The MO HealthNet Division provides hot tips to providers to assist them in receiving timely reimbursement for services provided. Please share these hot tips with your billing staff.

Changes to Remittance Advice

May 31, 2019

Effective with the 4/19/19 Health Care Claim Payment/Advice (835), MO HealthNet implemented a required system change to correct what is reported as the submitted line item charge on the 835 for crossover claims. This will affect 837I (Institutional; Outpatient, Nursing Home, Inpatient, etc.) and 837P Professional (Medical, Dental) claim types.

MO HealthNet is following the HIPAA compliance guidelines outlined in the ASC X12 Health Care Claim Payment/Advice (835) version 5010 TR3 Section 1.10.2.1.1. This will report the line Item charge amount (from 837I SV203 or 837P SV102) which was submitted by the provider on the claim to Medicare and forwarded to MO HealthNet versus using the total of the patient responsibility (PR) amounts from the explanation of benefits (EOB) to populate the 835 SVC02 field. This will result in more line items having adjustment amounts, reported as contractual obligation (CO) 45, to account for the difference between the submitted line item charge amount and the MO HealthNet paid amount.

Billing Initial Hospital Care Visit Reminders

May 22, 2019

Please refer to the November, 2017 INITIAL HOSPITAL CARE VISIT BULLETIN. The MO HealthNet Division (MHD) limits payment for Current Procedural Terminology (CPT) codes 99221, 99222, and 99223, to one (1) per inpatient stay. These codes are to be used to report the first hospital initial inpatient encounter by the admitting physician, according to The CPT Professional Codebook.

Multiple physicians cannot bill the initial inpatient visit. The CPT book says only the admitting physician can bill the initial hospital care code. These codes are not to be billed when providing a consultation; only initial hospital admission visit.

Providers should use a consultation, daily visit, or discharge code that accompanying documentation supports when submitting a paper claim.

Claims should report actual admission and discharge dates, not the date of the consultation or hospital visit.

Pharmacy Services for MO HealthNet Participants with Presumptive Eligibility - Revised

May 1, 2019

MO HealthNet will reimburse any medication for a MO HealthNet participant dispensed within the eligibility period shown on a MO HealthNet Presumptive Eligibility Authorization (PE-3) form.

MO HealthNet will also reimburse any medication for a MO HealthNet participant dispensed within the eligibility period shown on a Show Me Healthy Babies Presumptive Eligibility (SMHB-PE) Authorization form.

Both of these forms serve as proof of presumptive eligibility. Pharmacy providers should check the dates of eligibility on the authorization forms to ensure the presumptive eligibility period is active, and make a photocopy of the form and maintain it in the pharmacy file.

Missouri Medicaid Audit and Compliance (MMAC) considers this adequate documentation.

Pharmacies may contact Pharmacy Administration at (573) 751-6963 if they have questions.

Please follow the bellow link to see the March 30, 2017 bulletin which contains sample copies of the forms that participants will be presenting.

https://dss.mo.gov/mhd/providers/pdf/bulletin39-49_2017March30.pdf

Third Party Vendor Requesting Drug Prior Authorization

April 26, 2019

MO HealthNet does not accept drug prior authorization requests from third party vendors including, but not limited to, CoverMyMeds and ZAPPRX. All requests must originate from the prescriber’s office or pharmacy. Additionally MO HealthNet will not provide any participant or claims information to third party vendors nor accept information or documentation from a third party vendor. Providers may contact Pharmacy Administration at (573) 751-6963 if they have questions.

Financial Management Services (FMS)

March 13, 2019

This Hot Tip serves as a reminder that in order for an Independent Living Waiver (ILW) provider to be reimbursed for Financial Management Services (FMS), the provider must be enrolled as a MO HealthNet Consumer-Directed Services (CDS) provider and complete a MO HealthNet FMS addendum. MO HealthNet continues to see claims deny for ILW providers billing for FMS, as some providers do not have the required FMS addendum on their provider enrollment file. The FMS addendum form is available on the Missouri Medicaid Audit and Compliance (MMAC) web site at https://mmac.mo.gov/providers/provider-enrollment/home-and-community-based-services/provider-contracts-forms/ or by contacting Provider Enrollment at mmac.ihsconracts@dss.mo.gov.

FMS provides assistance to the participant with administrative assistance, payroll functions and other supportive services. The participant has decision-making authority over their services and takes direct responsibility to manage these services with the assistance of a Financial Management Services provider.

Each month providers shall not bill for FMS unless at least one unit of CDS Personal Care - ILW (T1019 U6) services has been delivered.

Reimbursement

  • One unit equals one month
  • Unit Cost equals $110.00
  • Procedure Code T2040 U6

Please refer to the Provider Bulletin Addition of Financial Management Services in the Independent Living Waiver, dated May 2, 2014 for additional information regarding FMS and provider enrollment information.

Additionally, MO HealthNet would like to remind ILW providers that all State Plan CDS Personal Care (T1019 U2) must be utilized (exhausted) prior to billing for CDS Personal Care – ILW (T1019 U6) in the ILW program.

NEW! TELEHEALTH BILLING WEBINARS

February 27, 2019

MO HealthNet will be offering webinars related to Telehealth billing. If you are a Telehealth provider or biller, please take advantage of a webinar to answer any questions you might have and gain information on billing Telehealth claims to MO HealthNet.

You may sign up for a webinar under Training Information on the MO HealthNet Provider Information Page/Education.

Reimbursement Issues - Pricing Inquiry Process

February 15, 2019

Missouri Maximum Allowable Cost (MAC) Pricing Inquiry

Providers may contact Pharmacy and Clinical Services at (573) 751-6963 to request review of a MAC rate.  If the MO HealthNet Division (MHD) determines there is a rate change, it will be made effective the date of review. 

If further review is necessary, the provider must submit a completed MAC Pricing Inquiry Worksheet and a copy of the invoice for the National Drug Code (NDC) in question.  Providers should NOT include Protected Health Information (PHI) on the worksheet.  Providers may only submit a worksheet upon request by the MHD and only for the drug(s) specified.  Upon completion of the review, the MHD will notify providers of the outcome.  If there is a rate change, it will be effective the date the MHD received the worksheet.  Providers may then resubmit claims for appropriate reimbursement. 

The Missouri Maximum Allowable Cost (MAC) pricing list can be found at dss.mo.gov/mhd/cs/pharmacy/pages/mac.htm

National Average Drug Acquisition Cost (NADAC) Pricing Inquiry

Providers may contact the NADAC Help Desk to request review of a NADAC rate or to provide notification of recent drug price changes.

Contact the NADAC Help Desk through the following means:

  • Toll-free phone: (855) 457-5264
  • Email: info@mslcrps.com
  • Fax: (844) 860-0236

Provides must submit a completed Help Desk Form and a copy of the invoice for the NDC in question.  The Help Desk will not address specific state claim reimbursement related questions or concerns.

The NADAC rate file is updated on a weekly basis.  There may be a delay between the release of the weekly NADAC rate file and the MHD receiving the file.  If there is a rate change, it will reflect the effective date found on the NADAC file.  Providers may then resubmit claims for appropriate reimbursement.

Please note the MHD does not set the NADAC rate and does not review NADAC pricing inquiries.  The Centers for Medicare & Medicaid Services (CMS) has entered into a contract with Myers & Stauffer, LC, to perform these services.  

The NADAC pricing file can be found at data.medicaid.gov/Drug-Pricing-and-Payment/NADAC-National-Average-Drug-Acquisition-Cost-/a4y5-998d.  More information about NADAC and the Retail Pricing Survey may be found on the Medicaid.gov website.

Missouri Child Psychiatry Access Project

February 6, 2019

The Missouri Child Psychiatry Access Project (MO-CPAP) is a pilot program, initially funded by Missouri Foundation for Health (MFH) with expansion funding provided by Health Resources and Services Administration (HRSA), aimed at supporting and strengthening primary care providers’ ability to provide mental health care to young patients with mild to moderate behavioral health issues.

Primary care physicians, family physicians, pediatricians, physician assistants and advanced practice nurses can enroll in the project. Enrolled providers are available to access support services such as:

  • Telephone consults with child and adolescent psychiatrists regarding screening, diagnosis and management of behavioral health issues
  • Linkage and referral services to connect their patients to community-based mental health care and other resources
  • Education and training in identification, assessment and treatment of mild to moderate behavioral health issues.

MO-CPAP invites MO HealthNet child providers to participate in the seven county Eastern region (St. Louis City, St. Louis County, Franklin, Jefferson, Lincoln, St. Charles and Warren Counties) as well as the eight county Central region (Boone, Cole, Cooper, Moniteau, Howard, Randolph, Audrain and Callaway counties) pilot. Statewide enrollment for all MO HealthNet providers will be available in October 2020.  For more information about the project, or to enroll, visit MO-CPAP’s website https://medicine.missouri.edu/mo-cpap.

Clarification for Provider Bulletin Volume 41 Number 32, dated December 28, 2018

January 30, 2019

In the 2019 Applied Behavior Analysis (ABA) CPT® Code Changes bulletin, the maximum quantity refers to the maximum number of units per day that can be billed. The unit for each ABA procedure code is 15 minutes, as noted in the Brief Description column. For example, the maximum quantity for 97151 is 8 units per day. Eight 15-minute units is equivalent to two hours. The maximum quantity of 97152 is 32 units per day. Thirty-two 15-minute units is equivalent to 8 hours.