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.
Hot Tip Indices
2022 Provider Tips Index
- Claims Processing and Payment Schedule for SFY 2023
- Claim Capture Dates
- COVID Testing and Specimen Collection Codes
- Enrolling Pharmacists
- Chiropractic Medicine
- At-Home COVID Test Coverage
- COVID-19 Outpatient Inhaler Treatment
- Telehealth Services
- Biopsychosocial Treatment of Obesity Policy Clarification
- COVID-19 Oral Antiviral Treatment
- DME Walker Criteria
Claims Processing and Payment Schedule for SFY 2023
May 12, 2022
Please access the Claims Processing Schedule for Fiscal Year 2023, for the updated claims processing schedule.
Claim Capture Dates
May 12, 2022
Please note, the last claim capture cycle for State Fiscal Year (SFY) 2022 will be Saturday, 5/28/2022 through 5:00 p.m. Tuesday, 6/7/2022 with a check date of 6/24/2022.
Claims not submitted by 5:00 pm on Tuesday, 6/7/2022 will process with the first claim capture cycle of SFY 2023.
For questions, please contact Provider Communications at 573-751-2896.
COVID Testing and Specimen Collection Codes
March 31, 2022
COVID-19: COVID Testing and Specimen Collection Codes – Updated
The MO HealthNet Division (MHD) continues to monitor Centers for Medicare & Medicaid Services (CMS) guidance related to COVID-19 testing and specimen collection. The tables below lists the COVID-19 testing and specimen collection procedure codes MHD currently covers as well as who can bill each code, effective dates, max units, and rates.
Effective for dates of service on or after March 1, 2020, and through the end of the public health emergency, claims submitted by independent laboratories for COVID-19 testing will not require a referring physician. Providers who perform other laboratory services on the same date as the COVID-19 test must bill for the COVID-19 test on a separate claim in order to be reimbursed. MHD will recycle all claims submitted by independent laboratories for COVID-19 tests that did not include a referring provider.
Effective for dates of service on or after January 1, 2021, pharmacists and pharmacies are included in the providers that can bill COVID-19 testing codes.
Effective for dates of service on or after January 1, 2021, providers can bill COVID-19 testing code U0005 in addition to either HCPCS code U0003 or U0004 only after receiving results within two calendar days from date and time of specimen collection.
COVID-19 Testing Codes |
|||||||
Code |
Description |
Who can bill this code? |
Effective with dates of service on or after: |
Max Units |
Rate |
||
U0001 |
CDC 2019 novel coronavirus (2019-ncov) real-time rt-pcr diagnostic panel |
Providers with the appropriate CLIA Certificate type for the test |
02/01/2020 |
2 |
$36.00 |
||
U0002 |
2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19) using any technique, multiple types or subtypes (includes all targets) |
Providers with the appropriate CLIA Certificate type for the test |
02/01/2020 |
2 |
$51.00 |
||
87635 |
Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique |
Providers with the appropriate CLIA Certificate type for the test |
03/13/2020 |
2 |
$51.00 |
||
86328 |
Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (e.g., reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]). |
Providers with the appropriate CLIA Certificate type for the test |
04/10/2020 |
3 |
$45.23 |
||
86769 |
Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]). |
Providers with the appropriate CLIA Certificate type for the test |
04/10/2020 |
3 |
$42.13 |
||
0202U |
Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected |
Providers with the appropriate CLIA Certificate type for the test |
05/20/2020 |
1 |
$416.78 |
||
87426 |
Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]). |
Providers with the appropriate CLIA Certificate type for the test |
06/25/2020 – 01/24/2021
01/25/2021 |
3 |
$45.23
$35.33 |
||
86408 |
Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); screen |
Providers with the appropriate CLIA Certificate type for the test |
08/10/2020 |
1 |
$42.13 |
||
86409 |
Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); titer |
Providers with the appropriate CLIA Certificate type for the test |
08/10/2020 |
1 |
$79.61 |
||
86413 |
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), antibody, quantitative |
Providers with the appropriate CLIA Certificate type for the test |
09/08/2020 |
3 |
$51.43 |
||
0240U |
Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 3 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B), upper respiratory specimen, each pathogen reported as detected or not detected |
Providers with the appropriate CLIA Certificate type for the test |
10/06/2020 |
1 |
$142.63 |
||
0241U |
Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B, respiratory syncytial virus [RSV]), upper respiratory specimen, each pathogen reported as detected or not detected |
Providers with the appropriate CLIA Certificate type for the test |
10/06/2020 |
1 |
$142.63 |
||
87636 |
Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex amplified probe technique |
Providers with the appropriate CLIA Certificate type for the test |
10/06/2020 |
3 |
$142.63 |
||
87637 |
Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique |
Providers with the appropriate CLIA Certificate type for the test |
10/06/2020 |
3 |
$142.63 |
||
87811 |
Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) |
Providers with the appropriate CLIA Certificate type for the test |
10/06/2020 |
3 |
$41.38 |
||
87428 |
Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzymelinked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B |
Providers with the appropriate CLIA Certificate type for the test |
11/10/2020 |
1 |
$63.59 |
||
U0003 |
Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R. |
Providers with the appropriate CLIA Certificate type for the test |
03/18/2020 – 12/31/2020
01/01/2021 |
2 |
$100.00
$75 |
||
U0004 |
2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R. |
Providers with the appropriate CLIA Certificate type for the test |
03/18/2020 – 12/31/2020
01/01/2021 |
2 |
$100.00
$75 |
||
U0005 |
Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, CDC or non-CDC, making use of high throughput technologies, completed within two calendar days from date and time of specimen collection. |
Providers with the appropriate CLIA Certificate type for the test |
01/01/2021 |
1 |
$25 |
||
COVID-19 Specimen Collection Codes |
|||||||
Code |
Description |
Who can bill this code? |
Effective with dates of service on or after: |
Max Units |
Rate |
||
99211 |
Medicare suggests using the Level 1 evaluation and management code for assessment and specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source |
Physician office |
03/01/2020 |
1 |
$15.31 |
||
C9803 |
Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source |
Hospital outpatient department |
03/01/2020 |
1 |
Percent of billed charges |
||
G2023 |
Specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source |
Independent Laboratories |
03/01/2020 |
1 |
$23.46 |
||
G2024 |
Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency, any specimen source |
Independent Laboratories |
03/01/2020 |
1 |
$25.46 |
Enrolling Pharmacists
March 7, 2022
Enrolling Pharmacists as Individual MO HealthNet Providers
Many pharmacists are currently interested in enrolling as individual MO HealthNet providers to bill MO HealthNet for prescriptions ordered by pharmacists, such as at-home COVID tests. Pharmacists interested in only ordering, prescribing, or referring services for MO HealthNet participants should enroll as Ordering, Prescribing, Referring providers. Pharmacists interested in performing or billing for services rendered to MO HealthNet participants should enroll as billing or performing provider.
Ordering Prescribing Referring Provider Enrollment:
Pharmacists interested in enrolling only to be the ordering, prescribing, or referring provider on claims, MO HealthNet recommends pharmacists enroll as Ordering, Prescribing, Referring Providers (OPR) if the pharmacist is not interested in also billing MO HealthNet for clinical services.
- Examples of items pharmacists can prescribe in Missouri are: COVID Tests and Nicotine Replacement Therapy
- Note: Providers who choose to enroll as “OPR only” providers cannot submit medical claims to MO HealthNet for payment of services rendered. If the provider wishes to be able to submit claims for payment, the provider must enroll with MO HealthNet as a billing or performing provider.
- Time to complete enrollment: 3 – 5 days after receipt of the completed enrollment packet
- Link to Application: https://mmac.mo.gov/wp-content/uploads/sites/11/2022/03/OPR-Application-2022.pdf
- Additional OPR Provider Information: https://mmac.mo.gov/providers/provider-enrollment/ordering-prescribing-referring-opr-providers/
- Helpful Hints to complete OPR application:
- Pharmacists must have an individual NPI to enroll. Pharmacists who do not already have an individual NPI can request one at https://nppes.cms.hhs.gov/#/
- Section 3 of the application asks for non-physician specialty, pharmacists should indicate:
- Unlisted Non-Physician Practitioner Type Specify: Pharmacist (E5)
- Completed applications must:
- Individually faxed to Provider Enrollment @ 573-634-3105 or email to: mmac.providerenrollment@dss.mo.gov
- Have the original wet signature of the individual provider
- No bank account information is needed to complete the application
Billing or Performing Provider Enrollment:
Pharmacists interested in enrolling with MO HealthNet to perform and be reimbursed for clinical services in addition to being able to order, prescribe and refer for MO HealthNet participants. Current pharmacist clinical services include but are not limited to: Medication Therapy Management and administration of healthcare administered drugs.
- Time to complete enrollment: 2 to 3 weeks after receipt of the completed enrollment packet
- Link to application and additional enrollment information:
https://mmac.mo.gov/providers/provider-enrollment/ - Helpful Hints to complete Billing or Performing Provider application:
- Pharmacists must have an individual NPI to enroll. Pharmacists who do not already have an individual NPI can request one at: https://nppes.cms.hhs.gov/#/
- Section 3 of the application asks for non-physician specialty pharmacists should indicate:
- Unlisted Non-Physician Practitioner Type Specify: Pharmacist (E5
- When enrolling, providers need to complete electronic funds transfer information for payment
- Completed Applications with an original wet signature of the individual provider may be submitted by:
- Online: https://mmac.mo.gov/providers/provider-enrollment/
- Email: mmac.providerenrollment@dss.mo.gov
- Fax: 573-634-3105
Chiropractic Medicine
Febuary 17, 2022
Chiropractic services are limited to examinations, diagnoses, adjustments, manipulations and treatments of malpositioned articulations, and structures of the body provided by licensed chiropractic physicians practicing within their scope of practice.
Chiropractic x-rays used as a diagnostic tool are covered services. The services must be within the chiropractic physician’s scope of practice.
Certain radiological procedures require a precertification. The procedures that require precertification and their respective guidelines are available online at: https://portal.healthhelp.com/mohealthnet.
At-Home COVID Test Coverage
January 31, 2022
Effective November 1, 2021, MO HealthNet will cover at-home COVID-19 tests through the Fee-for-Service pharmacy benefit when prescribed and dispensed by MO HealthNet enrolled providers. At-home COVID-19 tests will be covered for participants who are dually eligible for Medicaid and Medicare when the test is excluded from Medicare Part D coverage.
Reimbursement:
MO HealthNet will reimburse pharmacy providers the lesser of the Maximum Allowable Cost (MAC) rate plus a dispensing fee or the Usual & Customary submitted by the provider. The current reimbursement per unit for an at-home COVID-19 test is $12.
MO HealthNet will not reimburse participants directly for at-home COVID-19 tests. MO HealthNet will only reimburse for at-home COVID-19 tests when prescribed and dispensed by MO HealthNet enrolled providers.