2011 Archives Hot Tip of the Week

Claim Documentation

December 27, 2011

Reminder — If your claim should deny for lack of required documentation (e.g. trip ticket, operative report, medical records, etc), attach the required documentation to a new claim form (CMS-1500 or UB-04) and mail the claim and supporting documentation to Wipro Infocrossing 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 cannot be processed.

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

Wipro Infocrossing
P. O. Box —— (see right)
Jefferson City, MO 65102

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

Participant Liability Services at the Hospital

December 19, 2011

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.

Essure Product Reimbursement

December 12, 2011

The family planning product Essure, CPT procedure code 58565, is available in both the office and outpatient settings. For the professional services performed in an outpatient setting, providers must bill using CPT procedure code 58565 with a 52 modifier. CPT procedure code 58565 (without a modifier) is only to be used in the office setting. Providers must use the correct place of service code to ensure proper payment.

Please refer to the Hot Tip dated November 30, 2009.

Missouri Medicaid Audit and Compliance

December 5, 2011

The Missouri Medicaid Audit and Compliance (MMAC) Unit released their new web site at http://mmac.mo.gov. The new site provides information on MMAC’s programs and responsibilities. Also included are program required forms, information pertaining to compliance issues, provider enrollment, and contracts. The site also features links to pertinent regulatory documents and contact information.

MMAC was established in January 2011 and is responsible for administering and managing Medicaid (Title XIX) audit and compliance initiatives’ and managing and administering provider enrollment contracts under the Medicaid program. MMAC is charged with the responsibility of detecting, investigating, and preventing fraud, waste, and abuse of the Medicaid Title XIX, CHIP Title XXI and waiver programs. Those responsibilities include but are not limited to:

• Investigating allegations of Missouri Medicaid program fraud, false reporting, breach of contract, errors in billing, and Medicaid waste and abuse against both providers and participants; and when appropriate referring those cases to the Medicaid Fraud Control Unit within the Missouri Office of Attorney General, local law enforcement agencies or federal government agencies;
• Providing assistance to other state departments and/or divisions to detect, prevent and investigate fraud, waste and abuse of the Missouri Medicaid Program;
• Enrolling Medicaid providers into the Missouri Medicaid Program including periodic re–enrollment (renewing) of providers;
• General…Home and Community Based providers providing services to Department of Health and Senior Services participants;
• Conducting internal audits of Missouri Medicaid programs in various other state agencies including MO HealthNet, Department of Health and Senior Services and Department of Mental Health to ensure consistency and compliance with applicable state and federal laws and regulations;
• Overseeing the Recovery Audit contractor (RAC) program;
• Auditing of managed care organizations and other providers and developing Medicaid fraud and abuse standards for managed care organizations;
• Reviewing and monitoring statewide utilization and program compliance of the Missouri Medicaid fee–for–service providers including conducting post–payment reviews, issuing administrative remedies and detecting patterns of fraud; and
• Conducting reviews of participant activity in reference to physician and pharmacy visits to determine if there is a pattern of abuse which may result in the participant being locked into a specific physician or pharmacy.

MMAC’s goal is to provide you with the most up–to–date information regarding Missouri Medicaid audit, compliance, and enrollment issues. Check the web site periodically for updated information or contact us directly if you need further assistance.

Adult Incontinence Products

November 28, 2011

This hot tip is in follow-up to the Hot Tip dated November 14, 2011 on adult incontinence products.  While that hot tip is correct, this hot tip provides an additional link to information.

Adult incontinence products (briefs, diapers, pull-ons and underpads) for participants age 21 years and older may be requested utilizing the MO HealthNet Exceptions Program process.  If a prescriber believes that adult incontinence products are medically necessary for the MO HealthNet participant, they should utilize the Exceptions process for requesting authorization.  Providers should complete the Exception Request Form.  The information supplied on the Exceptions Request Form should incorporate the criteria required in the Exceptions Criteria Proposal and fax to 573/522-3061 for processing.  If assistance is needed, please contact 800/392-8030, and then select option 2.

For adult individuals in need of these items who are receiving assistance through Comprehensive Waiver, Community Support Waiver, Partnership for Hope Waiver, Independent Living Waiver, AIDS Waiver or Medically Fragile Adult Waiver, contact should be made with their waiver support coordinator for assistance.

Plak-Vac Oral Care System

November 21, 2011

The Missouri Department of Health and Senior Services recently issued a health update regarding a product recall of the Plak-Vac Oral Care System. Providers are urged to review the update for complete information.

Adult Incontinence Products

November 14, 2011

As a reminder, adult incontinence products (briefs, diapers, pull-ons, and underpads) for participants aged 21 years and older, may be requested utilizing the MO HealthNet Exceptions Program process. If a prescriber believes that adult incontinence products are medically necessary for the MO HealthNet participant, they should utilize the Exceptions process for requesting authorization. Providers should complete the Exception Request Form, and fax to 573-522-3061 for processing. If assistance is needed, please contact 800-392-8030, and then select option 2.

For adult individuals in need of these items, who are receiving assistance through Comprehensive Waiver, Community Support Waiver, Partnership for Hope Waiver, Independent Living Waiver, AIDS Waiver, or Medically Fragile Adult Waiver, contact should be made with their waiver support coordinator for assistance.

Healthy Children and Youth, Screening and Assessment Guides

November 7, 2011

Healthy Children and Youth (HCY) Screening and Lead Risk Assessment Guides are available in electronic format through MO HealthNet’s Web tool, CyberAccess^sm. Providers are strongly encouraged to complete the screening and assessment guides electronically through the CyberAccesssm tool. To sign up to receive training and become a CyberAccess^sm user, contact the ACS-Heritage help desk toll free at 1-888-581-9797 or send an email to CyberAccessHelpdesk@xerox.com.

HCY screening and assessment guides are also available for you to download and print through the forms link on the MO HealthNet Web site at http://manuals.momed.com/manuals/presentation/forms.jsp. All forms are listed alphabetically; just scroll to the form you wish to download and print.

Additional information on HCY screening and assessment is available in Section nine of the MO HealthNet Provider Manual.

Smoking Cessation

October 31, 2011

Billable by the following Provider Specialties:

• Physician
• Advanced Nurse Practitioners
• Nurse Midwives
• Psychiatry
• Advanced Mental Health Nurse Practitioners
• Clinical Nurse Specialists
• Psychologists
• Clinical Social Workers
• Provisionals of all of the above

Complete details for coverage of smoking cessation can be referenced in the MHD provider bulletin dated April 12, 2011.

Documentation Requirements for Wheelchair Prior Authorizations

October 24, 2011

MO HealthNet provider manuals are located at http://manuals.momed.com/manuals/.

Provider Initiated Self Disclosures

October 17, 2011

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:

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 Missouri Medicaid Audit and Compliance Unit at the address below:

MO HealthNet Division
Missouri Medicaid Audit and Compliance (MMAC) – 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 . Make sure to complete the form and include the patient’s name and DCN, date of service, Internal Control Number (ICN), paid amount, refund amount and reason for refund. Providers can direct questions regarding Self Disclosures to the MO HealthNet Division’s Missouri Medicaid Audit and Compliance Unit at 573-751-3399.

Outpatient Radiology Units

October 10, 2011

MO HealthNet has always required the units billed for a radiology service provided in the outpatient hospital setting to be the number of times a service or test was actually performed on that date of service for each participant, except when billing for facility charges. However, due to the payment methodology previously in place, the number of units billed did not affect the hospital’s payment for the service. This will no longer be the case for dates of service October 1, 2011 and after when outpatient hospital radiology services will be paid using a fee schedule. With the implementation of the fee schedule, hospitals will be reimbursed the lesser of either their usual and customary billed charge or the fee schedule amount for each radiology unit of service performed and billed.

For example, if radiology procedure 73090, Radiologic Examination Forearm Anteroposterior and Lateral, had to be performed on both arms for a patient in the emergency department, the units billed for that code will be two (2). Since the fee schedule has this code priced at $24.49 per unit, total payment will be $48.98. The submitted billed amount will be the hospital’s usual and customary amount for this procedure performed twice.

More information regarding the change to a fee schedule for outpatient hospital radiology procedures can be found in the provider bulletin titled “Hospital – Outpatient Radiology: Vol. 34, No. 03”, dated September 22, 2011. Provider manuals can be found at http://manuals.momed.com/manuals/.

Sending Claims for Special Handling—Medical Denials and/or Medicare Part C Non-QMB

October 3, 2011

When an enrolled MO HealthNet Division (MHD) provider sends claims directly to MHD for special handling, 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 case 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.

When submitting a claim that requires special handling by MHD staff, such as a participant who has Medicare Part C but is not QMB eligible or for denied Medicare services, please follow the instructions below to send your claims for special handling.

• Complete the appropriate paper claim form (CMS-1500 Medical claim form, UB-04 Inpatient claim form, UB-04 Outpatient claim form).
• Staple the claim, attachments, the Medicare denial and/or Medicare Part CEOMB 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

Implementation of X12 Version 5010 Transactions

September 26, 2011

A final compliance deadline of January 1, 2012 has been established for all covered entities to implement the new Accredited Standards Committee (ASC) X12 version 5010 standards for electronic health care transactions under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Providers can send in test files through their pre-established method, via the Upload HIPAA test file site on emomed.com or via FTP or NDM.

Please refer to the following resources for more information:

• 5010 EDI Companion Guide
• Provider Bulletin dated May 13, 2011
• Frequently Asked Questions [removed]

Home and Community Based Service Eligibility Verification

September 19, 2011

Following implementation of the Home and Community Based Service (HCBS) Web Tool in May 2011, HCBS providers have been able to view Medicaid eligibility information for their participants through this Web Tool. This information is displayed only as a resource in the ‘eligibility’ section of the HCBS Web Tool. It is still the provider’s responsibility to continue to verify eligibility through the MO HealthNet eligibility verification system. This may be done using the participant eligibility option at www.emomed.com or by calling the Interactive Voice Response at (573) 635-8908.

Please reference the Department of Health and Senior Services provider/vendor memo PM-12-02 and the MO HealthNet provider bulletin dated June 14, 2011.

Provider Audio/Visual Presentations

September 12, 2011

A provider training feature, audio/visual presentations, was recently updated on the MO HealthNet Web site adding instructions on manually filing crossover claims. Providers and others can view and listen to these and other 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.

These trainings are available at http://dss.mo.gov/mhd/providers/education/avtrain.htm.

Nursing Facilities & Patient Surplus

September 6, 2011

Patient surplus is not collected by the nursing facility the first month a participant is admitted if admission is after the first day of the month. If admission is the first day of the month, then surplus is charged to the participant for the first month.

When there are Medicare and MO HealthNet days in the same month, surplus is applied to the MO HealthNet days only. If the participant is in the hospital on the first day of the month and Medicare covers the cost of the remainder of the month, no surplus is due. For any month following the month of readmission in which there are Medicare and MO HealthNet days, the surplus is applied to the MO HealthNet days in the month regardless of the date of readmission.

If a participant enters a hospital during one month and is not readmitted to the nursing home until after the first day of the following month, surplus is to be billed to the participant or the participant’s representative (responsible party) for the month of readmission. If a participant is out of a nursing home for more than thirty (30) days, the Family Support Division Eligibility Specialist informs the nursing home and the participant or the participant’s representative if surplus should be collected for the month of readmission.

For more information on MO HealthNet’s nursing home program, providers can reference Section 13 of the MO HealthNet nursing home manual.

Resubmitting Professional Claims with Inpatient Place of Service

August 29, 2011

When resubmitting a CMS-1500 claim for payment through the MO HealthNet Web portal at www.emomed.com, and your place of service is inpatient, you must edit the header section of the claim and re-enter the inpatient facility name — then save. The facility name from a previous claim does not copy over when a resubmission is done and must be re-entered. If this is not done, your claim will deny for a missing facility name and address. This process must be done each time a claim is resubmitted.

Provider Enrollment Page Has Been Updated

August 22, 2011

The MO HealthNet Provider Enrollment Web page located at https://peu.momed.com/peu/momed/presentation/providerenrollmentgui/CivilRightsFormsWindow.jsp has been updated to include the revised Department of Social Services, Office for Civil Rights’ Non-Discrimination poster.

Provider enrollment inquiries can be emailed to providerenrollment@dss.mo.gov.

Medicare, Supplemental Insurance and MO HealthNet

August 15, 2011

There are times when you must file a Medicare Crossover claim for a participant that has a supplemental insurance policy. To enter your claim, do the following:

• Log onto the MO HealthNet Web Portal at www.emomed.com and enter your user ID and Password.
• Choose the appropriate crossover claim form.
• Complete the claim header Information and save claim header.
• Complete each line detail saving after each entry.
• Complete the other payers header summary using the information on the Medicare EOMB and “save other payer data and manage codes”.
• Complete the associated line items fields based on the information on the Medicare EOMB (show PR-Patient Responsibility and CO-Contractual Obligation) and “save codes to other payers” after completing the required fields for each line on the claim.
• Save other payer to claim.
• Complete the other payers header summary for the supplement policy and “save other payer data and manage codes”.
• Complete the associated line items fields. Under claim group code, you must choose OA-Other Adjustments. The claim adjustment reason code is 023 (payment and/or adjustments from other payer). The adjustment amount is the amount Medicare paid on the line. In the next claim group code field, you must choose PR-Patient Responsibility. The claim adjustment reason code is 001-Deductible or 002-Co-insurance. The adjustment amount is the amount of deductible/co-insurance due minus what the supplemental policy paid on the line. In the next claim group code field, you should choose CO-Contractual Obligation. The claim adjustment reason code is typically 045. The adjustment amount is the amount of the contractual or write-off. You must complete an associated line item for each line on the claim.

Note: If billing for inpatient services on the MedicareUB-04 Part A Institutional Crossover Claim, complete your claim header information and enter each revenue code and days/units billed to Medicare. Be sure to save after each entry. Then you must complete the other payer header summary for both Medicare and the supplemental insurance policy. Part A claims are processed at the header. Therefore, the Payer at Header Level box must be checked.

Receiving Email Alert Notices

August 8, 2011

Do you know of someone in your office or another provider’s office that is not signed up to receive email notices when information is posted to the MO HealthNet Web site? If so, please share this hot tip with them.

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 working for an enrolled provider can be signed up to receive email alerts. Email alerts are sent when bulletins are posted to the MO HealthNet Web site, when provider manuals are updated or anytime a special message needs to be delivered to providers.

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 the column on the right and follow the instructions to subscribe or unsubscribe. From the same Web site, you can also access any past notifications by clicking on the ‘MO HealthNet News Archives’.

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

Women’s Health Services Program

August 1, 2011

MO HealthNet offers Women’s Health Services to the following individuals:

• uninsured women who lose MO HealthNet eligibility 60 days after the birth of their child for up to one year (Medical Eligibility (ME) code 80), and
• women who are uninsured, defined as not having creditable coverage for family planning services; 18 through 55 years of age; have a net family income at or below 185% of the Federal Poverty Level (FPL); and have assets totaling no more than $250,000 (ME code 89) These women are not limited to one year of coverage.

Services and limitations for both eligibility groups are identical. Services include:

• Department of Health and Human Services approved methods of contraception;
• sexually transmitted disease testing and treatment, including pap tests and pelvic exams;
• family planning counseling/education on various methods of birth control; and
• drugs, supplies, or devices related to women's health services described above that are prescribed by a physician or advanced practice nurse (subject to the national drug rebate program requirements).

All services must be provided in connection with a family planning visit and billed with a primary diagnosis of V25-V25.9 or payment for the services will be denied.

For more information, reference the Physician Bulletin, Women’s Health Coverage, Volume 31, Number 44, dated February 9, 2009.

Radiology and Out-of-State Services

July 25, 2011

MO HealthNet services must be performed by enrolled providers physically located in Missouri or in a state bordering Missouri. Missouri’s bordering states are Arkansas, Illinois, Iowa, Kansas, Kentucky, Nebraska, Oklahoma, and Tennessee. All other states are considered ‘out–of–state’.

Exceptions include:

• Specific or comparable services that are not available in Missouri or a bordering state; these are reviewed on a case–by–case basis and also require prior authorization;
• When the participant is a dual eligible Medicare/MO HealthNet participant and the service is a Medicare/MO HealthNet covered service; or
• Services performed by an ‘out–of–state’ provider while the participant was physically traveling outside Missouri or a bordering state and services were the result of a medical emergency*. In accordance with Missouri Code of State Regulations 13 CSR 70–3.120:

  *Medical emergency services are defined as those services provided in a hospital, clinic, office or other facility that is equipped to furnish the required care, after sudden onset of medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in a) placing the patient’s health in serious jeopardy, b) serious impairment to bodily functions, or c) serious dysfunction of any bodily organ or part.

MO HealthNet will not enroll provider applicants who do not meet the medical emergency requirement. Participants may be responsible for payment of services provided by any out–of–state hospital, physician, nurse, etc. when the participant has not met the medical emergency exception criteria.

Maintaining a Missouri or bordering state license while being physically located out–of–state does not justify enrollment in MO HealthNet. Applications from providers physically located out–of–state, not bordering Missouri, and are not the result of one of the above exceptions will be denied. This includes but is not limited to telemedicine, teleradiology, heart monitor readings, or any other remote means of telecommunications and information technology services.

MO HealthNet enrolled providers who move outside of Missouri or a bordering state to a non-bordering state are required to notify the Missouri Medicaid Audit & Compliance Unit (MMAC), Provider Enrollment Section, of the date they were no longer physically located in Missouri or a bordering state. Dates of service billed while the provider was not physically located in Missouri/bordering state will be recouped if the medical emergency rule requirements are not met.

Already enrolled providers who have given a Missouri or bordering state address of a hospital or other entity of whom they are employed/contracted, while the actual provider is physically located out–of–state, will be made inactive and reimbursement may be recouped.

Enrollment inquiries may be directed to MMAC Provider Enrollment Section via email at providerenrollment@dss.mo.gov.

MO HealthNet DME Supplier Enrollment Requirements

July 18, 2011

MO HealthNet Durable Medical Equipment (DME) services must be performed by providers physically located in Missouri or in a state bordering Missouri. Missouri’s bordering states are Arkansas, Illinois, Iowa, Kansas, Kentucky, Nebraska, Oklahoma, and Tennessee. All other states are considered ‘out-of-state’.

In accordance with Missouri Code of State Regulations 13 CSR 70-60.010 (B) and (C) exceptions include:

• Specific or comparable services that are not available in Missouri or a bordering state, these are reviewed on a case-by-case basis and may also require prior authorization; or
• When the participant is a dual eligible Medicare/Medicaid participant.

DME suppliers must enroll at the specific address/location where the Medicare number is issued on the Medicare supplier approval letter. MO HealthNet does not enroll warehouses, distribution sites, or any other sites where supplies may be dispensed. Applications completed for sites other than the site listed on the Medicare approval letter will be denied.

MO HealthNet will not enroll applicants who do not meet one of the above requirements. This includes Competitive Bid suppliers, which are not treated differently than any other supplier.

Applications from providers physically located out-of-state, not bordering Missouri, and are not the result of one of the above exceptions will be denied.

Reimbursement paid to suppliers for services that do not meet the exception rule will be recouped.

Each Medicare approved DME supplier location must enroll separately and may not use one provider identifier to bill for multiple Medicare approved locations.

Enrollment inquiries may be directed to MMAC Provider Enrollment section via email at providerenrollment@dss.mo.gov.

Hospital Discharge—Emergency Ambulance vs. NEMT Transport

July 11, 2011

Emergency ambulance transports are covered for emergency services and if 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 Medical Transportation Management, Inc (MTM), 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 five (5) days in advance. NEMT services may be scheduled with less than five (5) 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.

MTM will provide the most appropriate mode of transportation based on the patient's medical needs. The medical needs should be communicated to MTM 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 MTM 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 MTM. 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.

Sending Claims for Special Handling

July 5, 2011

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.
• Do not submit the claim electronically. Instead, select Printer Friendly to print the claim.
• After printing the claim, select the ‘Finish’ button to return to the Welcome to eProvider page. From this point you may logout or access other features available on this 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

Vaccine for Children (VFC) Program

June 27, 2011

Through the Vaccine for Children (VFC) Program, federally provided vaccines are available at no cost to public and private providers for eligible children ages 0 through 18 years of age. Children that meet at least one of the following criteria are eligible for a VFC vaccine:

• MO HEALTHNET ENROLLED—means a child enrolled in the MO HealthNet Program
• UNINSURED—means a child has no health insurance coverage
• NATIVE AMERICAN/ALASKAN NATIVE—means those children as defined in the Indian Health Services Act
• UNDERINSURED—means the child has some type of health insurance, but the benefit plan does not include vaccinations. The child must be vaccinated in a Federally Qualified Health Clinic (FQHC) or a Rural Health Clinic (RHC).

MO HealthNet enrolled providers must participate in the VFC Program administered by the Missouri Department of Health and Senior Services and must use the free vaccine when administering a vaccine to qualified MO HealthNet eligible children. Providers may bill for the administration of the free vaccine by using the appropriate procedure code(s) found in VFC Administration Codes located on our website at: http://manuals.momed.com/collections/collection_phy/print.pdf. Providers must not use any additional administration procedure code. The MO HealthNet reimbursement for the administration is $5.00 per component. The administration fee(s) may be billed in addition to a Healthy Children and Youth (HCY) screen, a preventive medicine service, or in addition to an office visit if a service other than administration of a vaccine was provided to the child. Providers enrolled as Rural Health Clinics (RHCs) or Federally Qualified Health Centers (FQHCs) must not bill an additional administration fee for any vaccine.

Contacting Provider Education

June 20, 2011

Requests for training can be made by email to mhd.provtrain@dss.mo.gov 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, 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;
• Renee – 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.

Claim Processing Schedule FY 2012

June 13, 2011

The provider claim processing schedule has been updated for state fiscal year 2012 which begins July 1, 2011. The schedule lists the dates the cycles are run and their corresponding check dates. Providers may access the claim processing schedule at http://manuals.momed.com/ClaimsProcessingSchedule.html.

Billing Claims for Joplin, MO Tornado Victims

June 6, 2011

In a bulletin issued on January 20, 2006, titled ‘Instructions for Catastrophe/Disaster Related Claims’, providers were instructed to add a ‘CR’ modifier to professional claims and ‘DR’ Condition code to facility claims for disaster related claims. As a result, providers should use the modifier/condition code for all claims for participants affected by the Joplin, MO tornado disaster.

The modifier/condition code should be used on claims for services to treat conditions acquired by the participant during the tornado disaster. The modifier/condition code should be used as long as treatment continues for the condition.

Please refer to the bulletin link for additional information.

Filing Medicare Denied Claims

May 31, 2011

Medicare denied services for Medicare/MO HealthNet participants may be considered for payment by MO HealthNet if the service is a MO HealthNet covered service.

When providers receive a Medicare Remittance Advice that has a denied non-covered service, the provider may submit a claim to MO HealthNet for payment consideration using the appropriate claim type (i.e., CMS-1500, UB-04). Providers are encouraged to submit MO HealthNet claims electronically.

To bill through the MO HealthNet billing Web portal for a non-covered Medicare service, go to emomed.com. After logging on, follow these steps:

1. Choose the ‘Claim Management’ option;
2. Select the appropriate claim form (CMS-1500, UB-04, Nursing Home, etc.) under the ‘New Claim’ option. Do not select the Medicare Crossover claim form.
3. Complete all the required fields on the claim form;
4. Then, choose ‘Other Payers’. This brings up the Header Summary.
5. Complete the required fields.
6. Under ‘Associated Line Items’, choose Claim Group Code ‘PR-Patient Responsibility’.
7. Enter the reason code exactly as shown on the Medicare Remittance Advice.
8. The ‘Adjustment Amount’ is the billed amount for the line item and/or claim.
9. Click on ‘Save Codes to Other Payer’.
10. Click on ‘Save Other Payer to Claim’.
11. Click on ‘Submit Claim’.

For further assistance when filing electronically, billers may also select the question mark (?) option on the right-hand portion of the screen for field-by-field directions.

Reasons to Check MO HealthNet Eligibility

May 23, 2011

It is the desire of every MO HealthNet enrolled provider as well as the MO HealthNet Division, that payment be made on the initial claim submission for timely reimbursement of services. An important step for providers in meeting this goal is to make sure MO HealthNet participant eligibility is verified prior to services being rendered and billed. Following are reasons to check participant eligibility to avoid claim denials:

• Medical Eligibility (ME)/Codes — MO HealthNet utilizes a system of categories, or ME codes, to indicate the category under which a participant is eligible. Covered services and benefits are based on the ME code. Many categories of assistance have limited coverage or categories in which participants are responsible for co-payments.

  The ME codes and their descriptions are found in the MO HealthNet Provider Manual, Section1.1.A, Description of Eligibility Categories. Descriptions of the ME codes can also be found in a quick reference guide titled ‘Puzzled by the Terminology’.

• Lock-in participant or managed care participant — If a participant is locked-in to a certain provider(s) or enrolled in a MO HealthNet managed care plan, providers are given this information when eligibility is checked. If a participant is locked-in to a provider(s) or enrolled in a managed care plan, services must be obtained through the assigned provider or managed care plan.
• Medicare coverage — By checking eligibility, providers are informed if the participant has Medicare. The claims must be filed to Medicare first.
• Commercial insurance — A claim must be filed to the commercial insurance plan first if the MO HealthNet eligibility file reflects commercial coverage.
• Participant Name or Number Mismatch — Checking eligibility will verify the patient's name and MO HealthNet ID number as it appears on the enrollment file. The claim must be filed with the patient's current file name.

Providers can check eligibility by calling the Interactive Voice Response system at 573-751-2896 or through the Internet at emomed.com.

Drug Prior Authorization Inquiries

May 16, 2011

When calling the MO HealthNet program for pharmacy claims inquiries, you must have the National Drug Code (NDC) of the drug to be billed in the drug claim, not the HCPCS ‘J’ code. Each drug has its own specific NDC. The NDC is broken down into a 5 digit-4 digit-2 digit format. If the NDC does not appear in the 5-4-2 digit format on the packaging, a zero(s) (0) must be entered in front of the section that does not have the required number of digits. (Example 999-999-9 should be given as 00999-0999-09). The NDC gives the manufacturer of the drug, the strength of the drug specific to that manufacturer and the pack size of the drug.

Inquiries to the MO HealthNet Pharmacy Program may be made by calling the Pharmacy Administration Unit at 573-751-6963 for claims adjudication questions, or by calling the Pharmacy Help Desk at 800-392-8030 for clinical authorizations or edit overrides.

Encrypted E-mail

May 10, 2011

E-mail is not a secure method of transmitting information. Transmitting information of a confidential or sensitive nature, such as protected health information or participant Departmental Client Number (DCN), via e-mail to entities is only permitted if the e-mail is encrypted.

When an e–mail is sent encrypted by the Department of Social Services (DSS), MO HealthNet Division, it will require decryption by the recipient of the e-mail. The process of decrypting e-mails is simple. Upon receiving and opening a DSS encrypted e-mail; you will be instructed to open the attachment called “SecureMessageAtt.html”. When the attachment is opened, you will be instructed to click a button to read the message. You will also be prompted to register in the Proofpoint e-mail encryption system the first time you open an encrypted message. This is a one-time registration process and is required in order to view the encrypted message.

Detailed instructions outlining how to send, open and register to receive encrypted emails can be found at http://dss.mo.gov/encrypt.htm. Secure e-mails may also be sent to a state recipient by following “Instruction #3: How DSS clients, business partners and end-users can send an encrypted email to DSS” in the above link.

Claim Status Codes

May 2, 2011

Providers submitting claims using the MO HealthNet Web site, emomed.com, will see the status of such claims immediately after submission.

The “Claim Details” screen will show Claim Received and should state, ‘This claim has a status of one of the following’:

• I – To Be Paid
• K – To Be Denied
• C – Suspended (Still Processing)

NOTE: If the status of the claim is C–Suspended, this means the claim is still processing. The claim has not paid nor is it denied. Do not resubmit a claim that has a status of C–Suspended. You must wait until the claim has completed processing and received a status of “I” or “K” before the claim can be resubmitted should it be necessary.

Detailed descriptions of the Claim Adjustment Reason Codes on the claim confirmation report can also be found on the Washington Publishing Company HIPAA-Related Code Lists page.

Pre–Certification of Durable Medical Equipment

April 25, 2011

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 them self 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 the provider.

Optical Billing Reminders

April 18, 2011

Providers of optical services should keep the following in mind when submitting their claims to MO HealthNet:

• The date of service is always the date the participant receives their service. For the frame and lens(es) it is the date the participant receives their glasses, not the date they are ordered or the date of the examination if the participant isn’t given their glasses at the time of their examination.
• Optical services require pre-certification. Providers are encouraged to reference the Optical Pre-Certification Criteria Documents located on the MO HealthNet website at dss.mo.gov/mhd/cs/. Services/procedures that are pre-certified must be performed within 30 days of the date the pre-certification was issued.
• The prescription is not required when submitting an optical claim.
• Always verify participant eligibility before providing services by calling the Interactive Voice Response System (IVR) at 573-751-2896 or via the Internet at emomed.com.

NOTE: If the participant becomes ineligible or dies after the lenses or complete eyeglasses are ordered and before they are dispensed, payment may be made by MO HealthNet for the lenses or complete eyeglasses. Please reference Section 13.13 of the Optical Manual.

School District Administrative Claiming (SDAC)—Payment Inquiry

April 11, 2011

School Districts who receive payment from MO HealthNet through direct deposit can access check information through the Vendor Services Portal. The Vendor Services Portal provides, by vendor number, the checks issued and a description of the corresponding program for each payment.

Access the Vendor Services Portal at https://www.vendorservices.mo.gov/vendorservices/Portal/Default.aspx, choose Vendor Payment on the top left of the screen, select FEIN and enter your vendor number. You may look up the check by invoice number, check/EFT number, dollar amount, or date/location. To identify the program and corresponding payment amount, click on the check/EFT number.

Durable Medical Equipment Enrollment Guidelines

April 4, 2011

A Durable Medical Equipment (DME) provider must be an approved Medicare DME provider to enroll in the MO HealthNet DME program. Each DME supplier must enroll separately; claims for multiple suppliers may not be billed using one DME supplier’s provider identifier.

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.

Releasing Billing or Medical Record Information

March 28, 2011

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. The manuals are available at the following MHD Web site: http://manuals.momed.com/manuals/.

Adjusting Claims Electronically

March 21, 2011

Providers are urged to adjust their claims electronically. Whether you are replacing a paid claim or voiding a paid claim, claims can be adjusted electronically through the MO HealthNet billing Web site at www.emomed.com. Even if your claim was submitted by paper, any adjustment can be done electronically.

To void or replace a paid claim, go to www.emomed.com and log-in with your user ID and password. This opens the “Welcome to e-Provider” screen.

• Click on “Claim Management”.
• In “Search Scope”, enter the participant DCN and the date of service on the claim to be voided or replaced and click on “Search”. Be sure the correct NPI is displayed in the NPI box.
• A list of claims matching the search criteria will be displayed in the “Results” box. Click on the Internal Control Number (ICN) of the claim to be voided or replaced.
• To void a paid claim, click on “Void”. This will bring up the claim. Scroll to the bottom of the claim and click on “Submit Claim”. This will void the paid claim.
• To replace a paid claim, click on “Replacement”. This will bring up the claim. Enter the corrected information then click on “Submit Claim”.
• To help guide you through this process, you can access the “Help” screen on the right top of the screen which is identified by a question mark (?) icon.

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

Billing Laboratory Panel Tests

March 14, 2011

In order to bill a laboratory panel procedure code (80047 – 80076), it is required that all indicated components in the panel test be performed on the same date of service. When all components of a specific panel are performed on the same date of service, each test cannot be billed separately; only the laboratory panel procedure code can be reimbursed. Any laboratory tests performed on the same date of service that are included in the panel cannot be billed in addition to the laboratory panel procedure code.

A laboratory must have the appropriate CLIA certificate for all laboratory tests performed.

Information on billing laboratory panel tests can be referenced in Section 13.48.D of the MO HealthNet Physicians manual located on the Internet at http://manuals.momed.com/manuals/.

School District Administrative Claiming

March 7, 2011

As a reminder to all school districts participating in the School District Administrative Claiming (SDAC) program, the responsibilities of the school district are outlined in the cooperative agreement signed by each district’s superintendent. If a school district chooses to contract with another entity to assist with the administration of the SDAC program, the school district’s responsibilities do not change. Whether provided directly by the school district, or through its agent, the school district responsibilities include, but are not limited to:

• Provide and maintain a random moment sampling process;
• Provide and maintain a personnel roster, updated quarterly, of personnel who regularly provide SDAC claimable activities as outlined in “MO HealthNet School District Administrative Claiming Guide” available on the Internet at http://dss.mo.gov/mhd/providers/, under ‘Provider Manuals’;
• Provide and maintain salary and benefit information, updated quarterly, for personnel included in the cost pool;
• Certify the non-federal share for SDAC;
• Accept responsibility for disallowances resulting from activities associated with the agreement; and
• Provide quarterly claims to MO HealthNet as outlined in the “MO HealthNet School District Administrative Claiming Guide” available on the Internet at http://dss.mo.gov/mhd/providers/, under ‘Provider Manuals’.

Questions related to SDAC program requirements may be directed to the Program Operations Unit at 573/751-9290.

Durable Medical Equipment—Certificate of Medical Necessity

February 28, 2011

A Certificate of Medical Necessity (MN) is required for items in the Durable Medical Equipment (DME) Program.  Approval of the MN by MO HealthNet is based on the information provided.  It is important each field be completed so the consultant reviewing the MN can determine the medical necessity.  An incomplete MN or a MN with too few details for the consultant to make an appropriate decision on medical necessity will be denied.

The MN must be specific to each participant; approvals aren’t based solely on a diagnosis for a specific item, service, or supply.  The medical reason why the item, service, or supply is needed must be stated fully and clearly.  Stand alone phrases such as “for mobility”, “assist in breathing”, “to replace existing equipment”, are not sufficient reasons for service and will cause the MN to be denied.

The Certificate of Medical Necessity for DME providers is to be submitted electronically on the MO HealthNet Web Portal at www.emomed.com through the ‘Attachment Management’ link.  A complete list of procedure codes requiring the MN can be found in Section 19 of the MO HealthNet DME Provider manual located at http://manuals.momed.com/manuals/.  The MN must contain not only the appropriate procedure code but all applicable modifiers.

Checking Daily Claim Summary

February 22, 2011

A helpful feature on the MO HealthNet billing Web site at www.emomed.com is the ability to view all claims that have been individually submitted for the same business day. Below are the step-by-step directions for reviewing your daily claim summary:

1. Log onto www.emomed.com. You are at the Welcome/Home page.
2. Click on the ‘Claim Management’ option.
3. Under ‘Claim Search’, mark the radio button in front of ‘Daily Claim Summary’.
4. You can select all claim types or a specific claim type from the drop-down box.
5. Enter the daily submission date for the date for which you want a listing.
6. If you want a listing of all the claims for all NPIs for which you billed, be sure and check the box in front of ‘For All NPIs’. If you want a list for a specific provider for which you billed, be sure the appropriate NPI is showing at the top of the page, then ‘search’. If you checked the ‘For All NPIs’ box, the search will result in a complete list by provider type of all the claims you submitted on the date selected. If you did not check the ‘For All NPIs’ box, the search results is a list of claims by the provider shown in the NPI box at the top of the page.

Clicking search will bring up a list of all the claims you submitted on the date(s) selected in the “Results” field. The claims are listed by claim type and provider NPI.

Information under the “Claims summary” field in the lower left hand corner of the page details the total number of claims submitted and the total billed amount for each NPI selected. Information in the “Grand Total” field lists the total number of claims submitted and the total billed amount for all the selected NPIs.

To print the report, go to File on the far left side of the browser menu bar and select “print” from the drop down box.

Once you have reviewed the information, click on ‘Finish’. This will take you back to the Welcome/Home page.

Accessing www.emomed.com Features

February 14, 2011

Some providers have reported that they have encountered problems accessing some of the features available when using the MO HealthNet Internet Web portal, www.emomed.com. The following information is provided as possible solutions to the reported problems.

In order to utilize the features of www.emomed.com, the provider’s computer system must:

• Use an Internet Explorer of 7.0 or higher.
• Have the “Pop-Up Blocker” options turned off.
• Have Adobe Reader 8.0 or higher installed to view printable file.
• Have “cookies” enabled on the browser.
• Allow the user to have write access to the “Temporary Internet Files” folder on the local drive.
• Have Javascript enabled on the user’s browser.

Check with your IT person/staff or firm for assistance with any of the above items or you may call the IFOX Technical Help Desk at 573/635-3559.

How to Search for a Prior Authorization Online

(Supplemental information to the January 3, 2011 Hot Tip)

February 7, 2011

This Hot Tip is to add information to the January 3, 2011 Hot Tip regarding the search for Online Prior Authorizations.

You can check the status of a Prior Authorization request online at www.emomed.com. Enter your user ID and password. On the Welcome to eProvider Page, Click on Prior Authorization Status. Make sure you select the NPI and Taxonomy Code, if applicable, that was submitted on the Prior Authorization Request form and enter the desired search criteria.

In order to view the PA status, select at least one PA Status criteria option or the “all” option. The participant DCN is required when using the Procedure Code/Modifier option. Select the PA Number to view the PA Status Detail information. Search parameters are case sensitive. To end the search for PA status, select “Finished”. The Question Mark at the top of the page is the “Help” button and will provide field-by-field instructions.

NOTE: If the PA search is for Psychology services, just enter the participant DCN and hit “search”. It is not necessary to enter a procedure code or modifier for Psychology services.

This emomed application does not currently display drug or transplant Prior Authorizations.

Billing Hospital Outpatient Medications

January 31, 2011

A regular question from hospitals is what and how outpatient medications can be billed under revenue code 250 (medications). This Hot Tip is published to answer this question.

There are several ways revenue code 250 can be used for billing outpatient medications. The first pertains to billing for a covered medication which does not have a valid HCPCS or CPT code. In this instance, revenue code 250 may be billed without a corresponding code. Note the following:

• Quantity billed for revenue code 250 must be one (1) when a HCPCS or CPT code is not available. The charges for the medications must be totaled together for that line charge.
• Non-covered medications cannot be billed under the 250 revenue code. They are not billable to the agency and can be billed to the participant.
• Questions regarding whether or not a medication is covered by MO HealthNet should be directed to the agency’s Pharmacy and Clinical Services Administration Unit by phone at 573/751-6963 or by E-mail at clinical.services@dss.mo.gov.

Another choice when a valid HCPCS or CPT code is not available is to bill under revenue code 250 or 636 with one of the following J-codes.

J3490 – unclassified medication
J7599 - Immunosupppressive, not otherwise classified
J8499 - prescription drug, oral, non-chemotherapeutic, NOS
J8999 - oral prescription, chemotherapeutic, NOS

These codes can be filed on a paper UB-04 claim form and an invoice must be submitted with the claim which shows the medication’s name, the NDC and its cost. When the claim is filed through www.emomed.com, after completing the header detail and line detail segments, click on “Invoice of Cost”. This opens a new segment titled “Invoice of Cost Details Summary”. Complete and save this segment before submitting the claim.

NOTE: The National Drug Code (NDC) should be submitted for all medication administered in the outpatient hospital setting along with a valid HCPCS or CPT code. However, the NDC is required when a “Top 20” drug is administered. The "Top 20" drugs are defined by CMS, and can be found on their Web site at http://www.cms.gov/Reimbursement/15_PhysicianAdministeredDrugs.asp

Another use of the 250 revenue code pertains to billing a medication which has a valid HCPCS or CPT code and NDC. In this instance, the medication must be billed with a revenue code, either 250 or 636, along with a valid NDC. If the medication does not have a valid NDC but does have a CPT or HCPCS code, such as contrast media, the charges are to be billed without the NDC.

Ambulance Hospital to Hospital Transfers

January 24, 2011

Ground ambulance transfers of MO HealthNet participants from one hospital to another hospital to receive medically necessary inpatient services not available at the first facility are covered services.  Hospital transfers shall be covered when the participant has been stabilized at the first hospital but needs a higher level of care available only at a second hospital.  Examples of medically necessary transfers for services not available at the first facility include, but are not limited to:

• rehabilitation
• burn unit
• ventilator assistance
• other specialized care

Transport from a hospital capable of treating the participant because the participant and/or the participant’s family prefer a specific hospital or physician is not a covered service.

The hospital to hospital transfer may not be considered emergent; however, hospital to hospital transfers that meet the transfer criteria listed in section 13.13.O(1) of the MO HealthNet Ambulance provider manual qualify for coverage under the ambulance program.  MO HealthNet provider manuals are located at http://manuals.momed.com/manuals/.

The documentation in the participant’s record must support the procedure code billed.  For accurate reporting purposes, the appropriate base code from the following list should be billed with the “HH” modifier.

• A0428HH – Ambulance service, BLS, non-emergency transport, hospital to hospital transfer
• A0426HH – Ambulance service, ALS 1, non-emergency transport, hospital to hospital transfer
• A0429HH – Ambulance service, BLS, emergency transport, hospital to hospital transfer
• A0427HH – Ambulance service, ALS 1, emergency transport, hospital to hospital transfer
• A0433HH – Ambulance service, ALS 2, emergency transport, hospital to hospital transfer

Durable Medical Equipment Prior Authorizations

January 18, 2011

Durable Medical Equipment (DME) providers are required to obtain prior authorization (PA) for certain services before delivery of the services. Providers are encouraged to submit their PA requests by facsimile (fax) to 573-659-0207. The following criteria apply when submitting PA requests by fax:

• Only one PA request may be submitted per fax call. Multiple PA requests per call will not be processed.
• Attachments to the PA request should not be scaled down in an attempt to fit multiple pages on one sheet, this causes the document to be difficult to read. Requests that are not legible will be returned to the provider for resubmission.
• Use a business fax cover sheet when faxing the PA request. The cover sheet should include the return fax number. This will assist in the return of disposition letters by fax.
• Regardless if the PA request is approved or denied; providers will receive a MO HealthNet Authorization Determination (disposition) letter containing all of the detail information related to the PA request. Please ensure the fax number from which the PA request is sent is not a blocked number. A blocked fax number will prevent the disposition letter from being returned by fax and delay notification. Disposition letters that cannot successfully be returned via fax will be mailed to the provider.

PA requests can still be completed and mailed to:

Please do not mail PA requests that have been faxed.

A list of DME services requiring prior authorization can be found in Section 19 of the DME MO HealthNet provider manual located at: http://manuals.momed.com/manuals/.

Sterilizations

January 10, 2011

A Sterilization Consent Form is a required attachment for all claims containing the following CPT surgical procedure codes: 55250, 58565, 58600, 58605, 58611, 58615, 58670, and 58671. The MO HealthNet participant must be at least 21 years of age at the time the consent is obtained and be mentally competent. The participant must have given informed consent voluntarily in accordance with Federal and State requirements.

The Sterilization Consent Form must be completed and signed by the participant at least 31 days, but not more than 180 days, prior to the date of the sterilization procedure. There must be 30 days between the date of signing and the surgery date. The day after the signing is considered the first day when counting the 30 days.

There are provisions for emergency situations in Section 10.2.E (1) of the provider manual which reads in part: “The only exceptions to these time requirements are for situations involving premature delivery or emergency abdominal surgery.

• Premature delivery: The (Sterilization) Consent Form must be completed and signed by the participant at least 72 hours prior to sterilization and at least 30 days prior to the expected date of delivery. Expected date of delivery is required on the (Sterilization) Consent Form. (This also applies to consent forms used in lieu of the Missouri-approved (Sterilization) Consent Form for services provided in non-bordering states.)
• Emergency abdominal surgery: The (Sterilization) Consent Form must be completed and signed by the participant at least 72 hours prior to sterilization. The nature of the emergency abdominal surgery must be documented on the (Sterilization) Consent Form. (This also applies to consent forms used in lieu of the Missouri-approved (Sterilization) Consent Form for services provided in non-bordering states.).”

The Sterilization Consent Form can be submitted through the www.emomed Internet Web site under Attachment Management. Click on New Attachment and select Sterilization Consent. Complete the required fields and submit the attachment. The provider must still maintain a properly completed paper form in the patient’s files and must provide a copy of the paper form to the hospital or ambulatory surgical center if the service was performed in either facility.

How to Search for a Prior Authorization Online

January 3, 2011

You can check the status of a Prior Authorization request online at www.emomed.com. Enter your user ID and password. On the Welcome to eProvider Page, Click on Prior Authorization Status. Make sure you select the NPI and Taxonomy Code, if applicable, that was submitted on the Prior Authorization Request form and enter the desired search criteria.

In order to view the PA status, select at least one PA Status criteria option or the “all” option. The participant DCN is required when using the Procedure Code/Modifier option. Select the PA Number to view the PA Status Detail information. Search parameters are case sensitive. To end the search for PA status, select “Finished”. The Question Mark at the top of the page is the “Help” button and will provide field-by-field instructions.

This application does not currently display drug or transplant Prior Authorizations.