-2 form, and includes the “From” and “Through” dates of eligibility. The QP-2 form serves as official verification to the MO HealthNet provider of the participant’s eligibility for this program until the information is input into the system by the local FSD office. Coverage begins on the date the qualified entity makes the presumptive determination and ends the last day of the following month. In order to continue TEMP eligibility, the woman must be recertified for TEMP following the termination of her current eligibility.
The second program is Presumptive Eligibility (PE) for Children. It too is a period of presumptive eligibility while an official MO HealthNet for Kids application is being processed. The eligibility for PE for Children is indicated first on a PE for Children form, the PC-2 form. The PC-2 form serves as official verification to the MO HealthNet provider of the participant’s eligibility for this program until FSD inputs the information into the system. Children determined presumptively eligible for MO HealthNet receive the same coverage during the presumptive period. The children active under PE for Children are not enrolled in managed care. While the children must obtain their presumptive determination from a qualified entity, once eligible they can obtain covered services from any enrolled MO HealthNet fee-for-service provider. Coverage begins on the date the qualified entity makes the presumptive eligibility determination and coverage ends on the later of:
- 5th day after the PE for Children determination date;
- the day a MO HealthNet for Kids, Pregnant Women and Parents application is approved or rejected; or
- if the caretaker does not apply for MO HealthNet, coverage ends the last day of the month following the month of the presumptive eligibility determination.
Once FSD enters the eligibility information for either of these programs, MO HealthNet providers can verify eligibility the next day through the MHD fiscal agent’s Web Portal at www.emomed.com. To check eligibility, the provider must enter the person’s name and the anticipated date of service.
So if a patient presents the provider with either a QP-2 form for TEMP or a PC-2 form for MO HealthNet for Children, the provider can be assured that the patient is covered for each program’s benefits for that day’s services.
April 5, 2010
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 the claim along with the requested supporting documentation 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
P. O. Box (see below)
Jefferson City, MO 65102
- Inpatient Claims: Box 5200
- Outpatient Claims: Box 5200
- CMS-1500 Claims: Box 5600
March 29, 2010
When submitting a prior authorization request for orthodontic services, providers must complete and submit the Prior Authorization (PA) Request form. The following must be mailed with the PA form:
- Study models (unless a panoramic radiograph is necessary to evaluate unerupted teeth;
- A written treatment plan; and
- The Handicapping Labio-Lingual Deviation (HLD) Index
Photographs and cephalometric x-rays will only be required if requested by the state orthodontic consultant after review of the study models and panoramic radiograph. No reimbursement will be made for diagnostic photographs or cephalometric x-rays unless specifically requested by the state orthodontic consultant after review of the study models and panoramic radiograph. After the provider has received authorization to begin orthodontic treatment, a full set of orthodontic records must be obtained and maintained in the participant’s dental record.
The PA form and requested documentation must be mailed to:
Infocrossing Healthcare Services
PO Box 5700
Jefferson City, MO 65102
For more information on completion of the Prior Authorization Request form, providers can reference sections 8 and 14 of the dental provider manual.
Nursing Home Reimbursement
March 22, 2010
- The MO HealthNet Program reimburses an enrolled provider of long term care services based on the eligible participant’s days of care multiplied by the facility’s Title XIX per diem rate less any patient surplus amount.
- MO HealthNet pays for the day of admission but does not pay for the day of hospice election, transfer, discharge or date of death. The day of hospice election, transfer, discharge, or date of death may not be billed to the participant or their representative.
- If a participant dies on the day of admission, contact the Provider Communication Unit at 573-751-2896 or 573-635-8908 for special handling.
- MO HealthNet does not pay for any day a participant is not in the facility except for therapeutic home reserve and, under certain circumstances, hospital leave days; please refer to Section 13.13.C of the Nursing Home Manual. To determine a “day,” a bed count performed at 11:59 PM is most acceptable. If a participant is receiving outpatient hospital services that span midnight but is not admitted to the hospital, the nursing home may bill for that day.
- If the participant has both Medicare Part A and MO HealthNet coverage, the Medicare Part A benefit must be utilized until it has been exhausted. During a Medicare Part A coverage period, only claims reflecting Medicare days, revenue code 0189, are to be submitted. Nursing facilities are not to submit claims for room and board charges, revenue codes 0110, 0119, 0120, 0129, 0190, 0191, 0192, 0193, 0194 and 0199, during Part A coverage periods.
For more information providers can reference Section 13 of the MO HealthNet Nursing Home Manual.
Part C Crossover Claim Form
March 15, 2010
When entering Part C crossover claims through the MO HealthNet Web portal, providers often express confusion as to what information should be entered in the “Patient Medicare ID’ field. The participant’s Medicare ID (their HIC number) should be entered in the Patient Medicare ID field.
Field-by-field instructions can be found by selecting the ‘Help’ feature at the bottom of the page for all claim forms.
Hospital Discharge - Emergency Ambulance VS. NEMT Transports
March 8, 2010
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 to the participant’s home 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).
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. NEMT services may be scheduled with less than three (3) days notice if they are of an urgent nature. Urgent calls are defined as a serious, but not life-threatening illness/injury. Exceptions are made for hospital discharges, but 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. The medical needs should be communicated to LogistiCare when arranging transportation. 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.
For more information on NEMT and all the modes of transportation under NEMT, providers can reference Section 22 of any provider manual.
Contacting the Provider Education Training Unit (573) 751-6683
March 1, 2010
Requests for training can be made by email to email@example.com or by telephone at (573) 751-6683. All information, including the provider NPI number, must be readily available.
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 health care, nursing homes, dental, hospice, 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.
General claim billing, claim denials, Remittance Advices and participant eligibility questions should be directed to the Provider Communications Unit at (573) 751-2896. The Provider Education Unit should be contacted only for program training or questions regarding policy clarification.
Manually Priced Procedures
February 22, 2010
Current Procedural Terminology (CPT) procedure codes ending in “99” (unlisted codes) are always manually priced. In order to be manually priced, the claim must be filed on a paper claim form with documentation attached to the claim. Documentation must include an adequate definition or description of the nature, extent, and need for the procedure, and the time, effort and equipment necessary to provide the service. All claims are manually reviewed by the MO HealthNet state medical consultant for medical necessity and payment.
Unlisted procedure codes should not be coded unless the coder has reviewed the CPT coding system to ensure that a more specific code is not available.
Not all services contained in the CPT book are covered by MO HealthNet. Providers can reference the fee schedule to determine if specific codes are covered. Because a procedure code may not be covered by MO HealthNet, providers must not bill ‘Unlisted’ or ‘99’ codes instead of a more specific code.
Contacting Provider Communications
February 16, 2010
Providers can call the MO HealthNet Provider Communications Unit at (573) 751-2896 with inquiries, concerns, questions on proper claim filing or claims resolution. In order to expedite your inquiry, please have your NPI, patient ID number, CPT code and all other pertinent information readily available when you call. Providers are limited to three inquiries per call. This allows phone specialists to respond to more providers.
Providers also have the ability to send secure E-mail inquiries to the MO HealthNet Provider Communications Unit. This feature is available through the MO HealthNet Web portal page. Once you have logged in and are on the home page, select the ‘contact us’ option located at the bottom right of the page to be linked to a Provider Inquiry form.
Hospital Inpatient Pre-Certification Transition
February 8, 2010
Affiliated Computer Services (ACS) and MO HealthNet Division (MHD) continue to make progress on the transition of inpatient hospital certification services. ACS is continuing to bolster staffing resources to support the reviews of charts and faxes, and respond to provider phone calls.
- ACS added a new primary toll-free fax number, (866) 629-0737.
- Based on provider requests, ACS removed the routing of providers to voicemail except when calling a specific reviewer.
- ACS is increasing the number of staff, including additional registered nurses, in order to respond more timely to inquiries.
- MHD and ACS are moving forward on enhancing the CyberAccess Internet Web tool to reduce wait times. A Web report on certification status will be available mid to late February.
New Certification and Continued Stay Requests:
To facilitate the most expeditious review of certification requests, we are trying to minimize the amount of paper mailed and faxed to ACS:
- Do not submit duplications of previously faxed requests. This will only create delays.
- Use only the new Certification Request Form in order to facilitate our work flows.
- MHD’s goal is to receive Continued Stay Requests while a patient is still in the hospital. During this transition, if providers submit Continued Stay Requests within 14 days of patient discharge, there is no need to send the complete chart to ACS.
The review of 3200 backlogged retrospective cases is underway. Before you contact ACS or MHD regarding the status of retrospective cases, please note the following:
- Retrospective review cases will be worked in the order of date received.
- Please DO NOT call regarding the status of your retrospective review cases; your calls will only detract from the review process.
- If needed during the reconciliation process, there will be allowances made for timeliness.
- Providers will receive notification regarding their retrospective review cases as they are worked.
- Please DO NOT send any duplicate retrospective review cases.
- The immediate goal is to have the backlog current by March 31, 2010.
If you have not already done so, please complete a contact form so ACS may have preferred telephone and fax numbers as well as a primary contact if one is designated to facilitate timely communications. This form can be downloaded from the Web site.
In order to make the most effective use of staff time, ACS will attempt to call or fax providers back with certification information three times over a reasonable time frame, after which the information will be mailed.
Providers may direct their inquiries to:
- ACS -
- Phone - (800) 766-0686
Toll free fax - (866) 629-0737
- MO HealthNet Pharmacy and Clinical Services -
- E-mail - firstname.lastname@example.org
Registering for On-line Training Sessions
February 1, 2010
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 webinars are relatively short and are usually limited to 60 to 90 minutes in length. These webinars allow us to present training to individuals, staff members or multiple providers.
To register for a webinar:
- Log on to the Web site.
- Scroll down on the page to Education and Billing under Provider Options.
- Click on ‘Webinar 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 email@example.com. 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.
- If you schedule a training session and are unable to participate, please notify Provider Training by email at firstname.lastname@example.org or call 573-751-6683 to cancel your registration.
The provider must have access to the Internet and must be using a current browser program (Internet Explorer 6/7/8 or Netscape 5 or higher, that is Windows Vista /Windows 7 compatible).
MO HealthNet is the Last Payer
January 25, 2010
The MO HealthNet program is the payer of last resort when there is the possibility of a third party resource (TPR) for the payment of a participant’s claims. This is addressed in Section 5.1.A of the MO HealthNet provider manuals.
5.1.A MO HEALTHNET IS PAYER OF LAST RESORT
MO HealthNet funds are used after all other potential resources available to pay for the medical service have been exhausted. There are exceptions to this rule discussed in Section 5.7 (Third Party Liability Bypass). The intent of requiring MO HealthNet to be payer of last resort is to ensure that tax dollars are not expended when another liable party is responsible for all or a portion of the medical service charge. It is to the provider’s benefit to bill the liable TPR before billing MO HealthNet because many resources pay in excess of the maximum MO HealthNet allowable.
Federal and state regulations require that insurance benefits or amounts resulting from litigation are to be utilized as the first source of payment for medical expenses incurred by MO HealthNet participants. See 42 CFR 433 subpart D and RSMo 208.215 for further reference. In essence, MO HealthNet does not and should not pay a claim for medical expenses until the provider submits documentation that all available third party resources have considered the claim for payment. Exceptions to this rule are discussed in Section 5.7 (Third Party Liability Bypass) of the provider manual.
All TPR benefits for MO HealthNet covered services must be applied against the provider’s charges. These benefits must be indicated on the claim submitted to MO HealthNet. Subsequently, the amount paid by MO HealthNet is the difference between the MO HealthNet allowable and the TPR benefit amount, capping the payment at the MO HealthNet allowable. For example, a provider submits a charge for $100 to the MO HealthNet Program for which the MO HealthNet allowable is $80. The provider received $75 from the TPR. The amount MO HealthNet pays is the difference between the MO HealthNet allowable ($80) and the TPR payment ($75) or $5.
MRIs/CAT Scans and Eligibility
January 19, 2010
MO HealthNet requires providers to obtain pre-certification for more than 30 MRI and CAT scan procedures if the service is non emergent. No pre-certification is required if the service is for emergency reasons. Emergency reasons are defined as the patient being currently inpatient in the hospital, or the patient being in the Emergency Department of a hospital at the time of the test.
In addition, MO HealthNet will consider backdating a pre-certification to the date of service of the MRI or CAT scan if the patient is made retro-eligible (e.g. by administrative action). The physician who ordered the MRI or CAT scan and is encountering such a situation can contact the agency’s Clinical Services Help Desk at 800/392-8030 to request a backdated pre-certification. Note - the reason(s) for the MRI or CAT scan must still meet clinical criteria requirements for the service. The pre-certification criteria documents can be accessed on this site.
January 11, 2010
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 (Reference Section 19.5 of the Physician Provider Manual). Attach an invoice if applicable.
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.
For procedures subject to postoperative editing, please see Section 13.41.A of the Physician Manual.
For exceptions to the postoperative policy, please see Section 13.41.B of the Physician Manual.
Pregnancy Related Ultrasounds
January 4, 2010
Routine ultrasounds are not indicated in normal pregnancies. However, MO HealthNet reimbursement is available for up to three ultrasound procedures during any one rolling year when reasonable and necessary based on medical indication(s).
Ultrasounds provided in excess of three during any one rolling year must be medically necessary. All services must be adequately recorded in the participant’s record and must document appropriateness of use in proper diagnosis, management and treatment of pregnancy-complicating or potentially complicating conditions.
Denied services may not be submitted for exception consideration; however, a medical review of a denied service may be requested. Referring physicians are encouraged to include information regarding the patient’s diagnosis for use by the billing provider.
Failure of the medical record to adequately document and support the utilization of ultrasonography procedures shall result in the recovery of all payments made for these services at the provider’s liability.
This policy of limitation applies only to program reimbursement for the service. It does not apply to the exercise of medical judgment as to need.
Non-covered ultrasound services include:
- Routine screening of all pregnant women.
- Use of any apparatus in auscultation of fetal heart tones.
Section 13.67B of the Physician Provider Manual details MO HealthNet policy on ultrasounds and includes a check list of indications when an ultrasound might be medically indicated.