2018 MO HealthNet Provider Hot Tips
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.
2018 Provider Tips Index
- NADAC Pricing Inquiries
- Updated EBPT Invoice
- Maximum Daily Units Edits
- Social Security Number Removal Initiative
- Participants With Other Insurance Coverage
- Re-Pricing Medicare Inpatient Hospital Claims
- Fluoride Varnish During Well Child Check
- Outpatient Hospital Billing Tips for 340B Providers
- Pharmacy Services for Participants with Presumptive Eligibility
NADAC Pricing Inquiries
December 17, 2018
Providers may contact the NADAC Help Desk for support of the NADAC survey, to request review of a NADAC rate, or to provide notification of recent drug price changes not reflected in posted NADAC files.
he NADAC Help Desk may be contacted through the following means:
- Toll-free phone: (855) 457-5264
- Email: email@example.com
- Fax: (844) 860-0236
When contacting the NADAC Help Desk about a NADAC rate it is required to include the completed Help Desk Form and a copy of the invoice for the NDC in question. Please note that the Help Desk will not address pharmacy inquiries into specific state claim reimbursement related questions or concerns.
Additional information regarding NADAC and the Retail Pricing Survey may be found on the Medicaid.gov website.
Updated EBPT Invoice
Setember 24, 2018
The EBPT Invoice for Enhanced Reimbursement for Children with Severe Trauma has been updated. The updated invoice is available at: https://dss.mo.gov/mhd/providers/pdf/enhanced-reimbursement-invoice.pdf
Please begin using the updated invoice effective immediately. Invoices must be submitted via encrypted email. The invoice includes a link to encryption instructions. For more information about Enhanced Reimbursement for Children with Severe Trauma, see the provider bulletin: https://dss.mo.gov/mhd/providers/pdf/bulletin40-48_2018feb6.pdf
Maximum Daily Units Edit
August 17, 2018
On August 19, 2018, the MO HealthNet Division (MHD) will implement a maximum daily quantity edit. This quantity limit is based upon the maximum number of units of the drug allowed per day as determined by the MHD or First Databank’s (FDB) MedKnowledge. The correct day's supply must be submitted on drug claims based on the quantity dispensed and the directions as written by the prescriber. Claims submitted for a quantity above the maximum daily units will deny.
This edit will help ensure claims integrity and the accuracy of data transmitted on claims submitted to the MHD. Billing errors caused or committed by the provider or their employees, including but not limited to incorrect ingredient indicators, quantities, day’s supply, prescriber identification, dates of service, and usual and customary charges, are subject to adjustment or recoupment. For questions regarding billing or denied claims, providers may contact Pharmacy and Clinical Services at (573) 751-6963.
Social Security Number Removal Initiative
June 08, 2018
The Medicare Access and CHIP Reauthorization Act (MACRA) requires CMS to remove Social Security Numbers (SSNs) from Medicare beneficiary ID cards and issue new cards with Medicare Beneficiary Identification (MBI) numbers.
CMS will start mailing the new Medicare Beneficiary ID cards with the new MBI numbers to participants beginning in April 2018. They are allowing an 18-month transition period that ends December 31, 2019. During the transition period, physicians and other providers may submit a Medicare claim using either the participant's valid and active Health Insurance Claim Number (HICN) or the new MBI number.
All Medicare claims submitted after January 1, 2020, will be required to use the new MBI number. Claims filed with the participant's old HICN will be rejected, at that point.
With these new criteria, MO HealthNet will also have a transition period from April 1, 2018 through December 31, 2019, in which we are able to accept either the new MBI number or the old HICN. Effective January 1, 2020, providers will only be able to submit the new MBI number with all claims that are submitted to MO HealthNet.
Please be aware dual eligible Medicaid and Medicare participants are starting to receive their new Medicare cards. If a MO HealthNet participant contacts you with a question regarding his or her card and its anticipated arrival time, please direct the participant to this website: https://www.medicare.gov/newcard/
Please inform participants of the following, if they ask:
- New cards protect their identity by removing social security numbers
- New cards have a unique number that is unique to them
- The participants’ new Medicare cards will automatically come to them; they don’t need to do anything
Participants With Other Insurance Coverage
May 11, 2018
When you verify eligibility for a MO HealthNet participant, you may be surprised to learn the participant has commercial insurance, which includes Medicare Part C plans, in addition to MO HealthNet benefits. Individuals who have commercial health insurance may still be eligible for MO HealthNet benefits. Commercial insurance will always be the first source of payment as MO HealthNet is the payor of last resort.
The participant’s commercial health insurance carrier is billed first for consideration of coverage and payment. If services are not covered by the commercial insurance policy, MO HealthNet pays for the covered services with proof of a valid denial from the commercial insurance carrier.
There is no duplication of payment and if the other insurance pays as much as or more than MO HealthNet’s maximum allowed amount, the claim is considered paid in full. No additional payment will be made by MO HealthNet and the participant can't be billed for the balance.
Private insurance information is initially obtained by eligibility specialists at the Family Support Division when an individual makes application for public assistance. Once eligible, the participant is responsible for reporting to their eligibility specialist any changes to coverage by their commercial insurance carrier.
When checking the participant’s eligibility, you are given information about known possible insurance coverage. The insurance information on file at the MO HealthNet Division (MHD) does not guarantee the insurance(s) listed is (are) the only resource(s) available nor does it guarantee the coverage is currently in effect. If the participant has not informed the eligibility specialist of changes, the information on file may need to be updated.
As a provider, you have the ability to inform MHD of changes to a participant’s commercial insurance information by completing and submitting the MO HealthNet Insurance Resource Report form, commonly known as the TPL-4 form. This form should be mailed to: MO HealthNet Division, ATTN: TPL Unit, PO Box 6500, Jefferson City, MO, 65102-6500. Third Party Liability staff will verify the information before updating the TPL data on the participant’s eligibility file.
For detailed information on third party resources, refer to Section 5 of the MO HealthNet Provider Manual.
Re-Pricing Medicare Inpatient Hospital Claims
May 11, 2018
Since July 1, 1991, the MO HealthNet Division (MHD) has been re-pricing Medicare Part A inpatient hospital crossover claims for the possible payment of Medicare deductible and co-insurance amounts. This Hot Tip is a reminder that the re-pricing policy also applies to Medicare Part C/Advantage plans for inpatient hospital services for deductible, co-insurance and co-pay amounts for participants who are QMB eligible. The following information is taken from Section 12.5.A of the Hospital Provider Manual.
MO HealthNet is responsible for deductible and coinsurance amounts for Medicare Part A crossover claims only when the MO HealthNet applicable payment schedule exceeds the amount paid by Medicare. In those situations where MO HealthNet has an obligation to pay a crossover claim, the amount of MO HealthNet’s payment is limited to the lower of the actual crossover amount or the amount the MO HealthNet fee exceeds the Medicare payment. The hospital’s remittance advice will show the amount to be paid for each re-priced Part A/Part C crossover claim. The system will post claim adjustment reason code OA-045 (charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement) and remittance advice remark code N-59 (please refer to your provider manual for additional program and provider information) for those claims where Medicare has paid more than MO HealthNet would.
Amounts not reimbursed by MO HealthNet for allowable crossover claims may not be billed to the MO HealthNet participant.
The Part A Medicare deductible for inpatient services is always applied to the day of admission or the first day in the hospital stay that the individual becomes Medicare eligible. If the patient is not MO HealthNet eligible on the day the deductible is applied, MO HealthNet does not pay the deductible and it becomes the responsibility of the patient to pay for the deductible.
Fluoride Varnish During Well Child Check
April 16, 2018
Fluoride varnish is a covered service for participants age five and under, when the need is identified through an Early Periodic Screening, Diagnostic, and Treatment (EPSDT) visit. Fluoride varnish may be applied by physicians and nurse practitioners along with other medical professionals (RN, LPN, Physician Assistant) working in a physician’s office or clinic.Fluoride treatment is limited to 1 application of stannous fluoride, acid-phosphate fluoride or fluoride varnish per participant, 2 times per rolling year, per provider.
Training in the application of fluoride varnish is required in order for providers to bill MO HealthNet. Documentation to support their completed training must be retained by the medical office. This completed training documentation must be made available upon request by the MO HealthNet Division. Training is available on-line through the Department of Health and Senior Services, Division of Community and Public Health at http://health.mo.gov/blogs/psp/information-for-medical-professionals/.
Application of fluoride varnish should be billed on the CMS-1500 claim form or the appropriate electronic claim form. To bill MO HealthNet for fluoride varnish, enter the procedure code D1206 in Field 24.D on the CMS-1500 or the appropriate field on an electronic claim form.
Outpatient Hospital Billing Tips for 340B Providers
April 3, 2018
The submission of a National Drug Code (NDC) is not required for 340B providers on outpatient hospital claims; however, MO HealthNet prefers claims be submitted with a valid Healthcare Common Procedure Coding System (HCPCS) procedure code and a valid NDC. A valid NDC and/or a valid HCPCS procedure code (not a dump code) must be billed for each medication for MO HealthNet to identify drugs dispensed. For drugs without a valid HCPCS procedure code, revenue code 0250 "General Classification: Pharmacy” should be used with the appropriate NDC. A critical component to submitting claims with an NDC is to ensure that the appropriate HCPCS procedure code is billed with each NDC. To ensure accurate billing of drug charges, MHD will use the Noridian Crosswalk https://www.dmepdac.com/ to determine whether the appropriate HCPCS procedure code is billed for the submitted NDC. If the NDC submitted is not valid for the HCPCS procedure code submitted claims will deny.
Pharmacy Services for Participants with Presumptive Eligibility
February 26, 2018
The MO HealthNet Presumptive Eligibility Authorization (PE-3) form and the Show Me Healthy Babies Presumptive Eligibility (SMHB-PE) Authorization form serve as proof of presumptive eligibility. Pharmacy providers should check the dates of eligibility on the authorization form to determine if the presumptive eligibility period is active. Pharmacy providers should make a photocopy of the form and maintain the copy in the pharmacy files for documentation of eligibility.
MO HealthNet will reimburse any medication dispensed within the eligibility period shown on the form. Pharmacies may contact Pharmacy Administration at (573) 751-6963 if they have questions. For more information, please refer to Provider Bulletin on Presumptive Eligibility Authorization Notices.