2022 MO HealthNet Provider Hot Tips

The MO HealthNet Division publishes Hot Tips to supply information to clarify and assist in receiving timely reimbursement for services provided and claims disposition.

MO HealthNet has developed an index for historical and ongoing Hot Tips and a COVID-19 index for associated Hot Tips. The non-COVID-19 index location has not moved; it is also located below for quick reference.   Please share these Hot Tips with your billing staff.

Telehealth Services

January 11, 2022

MO HealthNet covers Telehealth services. MO HealthNet allows any licensed health care provider, enrolled as a MO HealthNet provider, to provide telehealth services if the services are within the scope of practice for which the health care provider is licensed. The services must be provided with the same standard of care as services provided in person.

Telehealth services may be provided to a MHD participant, while the participant is at an originating site, and the provider is at another location (the distant site.) The originating site facility fee cannot be billed to MO HealthNet when the originating site is the participant’s home.

There is not a separate telehealth fee schedule. Reimbursement to health care providers delivering the medical service at the distant site is equal to the current fee schedule amount for the service provided.

During the Public Health Emergency, MHD waived some requirements, including:

• The requirement that physicians must have an established relationship with the patient before providing services via telehealth, per RSMo 191.1146
• The requirement that, in order to treat patients in this state with telehealth, health care providers shall be fully licensed to practice in this state. The flexibility allowed providers to treat patients in this state if they are licensed in the state in which they practice.

While the State of Emergency in Missouri concluded December 31, 2021, MHD must submit requests to the Centers for Medicare & Medicaid Services (CMS) to discontinue any of the flexibilities allowed during the Public Health Emergency (PHE). Therefore, the flexibilities continue temporarily until CMS approval is granted. Providers will be notified when the state is approved to discontinue the two flexibilities listed above.

MHD also allowed the use of telephone for telehealth services, and allowed quarantined providers and/or providers working from alternate sites or facilities to provide and bill for telehealth services. These services should be billed as distant site services using the physician’s and/or clinic provider number. MHD did not require additional CMS flexibility for these options, and they will continue.

Providers must still be enrolled as MHD providers through Missouri Medicaid Audit and Compliance (MMAC).

Biopsychosocial Treatment of Obesity Policy Clarification

January 10, 2022

MO HealthNet coverage for biopsychosocial treatment of obesity (see Provider Bulletin Volume 44, Number 12 https://dss.mo.gov/mhd/providers/pdf/bulletin44-12.pdf) is an integrated approach to care that includes both medical nutrition therapy and behavioral health counseling to improve weight status. Prior authorization for either treatment component in isolation will not be granted.

The prescribing provider must obtain prior authorization before the participant starts receiving services. Pre-certification can be obtained by calling the Preventative Services Pre-Certification Hotline (800-392-8030 option 7) or by using CyberAccess. Servicing providers must be enrolled as a Biopsychosocial Treatment of Obesity provider. For any questions regarding enrollment, please email MMAC.ProviderEnrollment@dss.mo.gov.

The link to complete the electronic application is: https://health.mo.gov/living/healthcondiseases/communicable/novel-coronavirus/covid-therapeutics.php

Any questions regarding enrollment should be emailed to: MMAC.ProviderEnrollment@dss.mo.gov

COVID-19 Oral Antiviral Treatment

January 6, 2022

On December 22, 2021, the FDA issued an emergency use authorization (EUA) for Pfizer’s COVID-19 treatment, Paxlovid. Paxlovid is indicated for the treatment of mild-to-moderate coronavirus disease (COVID-19) in adults and pediatric patients (12 years of age and older weighing at least 40 kilograms) with positive results of direct SARS-CoV-2 testing and who are at high risk for progression to severe COVID-19, including hospitalization or death. Paxlovid is available by prescription only and should be initiated as soon as possible after a diagnosis of COVID-19 and within five days of symptom onset.

On December 23, 2021, the FDA issued an EUA for Merck’s molnupiravir for the treatment of mild-to-moderate coronavirus disease (COVID-19) in adults with positive results of direct SARS-CoV-2 viral testing, and who are at high risk for progression to severe COVID-19, including hospitalization or death, and for whom alternative COVID-19 treatment options authorized by the FDA are not accessible or clinically appropriate. Molnupiravir is available by prescription only and should be initiated as soon as possible after a diagnosis of COVID-19 and within five days of symptom onset.

While the federal government pays for the product, the product cost cannot be billed to MO HealthNet. Pharmacy providers filling prescriptions for Paxlovid or molnupiravir will be reimbursed the current professional dispensing fee, at the time the prescription is dispensed. For pharmacies to receive the full dispensing fee, the Usual & Customary charge submitted to MO HealthNet must be in excess of the current professional dispensing fee. Non-pharmacy providers (clinics, hospitals, ERs, etc.) do not receive a professional dispensing fee.

Information about Missouri’s distribution of COVID-19 oral antivirals is available here: https://health.mo.gov/living/healthcondiseases/communicable/novel-coronavirus/covid-therapeutics.php

For more information about Paxlovid: https://www.fda.gov/media/155052/download

For more information about molnupiravir: https://www.fda.gov/media/155053/download

DME Walker Criteria

January 4, 2022

MO HealthNet requires pre-certification for standard walkers, walkers with trunk support, walkers with variable wheel resistance, and heavy duty walkers. However, MO HealthNet does not cover rollator walkers. Therefore, rollator walkers cannot be billed to MO HealthNet under HCPCS E0143 or E0149.

Providers can obtain pre-certification for walkers by calling the DME Pre-Certification Hotline (800-392-8030 option 2) or by using CyberAccess.

For more information regarding specific walker criteria, please refer to our website at https://dss.mo.gov/mhd/cs/dmeprecert/pages/dmeprecert.htm.