MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION Medical Services Authorization Information Letter
Foster Youth Name:	Departmental Client Number:
Case Manager:	Telephone:
County Office or Private Agency:	Address: Date:
To the Medical Service Provider: The foster youth listed on this authorization letter is in the legal custody of the Missouri Department of Social Services Children’s Division. The foster youth has medical coverage with: MO HealthNet Division (MHD) (Medicaid on a fee for service basis), and/or A MO HealthNet Division/Managed Care (MHD/MC) health plan. The Missouri Department of Social Services will not pay for out-of-network and/or out-of-state services that have not received prior authorization from the MO HealthNet Division or the Managed Care health plan. Please refer to federal regulation 42 CFR §431.52, Payments for services furnished out of State If you are an enrolled provider with MO HealthNet Division, please submit the claim to MO HealthNet Division following standard procedure. If you are not an enrolled provider with MHD/MC but you are willing to work out of network with the State of Missouri’s Managed Care health plans, please refer to the contact information located on the back of the foster youth’s MO HealthNet identification card. If you are not an enrolled provider with MHD but you are willing to enroll with MHD for services rendered and agree to accept the MHD Fee-For-Service Program rate in effect at the time of service, please contact the Provider Enrollment Unit at https://peu.momed.com/peu//momed/presentation/commongui/PeHome.jsp Note: Managed Care health plans only cover emergency services when provided out of state. The Managed Care health plans will not cover any routine medical services provided out of state. If you require the resource parent to pay out of pocket for services rendered: Provide a letter to the resource parent stating that you will not bill MO HealthNet Division or the Managed Care health plan for the services rendered; and Please consider billing the resource parent the Medicaid rate for your state for any services rendered to the youth. The bearer of this letter is not authorized to execute authorization to approve payment for services for care or treatment on behalf of the State of Missouri, Department of Social Services, MO HealthNet Division or Children’s Division.