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.

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:
    • 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.