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.

Telemedicine : Here to stay!

September 27, 2022

As a reminder, MO HealthNet reimburses for services provided via telemedicine when the service can be performed with the same standard of care as a face-to-face service. For more information, sign up for a Telemedicine webinar via our Provider Training Calendar.

Reminder for Children’s Division Residential and Treatment Foster Care Providers

September 19, 2022

Effective October 1, 2022, residential and treatment foster care (TFC) providers must begin submitting claims for the comprehensive community support (CCS) rehab per diem either to Show Me Healthy Kids (SMHK) plan, managed by Home State Health, or to MO HealthNet Division (MHD) fee-for-service, depending on the individual’s coverage. The vast majority of COA 4 participants are covered by SMHK, but children and youth who have opted out of managed care will be covered through MHD fee-for-service.  Children’s Division (CD) will continue to pay room and board to residential facilities for individuals receiving services through MHD fee-for-service and for individuals receiving services through SMHK. SMHK is offering webinars on claim submission. If you would like to participate, please register for one of the training sessions and select Show Me Healthy Kids Claims Basic Training Session with a date and time that is convenient for your schedule.  The training sessions can be found here:  https://www.homestatehealth.com/providers/provider-training.html

Residential and TFC providers must enroll with Missouri Medicaid Audit and Compliance (MMAC) and contract with SMHK to receive reimbursement for services.  While there is transition of care language in the contract with SMHK to ensure continuity of care with out of network providers through 12/31/2022, providers must still enroll/contract to continue to receive reimbursement.  Further, the transition of care period does not apply to COA 4 participants that have opted out of managed care and are receiving services through MHD fee-for-service.

Please review this provider bulletin for additional information https://dss.mo.gov/rehd/providers/pdf/bulletin45-09-20220728.pdf.

If you are not yet contracted with SMHK through Home State Health, please visit https://www.homestatehealth.com/providers/join-our-network.html to request a contract.  Or you may send an email to the Managed Care Contracting Team at ManagedCareContracting@centene.com, be sure to include SMHK in the subject of your email.

The MHD Education and Training Unit educate providers on proper billing methods and procedures for claim filing. Contact Education and Training at MHD.ProvTrain@dss.mo.gov or (573)751-6683. For additional resources, visit the Education and Training Resources page.

For questions about MHD enrollment, you may contact MMAC online at https://mmac.mo.gov

New Resources and Training Materials for Providers

August 31, 2022

The MHD Education and Training Unit has added several new resources to its webpage to assist providers. These new resources are located on the Education and Training Resources page. For resources on eligibility, provider website navigation, eMOMED and more, refer to the General Resources bullet below and on the Education and Training Resources page.

Educational PowerPoints and Resources

The Education and Training Unit offers a variety of training opportunities and resources for providers. Email mhd.provtrain@dss.mo.gov or call 573-751-6683 for more information.

Health Help On-Demand Training Sessions!

August 30, 2022

The MO HealthNet Division’s Radiology Benefits Manager, HealthHelp, conducts Provider Satisfaction Surveys.  As a result of these surveys, HealthHelp has created on-demand training sessions so providers can access training anytime, anywhere. Please visit the following link today and start exploring your options. https://www.gotostage.com/channel/mohealth

RSV Prophylaxis

August 25, 2022

Respiratory syncytial virus (RSV) activity in the United States remains variable by region but is increasing in some parts of Missouri, including St. Louis and Kansas City metropolitan areas. The shift in seasonality for RSV was first noted in 2021. The American Academy of Pediatrics (AAP) supports the use of palivizumab in eligible infants in any region experiencing rates of RSV activity at any time in 2022, similar to a typical (pre-2020) fall-winter season.

Based on the increases in RSV activity, the MO HealthNet Division (MHD) will begin to review requests for RSV prophylaxis effective September 1, 2022. Participants who meet the clinical edit requirements, including age restrictions, may receive approval for up to five doses for the 2022 – 2023 RSV season, depending on the requested date for the initial prior authorization. MHD recommends pharmacies coordinate with providers to ensure a scheduled appointment exists with their patient to administer palivizumab before sending doses to reduce abandoned medication. MHD will evaluate claims to ensure there is no excessive waste.

Given the regional variation in RSV activity, please consider your local RSV rates when determining when to initiate palivizumab. The duration of the current RSV season cannot be predicted; consider ordering single doses of palivizumab each month (rather than five monthly doses at the start of the season). Close monitoring of local RSV activity will determine a stop date for RSV prophylaxis; MHD may end the approved prior authorization early if the RSV season is determined to conclude before all doses are administered. If the 2022 – 2023 RSV season ends earlier than typical (pre-2020) RSV seasons, MHD will send out a provider blast to notify providers. Providers with questions may call MO HealthNet at 800-392-8030.

1915(c) Home and Community-Based Waivers (HCBS) Department of Health and Senior Services (DHSS) Waivers:

August 25, 2022

1915(c) HCBS waiver services are included in the Missouri Medicaid Program under the authority of a Home and Community-Based Waiver granted by the Centers for Medicare & Medicaid Services (CMS). Under a waiver, certain services that could not otherwise be reimbursed under Title XIX may be provided to a select group of participants, in order to provide an alternative to institutional care.

The below waivers are administered by the Department of Health and Senior Services (DHSS), the operating agency; and MO HealthNet Division (MHD) provides the oversight as the single-state Medicaid agency. The chart below shows the operating agencies for each waiver, as well as the agencies’ waiver information and referral/intake websites.

 

Bureau Waiver Operating Agency Referrals and Informational Websites
Bureau of Long Term Services and Supports (BLTSS)
  • Adult Day Care Waiver
  • Aged and Disabled Waiver
  • Independant Living Waiver
  • Sructured Family Caregiving Waiver
https://health.mo.gov/seniors/hcbs/hcbsmanual/index.php

https://redcaphcbs.azurewebsites.net/redcap/surveys/?s=TNA8HLY49K
Bureau of HIV, STD, and Hepatitis (BHSH)
  • AIDS Waiver
https://health.mo.gov/living/healthcondiseases/communicable/hivaids/casemgmt.php

https://health.mo.gov/hivcasemanagement
Bureau of Special Health Care Needs (BSHCN)
  • Medically Fragile Adult Waiver
  • Brain Injury Waiver
https://health.mo.gov/living/families/shcn/
or
https://health.mo.gov/living/families/shcn/mfaweligibility.php
or
https://health.mo.gov/living/families/shcn/bi.php

Telemedicine

August 12, 2022

MO HealthNet covers services provided via Telemedicine. Telemedicine guidelines are reflected in the Missouri Code of State Regulations 13 CSR 70-3.330. You may also visit the MO HealthNet Telemedicine webpage, located at the following link, for more information related to billing for Telemedicine: https://dss.mo.gov/mhd/providers/pages/telemedicine.html.

Behavioral Health Precertification Refresher:

July 28, 2022

Behavioral Health providers may deliver 14 hours of psychotherapy services to a participant, each rolling year, in any combination of individual, family or group therapy (90832, 90834, 90837, 90846, 90847, or 90853).

If you provided individual, family, or group therapy to the participant in the last rolling year a precertification is required to continue services beyond the initial 14 hours.

All covered behavioral health services for participants under the age of 3 require precertification, with the exception of psychiatric diagnostic evaluation (90791, 90792).

Telemedicine

July 18, 2022

MO HealthNet covers services provided via Telemedicine when the service can be performed with the same standard of care as a face to face service.

Telemedicine services may be provided to a MO HealthNet 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 telemedicine 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.

Please view Telemedicine Originating and Distant Site Reimbursement Scenarios for more information.

Immunizations for Dual Eligible Participants

July 14, 2022

MO HealthNet providers billing vaccines for dual eligible participants shall bill Medicare for all vaccines. Vaccine coverage under Medicare Part B includes the pneumococcal, influenza, and Hepatitis B vaccines for individuals at high or intermediate risk and vaccines directly related to, the treatment of an injury or direct exposure to a disease or condition. Other vaccines not covered by Part B, such as but not limited to Tdap, Zoster, and Hepatitis B are covered by Medicare Part D. When a provider cannot bill the Part D plan directly, the vaccine should be dispensed at a pharmacy. In some cases, a pharmacist may administer the vaccine following the MO Board of Pharmacy guidelines.

Long-Acting Reversible Contraception (LARC) Devices for Dual Eligible Participants

July 14, 2022

The MO HealthNet Division (MHD) reimburses providers for long-acting reversible contraception (LARC) devices for dual eligible participants even if their Medicare benefit does not cover it. The MHD currently has a Fiscal Edit in place to prevent duplicate billing of non-oral contraceptive products. Providers are responsible for checking criteria to confirm their patient’s eligibility for a LARC device prior to billing MHD. The criteria for non-oral contraceptive products are available at: http://dss.mo.gov/mhd/cs/pharmacy/pdf/non-oral-contraceptives.pdf. Once a provider has determined a dual eligible participant meets the criteria for a LARC, they must submit a claim to MHD, then contact the Pharmacy Administration Unit at 573-751-6963 or MHD.PharmacyAdmin@dss.mo.gov to obtain an override.

Dental Program

American Dental Association (ADA) Dental Claim Form:
July 8, 2022

When completing and submitting a paper ADA Dental Claim form, dental providers should complete Field 23 with the participant’s MO HealthNet number exactly as shown on the participant's ID card. Anything other than the participant’s DCN, or leaving the field blank, will cause the claim to deny. For additional information regarding how to complete the ADA Dental Claim form, reference Section 15.7 of the Dental Manual at http://manuals.momed.com/collections/collection_den/print.pdf.

Proper Billing for Drugs Billed to MO HealthNet

July 8, 2022

MO HealthNet Division (MHD) will begin desk audits of providers to ensure proper billing units are used for drugs billed to MO HealthNet. Providers are responsible for proper billing of claims as outlined in Section 15 of the Pharmacy Provider Manual (http://manuals.momed.com/collections/collection_pha/print.pdf). Billing a claim with the incorrect unit of measure may result in greater compensation than entitled. Providers are reminded that they must have adequate documentation, as defined in 13 CSR 70.3.030(2)(A), from which services rendered and the amount of reimbursement received by a provider can be readily discerned and verified with reasonable accuracy. These records must be made available to MO HealthNet upon request.
For more information on what to expect during a desk audit please see here: https://mmac.mo.gov/wp-content/uploads/sites/11/2016/02/Audit-guidance.pdf.

MO HealthNet Division will host a series of webinars to aid providers in proper billing of drug claims to MO HealthNet. These webinars will allow for live questions and will be recorded for future reference. Click below to register.
If MO HealthNet providers have questions on proper billing of drug claims, contact PAU at 573-751-6963 or email MHD.PharmacyAdmin@dss.mo.gov.

 

Webinar

Time

Link to Register

August 3rd, 2022

1:00pm to 2:00pm

Here

August 31st, 2022

9:00am to 10:00am

Here

PERSONAL CARE PROGRAM

July 8, 2022

This bulletin updates guidance regarding COVID-19 flexibilities previously issued via a MHD Hot Tip on April 17, 2020.  This bulletin reinstates various oversight measures and programmatic practices intended to ensure the health, safety, and welfare of participants. 

FAMILY CARE SAFETY REGISTRY (FCSR)/GOOD CAUSE WAIVER (GCW)

Effective August 1, 2022, all flexibilities surrounding Family Care Safety Registry (FCSR) background checks and Good Cause Waiver (GCW) are rescinded.  Providers must resume pre-COVID requirements. 

TRAINING

Effective August 1, 2022, providers are required to resume training requirements in a modified nature.  Providers are not required to retroactively complete trainings flexed from March 2020 through July 2022.  Modified training requirements include: 

  • Twelve (12) hours of orientation training for in-home service workers, including at least two (2) hours orientation to the provider agency and the agency’s protocols for handling emergencies.  A minimum of six (6) hours of training will be provided prior to the first day of participant contact.
    • Four (4) hours of required orientation training may be waived for aides and homemakers with adequate documentation in the employee’s records that they have received similar training during the previous twelve (12) months.
    • All orientation training hours, with the exception of the statutorily required dementia training and two (2) hours of provider agency orientation, may be waived with adequate documentation, placed in the aide’s personnel record, that the aide is a licensed practical nurse, registered nurse or certified nurse assistant. The documentation shall include the employee’s license or certification number which must be current and in good standing at the time the training was waived;
  • Five (5) hours of in-service training annually are required after the first twelve (12) months of employment. The provider may waive the required annual five (5) hours of in-service training and require only two (2) hours of refresher training annually, when the personal care aide has been employed for three (3) years and has completed fifteen (15) hours of in-service training.

IN-HOME SUPERVISORY VISITS/CDS MONITORING VISITS

Effective August 1, 2022, providers are required to resume required in-person visits.  Retroactive visits/monitoring are not required. 

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:
    • 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:

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.

The current list of covered at-home COVID-19 tests is:

  • PIXEL COVID-19 HOME COLLECT KT
  • INTELISWAB COVID-19 HOME TEST
  • LUCIRA CHECK-IT COVID HOME TST
  • BINAXNOW COVD AG CARD HOME TST
  • BINAXNOW COVID-19 AG SELF TEST
  • QUICKVUE AT-HOME COVID-19 TEST
  • CARESTART COVID-19 AG HOME TST
  • EVERLYWELL COVID19 HOM COLLECT
  • IHEALTH COVID-19 AG HOME TEST
  • ELLUME COVID-19 HOME TEST
  • FLOWFLEX COVID-19 AG HOME TEST

Additional at-home COVID-19 tests continue to be authorized and may be added to the covered list. MAC pricing for at-home COVID-19 tests can be found at: https://dss.mo.gov/mhd/cs/pharmacy/pages/mac.htm

Pharmacists prescribing at-home COVID-19 tests for MO HealthNet participants:

Per the PREP Act Declaration 3rd Amendment, pharmacists can prescribe at-home COVID-19 tests. At-home COVID-19 tests must be prescribed by an enrolled MO HealthNet provider for MO HealthNet to reimburse for the at-home COVID-19 test. Pharmacists who prescribe at-home COVID-19 tests for MO HealthNet participants, must be an enrolled MO HealthNet provider to receive reimbursement.

Additional information:

At-home COVID-19 tests may also be ordered from the Federal Government at no cost. More information is available at: https://www.covidtests.gov/.

COVID-19 Outpatient Inhaler Treatment

January 28, 2022

Effective for dates of service on or after 7/1/2021, MO HealthNet will allow Hospital & Clinic providers to bill for an inhaler if the participant is diagnosed with COVID or the participant has been exposed to COVID-19, and the facility is awaiting test results.

  • The claim must include the primary diagnosis code U07.1 (COVID-19) or Z20.822 (Contact with and (suspected) exposure to COVID-19).
  • The participant must be given the inhaler to take home to avoid refill too soon rejections at the hospital, clinic, and pharmacy.
  • This coverage exception is limited to the following classes of inhalers: Short-Acting Beta-Adrenergic Agents, COPD Anticholinergic Agents, and Oral Inhaled Corticosteroids.
  • MO HealthNet has preferred drug lists for most inhalers before utilizing an inhaler. MO HealthNet recommends checking the preferred drug list. Non-preferred products require prior authorization on or before the date of service. MO HealthNet’s current preferred inhalers are available through the searchable database: https://pdlsearchabledatabase.pharmacy.services.conduent.com/.
  • MO HealthNet will not reimburse hospital & clinic providers for inhalers if the claim lacks an approvable diagnosis.
  • MO HealthNet will only reimburse inhalers billed with the correct NDC units (for example, a standard ProAir HFA inhaler is 8.5 grams)
  • If the visit extends across multiple dates of service, MO HealthNet will only pay for 1 (one) of each inhaler for the full visit. Claims billed for multiple of the same inhaler will be subject to audit and potential recoupment.
  • Drug claims from non-pharmacy providers must still be billed as a one-day supply.
  • The coverage of take-home inhalers due to COVID-19 is a time-limited exception to MO HealthNet’s policy on take-home drugs and supplies. Providers will be notified by Hot Tip prior to this exception expiring. For more information on the Take-Home Drugs and Supplies policy, please see section 13.49 of the MO HealthNet Hospital Provider Manual.

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://peu.momed.com/peu/momed/presentation/commongui/PeHome.jsp

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.