Missouri Behavioral Health Services Manual 2013

STATE OF MISSOURI
BEHAVIORAL HEALTH SERVICES MANUAL
Section 1 - Client Conditions of Participation
SECTION 1 - PARTICIPANT CONDITIONS OF PARTICIPATION

1.1 INDIVIDUALS ELIGIBLE FOR MO HEALTHNET, MANAGED CARE OR STATE FUNDED BENEFITS.........................................................................................................................5 1.1.A DESCRIPTION OF ELIGIBILITY CATEGORIES ................................................................5 MO HealthNet ..................................................................................................................5 MO HealthNet for Kids ...................................................................................................6 Temporary MO HealthNet During Pregnancy (TEMP) ..................................................8 Voluntary Placement Agreement for Children ................................................................8 State Funded MO HealthNet............................................................................................9 MO Rx .............................................................................................................................9 Womens Health Services ..............................................................................................10 ME Codes Not in Use ....................................................................................................10
1.1.A(1) 1.1.A(2) 1.1.A(3) 1.1.A(4) 1.1.A(5) 1.1.A(6) 1.1.A(7) 1.1.A(8)
1.2 MO HEALTHNET AND MO HEALTHNET MANAGED CARE ID CARD ..........................11 1.2.A 1.2.B 1.2.C FORMAT OF MO HEALTHNET ID CARD .........................................................................12 ACCESS TO ELIGIBILITY INFORMATION ......................................................................12 IDENTIFICATION OF PARTICIPANTS BY ELIGIBILITY CODES ................................12 MO HealthNet Participants ............................................................................................12 MO HealthNet Managed Care Participants ..................................................................12 TEMP .............................................................................................................................13 Temporary Medical Eligibility for Reinstated TANF Individuals ................................13 Presumptive Eligibility for Children..............................................................................13 Breast or Cervical Cancer Treatment Presumptive Eligibility ......................................14 Voluntary Placement Agreement ...................................................................................14
1.2.C(1) 1.2.C(2) 1.2.C(3) 1.2.C(4) 1.2.C(5) 1.2.C(6) 1.2.C(7) 1.2.D
THIRD PARTY INSURANCE COVERAGE ........................................................................14 Medicare Part A, Part B and Part C ...............................................................................14
1.2.D(1)
1.3 MO HEALTHNET, STATE FUNDED MEDICAL ASSISTANCE AND MO HEALTHNET MANAGED CARE APPLICATION PROCESS ................................................15 1.4 AUTOMATIC MO HEALTHNET ELIGIBILITY FOR NEWBORN CHILDREN ................15 1.4.A NEWBORN INELIGIBILITY ...............................................................................................16 1 Production - 04/30/2012
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1.4.B 1.4.C
NEWBORN ADOPTION.......................................................................................................17 MO HEALTHNET MANAGED CARE HEALTH PLAN NEWBORN ENROLLMENT ...17
1.5 PARTICIPANTS WITH RESTRICTED/LIMITED BENEFITS ...............................................18 1.5.A 1.5.B 1.5.C LIMITED BENEFIT PACKAGE FOR ADULT CATEGORIES OF ASSISTANCE ...........18 ADMINISTRATIVE PARTICIPANT LOCK-IN ..................................................................19 MO HEALTHNET MANAGED CARE PARTICIPANTS...................................................20 Home Birth Services for the MO HealthNet Managed Care Program ..........................21
1.5.C(1) 1.5.D 1.5.E 1.5.F 1.5.G 1.5.H
HOSPICE BENEFICIARIES .................................................................................................22 QUALIFIED MEDICARE BENEFICIARIES (QMB) ..........................................................23 CHILDREN'S HEALTH INSURANCE PROGRAM/MO HEALTHNET FOR KIDS .........24 WOMENS HEALTH SERVICES PROGRAM (ME CODES 80 AND 89) ...........................24 TEMP PARTICIPANTS ........................................................................................................25 TEMP ID Card ...............................................................................................................25 TEMP Service Restrictions ............................................................................................26 Full MO HealthNet Eligibility After TEMP ..................................................................26
1.5.H(1) 1.5.H(2) 1.5.H(3) 1.5.I 1.5.J
PROGRAM FOR ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) .......................27 MISSOURI'S BREAST AND CERVICAL CANCER TREATMENT (BCCT) ACT ...........27
1.5.J(1) Eligibility Criteria ..............................................................................................................28 1.5.J(2) Presumptive Eligibility ......................................................................................................28 1.5.J(3) Regular BCCT MO HealthNet...........................................................................................28 1.5.J(4) Termination of Coverage ...................................................................................................29 1.5.K TICKET TO WORK HEALTH ASSURANCE PROGRAM .................................................29 Disability ........................................................................................................................29 Employment ...................................................................................................................30 Premium Payment and Collection Process ....................................................................30 Termination of Coverage ...............................................................................................31
1.5.K(1) 1.5.K(2) 1.5.K(3) 1.5.K(4) 1.5.L
PRESUMPTIVE ELIGIBILITY FOR CHILDREN ...............................................................31 Eligibility Determination ...............................................................................................31 MO HealthNet for Kids Coverage .................................................................................32
1.5.L(1) 1.5.L(2) 1.5.M
MO HEALTHNET COVERAGE FOR INMATES OF A PUBLIC INSTITUTION .............32 2 Production - 04/30/2012
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1.5.M(1) 1.5.M(2) 1.5.N
MO HealthNet Coverage Not Available ........................................................................33 MO HealthNet Benefits .................................................................................................34
VOLUNTARY PLACEMENT AGREEMENT, OUT-OF- HOME CHILDREN'S SERVICES .............................................................................................................................34
1.5.N(1) 1.5.N(2) 1.5.N(3)
Duration of Voluntary Placement Agreement ...............................................................35 Covered Treatment and Medical Services .....................................................................35 Medical Planning for Out-of-Home Care ......................................................................35
1.6 ELIGIBILITY PERIODS FOR MO HEALTHNET PARTICIPANTS .....................................36 1.6.A 1.6.B DAY SPECIFIC ELIGIBILITY .............................................................................................37 SPENDDOWN .......................................................................................................................38 Notification of Spenddown Amount ..............................................................................38 Notification of Spenddown on New Approvals .............................................................39 Meeting Spenddown with Incurred Expenses................................................................39 Preventing MO HealthNet Payment of Expenses Used to Meet Spenddown ...............40 Spenddown Pay-In Option .............................................................................................40 Prior Quarter Coverage ..................................................................................................41 MO HealthNet Coverage End Dates ..............................................................................41
1.6.B(1) 1.6.B(2) 1.6.B(3) 1.6.B(4) 1.6.B(5) 1.6.B(6) 1.6.B(7) 1.6.C 1.6.D
PRIOR QUARTER COVERAGE ..........................................................................................42 EMERGENCY MEDICAL CARE FOR INELIGIBLE ALIENS ..........................................42
1.7 PARTICIPANT ELIGIBILITY LETTERS AND CLAIMS CORRESPONDENCE ...............43 1.7.A NEW APPROVAL LETTER .................................................................................................43 Eligibility Letter for Reinstated TANF (ME 81) Individuals ........................................44 BCCT Temporary MO HealthNet Authorization Letter ................................................44 Presumptive Eligibility for Children Authorization PC-2 Notice..................................44
1.7.A(1) 1.7.A(2) 1.7.A(3) 1.7.B 1.7.C 1.7.D 1.7.E 1.7.F
REPLACEMENT LETTER ...................................................................................................44 NOTICE OF CASE ACTION.................................................................................................45 PARTICIPANT EXPLANATION OF MO HEALTHNET BENEFITS ................................45 PRIOR AUTHORIZATION REQUEST DENIAL ................................................................45 PARTICIPANT SERVICES UNIT ADDRESS AND TELEPHONE NUMBER ..................46
1.8 TRANSPLANT PROGRAM ...........................................................................................................46 General Manual Production - 04/30/2012 3
1.8.A 1.8.B 1.8.C 1.8.D 1.8.E 1.8.F
COVERED ORGAN AND BONE MARROW/STEM CELL TRANSPLANTS ..................46 PATIENT SELECTION CRITERIA......................................................................................47 CORNEAL TRANSPLANTS ................................................................................................47 ELIGIBILITY REQUIREMENTS .........................................................................................47 MANAGED CARE PARTICIPANTS ...................................................................................48 MEDICARE COVERED TRANSPLANTS ..........................................................................48
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SECTION 1-PARTICIPANT CONDITIONS OF PARTICIPATION 1.1 INDIVIDUALS ELIGIBLE FOR MO HEALTHNET, MANAGED CARE OR STATE FUNDED BENEFITS
MO HealthNet benefits are available to individuals who are determined eligible by the local Family Support Division (FSD) office. Each eligibility group or category of assistance has its own eligibility determination criteria that must be met. Some eligibility groups or categories of assistance are subject to Day Specific Eligibility and some are not (refer to Section 1.6.A). 1.1.A DESCRIPTION OF ELIGIBILITY CATEGORIES
The following list includes a simple description and applicable ME codes for all categories of assistance: 1.1.A(1) ME CODE MO HealthNet DESCRIPTION
01, 04, 11, 12, 13, Elderly, blind and disabled individuals who 14, 15, 16 meet the MO HealthNet eligibility criteria in the community or a vendor facility; or receive a Missouri State Supplemental Conversion or Supplemental Nursing Care check. 03 Individuals who receive a Supplemental Aid to the Blind check or a Missouri State Supplemental check based on blindness. Individuals who do not qualify for a public assistance program but who meet the Qualified Medicare Beneficiary (QMB) eligibility criteria. Pregnant women who meet eligibility factors for the MO HealthNet for Pregnant Women Program. Individuals eligible for MO HealthNet under the Refugee Act of 1980 or the Refugee Education Assistance Act of 1980. 5 Production - 04/30/2012
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18, 43, 44, 45, 61
10, 19, 21, 24, 26
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23, 41 28, 49, 67 33, 34 81
Children in a Nursing Facility/ICF/MR. Children placed in foster residential care by DMH. homes or
Missouri Children with Developmental Disabilities (Sarah Jean Lopez) Waiver. Temporary medical eligibility code. Used for individuals reinstated to MHF for 3 months (January-March, 2001), due to loss of MO HealthNet coverage when their TANF cases closed between December 1, 1996 and February 29, 2000. Used for White v. Martin participants and used for BCCT. Women under age 65 determined eligible for MO HealthNet based on Breast or Cervical Cancer Treatment (BCCT) Presumptive Eligibility. Women under age 65 determined eligible for MO HealthNet based on Breast or Cervical Cancer Treatment (BCCT). Ticket to Work Health Assurance Program (TWHAP) participants--premium Ticket to Work Health Assurance Program (TWHAP) participants--non-premium MO HealthNet for Kids DESCRIPTION Eligible children under the age of 19 in MO HealthNet for Families (based on 7/96 AFDC criteria) and the eligible relative caring for the children including families eligible for Transitional MO HealthNet.
83
84
85 86
1.1.A(2) ME CODE 05, 06
60
Newborns (infants under age 1 born to a MO HealthNet or managed care participant). Coverage for non-CHIP children up to age 19 in families with income under the applicable poverty standard. Children in custody of the Department of Social Services (DSS) Children's Division who meet Federal Poverty Level (FPL) requirements and children in residential care or foster care under custody of the Division of Youth Services (DYS) or Juvenile Court who meet MO HealthNet for Kids non-CHIP criteria. Children who receive a federal adoption subsidy payment. Children's Health Insurance Program covers uninsured children under the age of 19 in families with gross income above the nonCHIP limits up to 150% of the FPL. (Also known as MO HealthNet for Kids.) Covers uninsured children under the age of 19 in families with gross income above 185% of the FPL. (Also known as MO HealthNet for Kids.) Covers uninsured children under the age of 19 in families with gross income above 225% of the FPL. (Also known as MO HealthNet for Kids.) Covers uninsured children under the age of 19 in families with gross income above 225% of the FPL up to 300% of the FPL. (Also known as MO HealthNet for Kids.) Families must pay a monthly premium. 7 Production - 04/30/2012
40, 62
07, 29, 30, 37, 38, 50, 63, 66, 68, 69, 70
36, 56 71, 72
73
74
75
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Children under the age of 19 determined to be presumptively eligible for benefits prior to having a formal eligibility determination completed.
NOTE: Providers should encourage pregnant women with an ME code of 71, 72, 73, 80 or 89 to apply for regular MO HealthNet. The advantage to the woman is the elimination of the copay requirement (ME code 80 and 89) or receipt of more services including Non-Emergency Medical Transportation (NEMT). The advantage to the provider is that under regular MO HealthNet the provider does not collect copay, nor is copay deducted from the reimbursement amount of the claim. 1.1.A(3) ME CODE 58 Temporary MO HealthNet During Pregnancy (TEMP) DESCRIPTION Pregnant women who qualify under the Presumptive Eligibility (TEMP) Program receive limited coverage for ambulatory prenatal care while they await the formal determination of MO HealthNet eligibility. Pregnant women who received benefits under the Presumptive Eligibility (TEMP) Program but did not qualify for regular MO HealthNet benefits after the formal determination. The eligibility period is from the date of the formal determination until the last day of the month of the TEMP card or shown on the TEMP letter. NOTE: Providers should encourage women with a TEMP card to apply for regular MO HealthNet. 1.1.A(4) ME CODE 88 Voluntary Placement Agreement for Children DESCRIPTION Children seventeen (17) years of age or younger in need of mental health treatment 8 Production - 04/30/2012
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whose parent, legal guardian or custodian has signed an out-of-home care Voluntary Placement Agreement (VPA) with the Department of Social Services (DSS) Children's Division. 1.1.A(5) ME CODE 02 08 State Funded MO HealthNet DESCRIPTION Individuals who receive a Blind Pension check. Children and youth under age 21 in DSS Children's Division foster homes or who are receiving state funded foster care. Children who are in the custody of the Division of Youth Services (DYS-GR) who do not meet MO HealthNet for Kids nonCHIP criteria. (NOTE: GR in this instance means general revenue as services are provided by all state funds. Services are not restricted.) Children who receive a state only adoption subsidy payment. Children who are in the custody of Juvenile Court who do not qualify for federally matched MO HealthNet under ME codes 30, 69 or 70. Children placed in residential care by their parents, if eligible for MO HealthNet on the date of placement. MO Rx DESCRIPTION Participants only have pharmacy Medicare Part D wrap-around benefits through the MoRx. 9 Production - 04/30/2012
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57 64
65
1.1.A(6) ME CODE 82
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1.1.A(7) ME CODE 80
Womens Health Services DESCRIPTION Uninsured women, ages 18 through 55, who do not qualify for other benefits, and lose their MO HealthNet for Pregnant Women eligibility 60 days after the birth of their child, will continue to be eligible for family planning and limited testing and treatment of Sexually Transmitted Diseases if the family income is at or below 185 percent of the Federal poverty level (FPL), and assets total less than $250,000, and who are not otherwise eligible for Medicaid, the Childrens Health Insurance Program (CHIP), Medicare, or health insurance coverage that provides family planning services. Womens Health Services Program provides family planning and limited testing and treatment of Sexually Transmitted Diseases to women, ages 18 through 55, who have family income at or below 185 percent of the Federal poverty level (FPL), and assets totaling less than $250,000, and who are not otherwise eligible for Medicaid, the Childrens Health Insurance Program (CHIP), Medicare, or health insurance coverage that provides family planning services. ME Codes Not in Use
89
1.1.A(8)
The following ME codes are not currently in use: 09, 17, 20, 22, 25, 27, 31, 32, 35, 39, 42, 46, 47, 48, 51, 53, 54, 76, 77, 78, 79
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1.2
MO HEALTHNET AND MO HEALTHNET MANAGED CARE ID CARD
The Department of Social Services issues a MO HealthNet ID card for each MO HealthNet or managed care eligible participant. For example, the eligible caretaker and each eligible child receives his/her own ID card. Providers must use the card that corresponds to each individual/child to verify eligibility and determine any other pertinent information applicable to the participant. Participants enrolled in a MO HealthNet managed health care plan also receive an ID card from the managed health care plan. (Refer to Section 1.2.C for a listing of MO HealthNet/MO HealthNet Managed Care Eligibility (ME) codes identifying which individuals are to receive services on a feefor-service basis and which individuals are eligible to enroll in a managed health care plan. An ID card does not show eligibility dates or any other information regarding restrictions of benefits or Third Party Resource (TPR) information. Providers must verify the participants eligibility status before rendering services as the ID card only contains the participants identifying information (ID number, name and date of birth). As stated on the card, holding the card does not certify eligibility or guarantee benefits. The local Family Support Division (FSD) office issues an approval letter for each individual or family at the time of approval to be used in lieu of the ID card until the permanent ID card can be mailed and received by the participant. The card should normally be received within a few days of the caseworkers action. Replacement letters are also furnished when a card has been lost, destroyed or stolen until an ID card is received in the mail. Providers may accept these letters to verify the participants ID number. The card carrier mailer notifies participants not to throw the card away as they will not receive a new ID card each month. The participant must keep the ID card for as long as the individual named on the card qualifies for MO HealthNet or managed care. Participants who are eligible as spenddown participants are encouraged to keep the ID card to use for subsequent spenddown periods. Replacement cards are issued whenever necessary as long as the participant remains eligible. Participants receive a new ID card within a few days of the caseworkers action under the following circumstances: The participant is determined eligible or regains eligibility; The participant has a name change; A file correction is made to a date of birth which was invalid at time of card issue; or The participant reports a card as lost, stolen or destroyed.
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1.2.A
FORMAT OF MO HEALTHNET ID CARD
The plastic MO HealthNet ID card will be red if issued prior to January 1, 2008 or white if issued on or after January 1, 2008. Each card contains the participants name, date of birth and MO HealthNet ID number. The reverse side of the card contains basic information and the Participant Services Hotline number. An ID card does not guarantee benefits. It is important that the provider always check eligibility and the MO HealthNet/Managed Care Eligibility (ME) code on file for the date of service. The ME code helps the provider know program benefits and limitations including copay requirements. 1.2.B ACCESS TO ELIGIBILITY INFORMATION
Providers must verify eligibility via the Internet or by using the interactive voice response (IVR) system by calling (576) 751-2896 and keying in the participant ID number shown on the face of the card. All MO HealthNet enrolled providers receive the Interactive Voice Response (IVR) System User Manual which provides instructions for making eligibility inquiries, and explains the different options available and the different responses received. Refer to Section 3 for information regarding the Internet and the IVR inquiry process. Participants may be subject to Day Specific Eligibility. Refer to Section 1.6.A for more information. 1.2.C IDENTIFICATION OF PARTICIPANTS BY ELIGIBILITY CODES 1.2.C(1) MO HealthNet Participants
The following ME codes identify people who get a MO HealthNet approval letter and MO HealthNet ID card: 01, 02, 03, 04, 11, 12, 13, 14, 15, 16, 23, 28, 33, 34, 41, 49, 55, 67, 83, 84 1.2.C(2) MO HealthNet Managed Care Participants
MO HealthNet Managed Care refers to: some adults and children who used to get a MO HealthNet ID card people eligible under the MO HealthNet for Kids (SCHIP) and the uninsured parent's program people enrolled in a MO HealthNet managed care health plan*
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The following ME codes identify people who get a MO HealthNet Managed Care health insurance approval letter and MO HealthNet Managed Care ID Card 05, 06, 07, 08, 10, 18, 19, 21, 24, 26, 29, 30, 36, 37, 40, 43, 44, 45, 50, 52, 56, 57, 60, 61, 62, 63, 64, 65, 66, 68, 69, 70, 71, 72, 73, 74, 75
*An individual may be eligible for managed care and not be in a MO HealthNet managed care health plan because they do not live in a managed care health plan area. Individuals enrolled in MO HealthNet Managed Care also get a MO HealthNet Managed Care health plan card issued by the managed care health plan. Refer to Section 11 for more information regarding Missouri's managed care program.
1.2.C(3)
TEMP
A pregnant woman who has not applied for MO HealthNet can get a white temporary MO HealthNet ID card. The TEMP card provides limited benefits during pregnancy. The following ME codes identify people who have TEMP eligibility: 58, 59 1.2.C(4) Temporary Medical Eligibility for Reinstated TANF Individuals
Individuals who stopped getting a Temporary Assistance for Needy Families (TANF) cash grant between December 1, 1996 and February 29, 2000 and lost their MO HealthNet/MO HealthNet Managed Care benefits had their medical benefits reinstated for three months from January 1, 2001 to March 31, 2001. ME code 81 identifies individuals who received an eligibility letter from the Family Support Division. These individuals are not enrolled in a MO HealthNet managed care health plan. 1.2.C(5) Presumptive Eligibility for Children
Children in families with income below 225% of the Federal Poverty Level (FPL) determined eligible for MO HealthNet benefits prior to having a formal eligibility determination completed by the Family Support Division (FSD) office. The families receive an MO HealthNet for Kids Presumptive Eligibility Authorization (PC-2) notice which includes the MO HealthNet for Kids number(s) and effective date of coverage. ME code 87 identifies children determined eligible for Presumptive Eligibility for Children.
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1.2.C(6)
Breast or Cervical Cancer Treatment Presumptive Eligibility
Women determined eligible by the Department of Health and Senior Services' Breast and Cervical Cancer Control Project (BCCCP) providers for benefits under the Breast or Cervical Cancer Treatment (BCCT) Presumptive Eligibility (PE) Program receive a BCCT Temporary MO HealthNet Authorization letter which provides for limited MO HealthNet benefits while they wait for a formal eligibility determination by the FSD. ME code 83 identifies women receiving benefits through BCCT PE. 1.2.C(7) Voluntary Placement Agreement
Children determined eligible for out-of-home care, per a signed Voluntary Placement Agreement (VPA), require medical planning and are eligible for a variety of children's treatment services, medical and psychiatric services. The Children's Division (CD) worker makes appropriate referrals to CD approved contractual treatment providers. Payment is made at the MO HealthNet or state contracted rates. ME code 88 identifies children receiving coverage under a VPA. 1.2.D THIRD PARTY INSURANCE COVERAGE
When the MO HealthNet Division (MHD) has information that the participant has third party insurance coverage, the insurance coverage code, relationship code and the full name and address of the third party coverage are identified. A provider must always bill the other insurance before billing MO HealthNet unless the service qualifies as an exception as specified in Section 5. For additional information, contact Provider Communications at (573) 751-2896 or the TPL Unit at (573) 751-2005. NOTE: The provider must always ask the participant if they have third party insurance regardless of information on the participant file. It is the providers responsibility to obtain from the participant the name and address of the insurance company, the policy number, policy holder and the type of coverage. See Section 5, Third Party Liability. 1.2.D(1) Medicare Part A, Part B and Part C
The eligibility file (IVR/Internet) provides an indicator if the MO HealthNet Division has information that the participant is eligible for Medicare Part A, Part B and/or Medicare Part C.
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NOTE: The provider must always ask the participant if they have Medicare coverage, regardless of information on the participant file. It is also important to identify the participants type of Medicare coverage. Part A provides for nursing home, inpatient hospital and certain home health benefits; Part B provides for medical insurance benefits; and Part C provides the services covered under Part A and Part B through a Medicare Advantage Plan (private companies approved by Medicare). When MO HealthNet is secondary to Medicare Part C, a crossover claim for coinsurance and deductible may be reimbursed for participants who have MO HealthNet QMB (reference Section 1.5.E). For non-QMB participants enrolled in a Medicare Advantage/Part C Plan, MO HealthNet secondary claims will process in accordance with the established MHD coordination of benefits policy (reference Section 5.1.A).
1.3
MO HEALTHNET, STATE FUNDED MEDICAL ASSISTANCE AND MO HEALTHNET MANAGED CARE APPLICATION PROCESS
If a patient who has not applied for MO HealthNet, state funded Medical Assistance or MO HealthNet Managed Care benefits is unable to pay for services rendered and appears to meet eligibility requirements, the provider should encourage the patient or the patients representative (related or unrelated) to apply for benefits through the Family Support Division in the patients county of residence. Applications for MO HealthNet Managed Care may be requested by phone by calling (888) 275-5908. The county office accepts and processes the application and notifies the patient of the resulting determination. Any individual authorized by the participant may make application for MO HealthNet Managed Care, MO HealthNet and other state funded Medical Assistance on behalf of the client. This includes staff members from hospital social service departments, employees of private organizations or companies, and any other individual designated by the client. Clients must authorize non-relative representatives to make application for them through the use of the IM Authorized Representative form. A supply of this form and instructions for completion may be obtained from the Family Support Division county office.
1.4
AUTOMATIC MO HEALTHNET ELIGIBILITY FOR NEWBORN CHILDREN
A child born to a woman who is eligible for and is receiving MO HealthNet or under a federally funded program on the date the child is born, is automatically eligible for MO HealthNet. Federally funded MO HealthNet programs that automatically cover newborn children are MO HealthNet for Families, Pregnant Women, Supplemental Nursing Care, Refugee, Supplemental Aid to the Blind, General Manual Production - 04/30/2012 15
Supplemental Payments, MO HealthNet for Children in Care, Children's Health Insurance Program, and Uninsured Parents. Coverage begins on the date of birth and extends through the date the child becomes one year of age as long as the mother remains continuously eligible for MO HealthNet or who would remain eligible if she were still pregnant and the child continues to live with the mother. Notification of the birth should be sent immediately by the mother, physician, nurse-midwife, hospital or managed care health plan to the Family Support Division office in the county in which the mother resides and should contain the following information: The mothers name and MO HealthNet or Managed Care ID number The childs name, birthdate, race, and sex Verification of birth. If the mother notifies the Family Support Division office of the birth, that office verifies the birth by contacting the hospital, attending physician, or nurse-midwife. The Family Support Division office assigns a MO HealthNet ID number to the child as quickly as possible and gives the ID number to the hospital, physician, or nurse-midwife. Family Support Division staff works out notification and verification procedures with local hospitals. The Family Support Division office explores the childs eligibility for other types of assistance beyond the newborn policy. However, the eligibility determination for another type of assistance does not delay or prevent the newborn from being added to the mothers case when the Family Support Division staff is notified of the birth. 1.4.A NEWBORN INELIGIBILITY
The automatic eligibility for newborns is not available in the following situations: The mother is eligible under the Blind Pension (state-funded) category of assistance. The mother has a pending application for assistance but is not receiving MO HealthNet at the time of the child's birth. The mother has TEMP eligibility, which is not considered regular MO HealthNet eligibility. If the mother has applied for and has been approved for a federally funded type of assistance at the time of the birth, however, the child is automatically eligible. MO HealthNet spenddown: if the mothers spenddown amount has not been met on the day of the childs birth, the child is not automatically eligible for MO HealthNet. If the mother has met her spenddown amount prior to or on the date of birth, the child is automatically eligible. Once the child is determined automatically eligible, they remain eligible, regardless of the mothers spenddown eligibility. General Manual Production - 04/30/2012 16
Emergency Medical Care for Ineligible Aliens: The delivery is covered for the mother, however the child is not automatically eligible. An application must be filed for the newborn for MO HealthNet coverage and must meet CHIP or non-CHIP eligibility requirements. Women covered by the Extended Women's Health Services Program. 1.4.B NEWBORN ADOPTION
MO HealthNet coverage for an infant whose birth mother intends to relinquish the child continues from birth until the time of relinquishment if the mother remains continuously eligible for MO HealthNet or would if still pregnant during the time that the child continues to live with the mother. This includes the time period in which the child is in the hospital, unless removed from mothers custody by court order. 1.4.C MO HEALTHNET MANAGED CARE HEALTH PLAN NEWBORN ENROLLMENT
The managed care health plan must have written policies and procedures for enrolling the newborn children of program members effective to the time of birth. Newborns of program eligible mothers who were enrolled at the time of the childs birth are automatically enrolled with the mothers managed care health plan. The managed care health plan should have a procedure in place to refer newborns to an enrollment counselor or Family Support Division to initiate eligibility determinations or enrollment procedures as appropriate. A mother of a newborn may choose a different managed care health plan for her child; unless a different managed care health plan is requested, the child remains with the mothers managed care health plan. Newborns are enrolled with the mothers managed care health plan unless a different managed care health plan is specified. The mothers managed care health plan shall be responsible for all medically necessary services provided under the standard benefit package to the newborn child of an enrolled mother. The childs date of birth shall be counted as day one. When the newborn is assigned an ID number, the managed care health plan shall provide services to the child until the child is disenrolled from the managed care health plan. The managed care health plan shall receive capitation payment for the month of birth and for all subsequent months the child remains enrolled with the managed care health plan. If there is an administrative lag in enrolling the newborn and costs are incurred during that period, it is essential that the participant be held harmless for those costs. The managed care health plan is responsible for the cost of the newborn. General Manual Production - 04/30/2012 17
1.5
PARTICIPANTS WITH RESTRICTED/LIMITED BENEFITS
Participants may have restricted or limited benefits, be subject to administrative lock-in, be managed care enrollees, be hospice beneficiaries or have other restrictions associated with their category of assistance. Participants with restrictions or limitations are identified on the Internet or on the IVR informational response. It is the providers responsibility to determine if the participant has restricted or limited coverage. Restrictions can be added, changed or deleted at any time during a month. The following information is furnished to assist providers to identify those participants who may have restricted/limited benefits. 1.5.A LIMITED BENEFIT PACKAGE FOR ADULT CATEGORIES OF ASSISTANCE
Senate Bill 539 was passed by the 93rd General Assembly and became effective August 28, 2005. Changes in MO HealthNet Program benefits were effective for dates of service on or after September 1, 2005. The bill eliminated certain optional MO HealthNet services for individuals age 21 and over that are eligible for MO HealthNet under one of the following categories of assistance: ME CODE 01 04 05 10 11 13 14 16 19 21 24 26 83 84 General Manual Production - 04/30/2012 DESCRIPTION MO HealthNet for the Aged Permanently and Totally Disabled (APTD) MO HealthNet for Families - Adult (ADC-AD) Vietnamese or Other Refugees (VIET) MO HealthNet - Old Age (MHD-OAA) MO HealthNet - Permanently and Totally Disabled (MHD-PTD) Supplemental Nursing Care - MO HealthNet for the Aged Supplemental Nursing Care - PTD (NC-PTD) Cuban Refugee Haitian Refugee Russian Jew Ethiopian Refugee Presumptive Eligibility - Breast or Cervical Cancer Treatment (BCCT) Regular Benefit - Breast or Cervical Cancer Treatment (BCCT) 18
85 86
Ticket to Work Health Assurance Program (TWHAP) --premium Ticket to Work Health Assurance Program (TWHAP) -- non-premium
MO HealthNet coverage for the following programs or services has been eliminated or reduced for adults with a limited benefit package. Providers should refer to Section 13 of the applicable provider manual for specific restrictions or guidelines. Comprehensive Day Rehabilitation Dental Services Diabetes Self-Management Training Services Hearing Aid Program Home Health Services Outpatient Therapy Physician Rehabilitation Services Podiatry Services NOTE: MO HealthNet participants residing in nursing homes are able to use their surplus to pay for federally mandated medically necessary services. This may be done by adjudicating claims through the MO HealthNet claims processing system to ensure best price, quality, and program integrity. MO HealthNet participants receiving home health services receive all federally mandated medically necessary services. MO HealthNet children and those in the assistance categories for pregnant women or blind participants are not affected by these changes. 1.5.B ADMINISTRATIVE PARTICIPANT LOCK-IN
Some MO HealthNet participants are restricted or locked-in to authorized MO HealthNet providers of certain services to help the participant use the MO HealthNet Program properly. When the participant has an administrative lock-in provider, the providers name and telephone number are identified on the Internet, IVR, or point of service terminal when verifying eligibility. Payment of services for a locked-in participant is not made to unauthorized providers for other than emergency services or authorized referral services. Emergency services are only considered for payment if the claim is supported by an attached Certificate of Medical Necessity and medical records documenting the emergency circumstances. When a physician is the designated/authorized provider, they are responsible for the participants primary care and for making necessary referrals to other providers as medically General Manual Production - 04/30/2012 19
indicated. When a referral is necessary, the authorized physician must complete a Medical Referral Form of Restricted Participant (PI-118) and send it to the provider to whom the participant is referred. This referral is good for 30 days only from the date of service. This form must be mailed or submitted via the Internet (Refer to Section 23) by the unauthorized provider. The Referred Service field should be completed on the claim form. These referral forms are available from Missouri Medicaid Audit and Compliance (MMAC) Provider Review, P.O. Box 6500, Jefferson City, Missouri 65102. If a participant presents an ID card that has administrative lock-in restrictions to other than the authorized provider and the service is not an emergency, an authorized referral, or if a provider feels that a participant is improperly using benefits, the provider is requested to notify MMAC Provider Review, P.O. Box 6500, Jefferson City, Missouri 65102. 1.5.C MO HEALTHNET MANAGED CARE PARTICIPANTS
Participants who are enrolled in MO HealthNet's Managed Care programs are identified on the Internet, IVR, or point of service terminal when verifying eligibility. The response received identifies the name and phone number of the participants selected managed care health plan. The response also includes the identity of the participants primary care provider in the managed care program areas. Participants who are eligible for MO HealthNet and who are enrolled with a managed care health plan must have their basic benefit services provided by or prior authorized by the managed care health plan. MO HealthNet Managed Care health plans may also issue their own individual health plan ID cards. The individual must be eligible for MO HealthNet and enrolled with the managed care health plan on the date of service for the managed care health plan to be responsible for services. MO HealthNet eligibility dates are different from managed care health plan enrollment dates. Managed care enrollment can be effective on any date in a month. Sometimes a participant may change managed care health plans and be in one managed care health plan for part of the month and another managed care health plan for the remainder of the month. Managed care health plan enrollment can be verified by the IVR/Internet. Providers must verify the eligibility status including the participant's ME code and managed care health plan enrollment status on all MO HealthNet participants before providing service. The following information is provided to assist providers in determining those participants who are eligible for inclusion in MO HealthNet Managed Care Programs. The participants who are eligible for inclusion in the health plan are divided into five groups.* Refer to Section 11 for a listing of included counties and the managed care benefits package.
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Group 1 and 2 have been combined and are referred to as Group 1. Group 1 generally consists of the MO HealthNet for Families population (both the caretaker and child[ren]), the children up to age 19 of families with income under the applicable poverty standard, Refugee MO HealthNet participants and pregnant women. NOTE: Previous policy stated that participants over age 65 were exempt from inclusion in managed care. There are a few individuals age 65 and over who are caretakers or refugees and who do not receive Medicare benefits and are therefore included in managed care. The following ME codes fall into Group 1: 05, 06, 10, 18, 19, 21, 24, 26, 40, 43, 44, 45, 60, 61 and 62. Group 3 previously consisting of General Relief participants has been deleted from inclusion in the managed care program at this time. Group 4 generally consists of those children in state care and custody. The following ME codes fall into this group: 07, 08, 29, 30, 36, 37, 38, 50, 52, 56, 57, 63, 64, 66, 68, 69, 70, and 88. Group 5 consists of uninsured children. The following ME codes for uninsured children are included in Group 5: 71, 72, 73, 74 and 75.
* Participants who are identified as eligible for inclusion in the managed care program are not enrolled with a managed care health plan until 15 days after they actually select or are assigned to a managed care health plan. When the selection or assignment is in effect, the name of the managed care health plan appears on the IVR/Internet information. If a managed care health plan name does not appear for a particular date of service, the participant is in a fee-for-service status for each date of service that a managed care health plan is not listed for the participant. "OPT" OUT POPULATIONS: The Department of Social Services is allowing participants, who are currently in the managed care program because they receive SSI disability payments, who meet the SSI disability definition as determined by the Department of Social Services, or who receive adoption subsidy benefits, the option of choosing to receive services on a fee-for-service basis or through the managed care program. The option is entirely up to the participant, parent or guardian.
1.5.C(1)
Home Birth Services for the MO HealthNet Managed Care Program
If a managed care health plan member elects a home birth, the member may be disenrolled from the managed care program at the request of the managed care health plan. The disenrolled member then receives all services through the fee-forservice program. The member remains disenrolled from the managed care health plan if eligible under the MO HealthNet for Pregnant Women category of assistance. If the member is not in the MO HealthNet for Pregnant Women category and is General Manual Production - 04/30/2012 21
disenrolled for the home birth, she is enrolled/re-enrolled in a managed care health plan six weeks post-partum or after a hospital discharge, whichever is later. The baby is enrolled in a managed care health plan once a managed care health plan number is assigned or after a hospital discharge, whichever is later. 1.5.D HOSPICE BENEFICIARIES
MO HealthNet or participants not enrolled with a managed care health plan who elect hospice care are identified as such on the Internet or IVR. The name and telephone number of the hospice provider is identified on the Internet or IVR. Hospice care is palliative not curative. It focuses on pain control, comfort, spiritual and emotional support for a terminally ill patient and his or her family. To receive MO HealthNet covered hospice services the participant must: be eligible for MO HealthNet on all dates of service; be certified by two physicians (M.D. or D.O.) as terminally ill and as having less than six months to live; elect hospice services and, if an adult, waive active treatment for the terminal illness; and obtain all services related to the terminal illness from a MO HealthNet-participating hospice provider, the attending physician, or through arrangements by the hospice. When a participant elects the hospice benefit, the hospice assumes the responsibility for managing the participant's medical care related to the terminal illness. The hospice provides or arranges for services reasonable and necessary for the palliation or management of the terminal illness and related conditions. This includes all care, supplies, equipment and medicines. Any provider, other than the attending physician, who provides care related to the terminal illness to a hospice participant, must contact the hospice to arrange for payment. MO HealthNet reimburses the hospice provider for covered services and the hospice reimburses the provider of the service(s). For adults age 21 and over, curative or active treatment of the terminal illness is not covered by the MO HealthNet Program while the patient is enrolled with a hospice. If the participant wishes to resume active treatment, they must revoke the hospice benefit for MO HealthNet to provide reimbursement of active treatment services. The hospice is reimbursed for the date of revocation. MO HealthNet does not provide reimbursement of active treatment until the day following the date of revocation. Children under the age of 21 may continue to receive curative treatment services while enrolled with a hospice. General Manual Production - 04/30/2012 22
Services not related to the terminal illness are available from any MO HealthNetparticipating provider of the participants choice. Claims for these services should be submitted directly to Wipro Infocrossing. Refer to the Hospice Manual, Section 13 for a detailed discussion of hospice services. 1.5.E QUALIFIED MEDICARE BENEFICIARIES (QMB)
To be considered a QMB an individual must: be entitled to Medicare Part A have an income of less than 100% of the Federal Poverty Level have resources of less than $4000 (or no more than $6000 if married) Participants who are eligible only as a Qualified Medicare Beneficiary (QMB) are eligible for reimbursement of their Medicare deductible and coinsurance amounts only for Medicare covered services whether or not the services are covered by MO HealthNet. QMB-only participants are not eligible for MO HealthNet services that are not generally covered by Medicare. QMB-only participants are identified with an ME code 55 when verifying eligibility. Some participants who are eligible for MO HealthNet covered services under the MO HealthNet or MO HealthNet spenddown categories of assistance may also be eligible as a QMB participant and are identified on the IVR/Internet by a QMB indicator Y. If the participant has a QMB indicator of Y and the ME code is not 55 the participant is also eligible for MO HealthNet services and not restricted to the QMB-only providers and services. QMB coverage includes the services of providers who by choice do not participate in the MO HealthNet Program and providers whose services are not currently covered by MO HealthNet but who are covered by Medicare, such as chiropractors and independent therapists. Providers who do not wish to enroll in the MO HealthNet Program for MO HealthNet participants and providers of Medicare-only covered services may enroll as QMBonly providers to be reimbursed for deductible, coinsurance, and copay amounts only for QMB eligibles. Providers who wish to be identified as QMB-only providers may contact the Provider Enrollment Unit via their e-mail address: mmac.providerenrollment@dss.mo.gov Providers who are enrolled with MO HealthNet as QMB-only providers need to ascertain a participants QMB status in order to receive reimbursement of the deductible and coinsurance amounts for QMB-only covered services.
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1.5.F
CHILDREN'S HEALTH INSURANCE PROGRAM/MO HEALTHNET FOR KIDS
Title XXI, of the Social Security Act, established the Children's Health Insurance Program (CHIP), to assist state efforts to provide health care coverage to uninsured, low-income children. This program is known as MO HealthNet for Kids regardless of whether services are provided through a managed care health plan or on a fee-for-service basis. Some families are required to pay a premium for coverage. The uninsured low-income children eligible for health coverage under Title XXI ME codes 71 and 72 receive all services. ME codes 73, 74 and 75 receive all services, except NonEmergency Medical Transportation (NEMT). All limits and prior authorization requirements of all programs and services apply when providing services. Refer to information in specific provider manuals regarding copay requirements. 1.5.G WOMENS HEALTH SERVICES PROGRAM (ME CODES 80 and 89)
The Womens Health Services Program provides family planning and family planningrelated services to low income women, ages 18 through 55, who are not otherwise eligible for Medicaid, the Childrens Health Insurance Program (CHIP), Medicare, or health insurance that provides family planning services. Women who have been sterilized are not eligible for the Womens Health Services Program. Women who are sterilized while participating in the Womens Health Services Program become ineligible 90 days from the date of sterilization. Services for ME codes 80 and 89 are limited to family planning and family planning-related services, and testing and treatment of Sexually Transmitted Diseases (STDs) which are provided in a family planning setting. Services include: approved methods of birth control including sterilization and x-ray services related to the sterilization family planning counseling and education on birth control options testing and treatment for Sexually Transmitted Diseases (STDs) pharmacy, including birth control devices & pills, and medication to treat STDs Pap Test and Pelvic Exams All services under the Womens Health Services Program must be billed with a primary diagnosis code within the range of V25 through V25.9.
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1.5.H
TEMP PARTICIPANTS
The purpose of the Temporary MO HealthNet During Pregnancy (TEMP) Program is to provide pregnant women with access to ambulatory prenatal care while they await the formal determination of MO HealthNet eligibility. Certain qualified providers, as determined by the Family Support Division, may issue TEMP cards. These providers have the responsibility for making limited eligibility determinations for their patients based on preliminary information that the patients family income does not exceed the applicable MO HealthNet for Pregnant Women income standard for a family of the same size. If the qualified provider makes an assessment that a pregnant woman is eligible for TEMP, the qualified provider issues her a white paper temporary ID card. The participant may then obtain ambulatory prenatal services from any MO HealthNet-enrolled provider. If the woman makes a formal application for MO HealthNet with the Family Support Division during the period of TEMP eligibility, her TEMP eligibility is extended while the application is pending. If application is not made, the TEMP eligibility ends in accordance with the date shown on the TEMP card. Infants born to mothers who are eligible under the TEMP Program are not automatically eligible for MO HealthNet benefits. Information regarding automatic MO HealthNet Eligibility for Newborn Children is addressed in this manual. Providers and participants can obtain the name of MO HealthNet enrolled Qualified Providers in their service area by contacting the local Family Support Division Office. Providers may call Provider Relations at (573) 751-2896 and participants may call Participant Services at (800) 392-2161 for questions regarding TEMP. 1.5.H(1) TEMP ID Card
Pregnant women who have been determined presumptively eligible for Temporary MO HealthNet During Pregnancy (TEMP) do not receive a plastic MO HealthNet ID card but receive a white paper TEMP card. A valid TEMP number begins with the letter "P" followed by seven (7) numeric digits. The 8-character temporary number should be entered in the appropriate field of the claim form until a permanent number is issued to the participant. The temporary number appearing on the claim form is converted to the participant's permanent MO HealthNet identification number during claims processing and the permanent number appears on the provider's Remittance Advice. Providers should note the new number and file future claims using the permanent number. A white paper TEMP card can be issued by qualified providers to pregnant women whom they presume to be eligible for MO HealthNet based on income guidelines. 25 Production - 04/30/2012
General Manual
A TEMP card is issued for a limited period but presumptive eligibility may be extended if the pregnant woman applies for public assistance at the county Family Support Division office. The TEMP card may only be used for ambulatory prenatal services. Because TEMP services are limited, providers should verify that the service to be provided is covered by the TEMP card. The start date (FROM) is the date the qualified provider issues the TEMP card, and coverage expires at midnight on the expiration date (THROUGH) shown. A TEMP replacement letter (IM-29 TEMP) may also be issued when the TEMP individual has formally applied for MO HealthNet and is awaiting eligibility determination. Third party insurance information does not appear on a TEMP card. 1.5.H(2) TEMP Service Restrictions
TEMP services for pregnant women are limited to ambulatory prenatal services (physician, clinic, nurse midwife, diagnostic laboratory, x-ray, pharmacy, and outpatient hospital services). Risk Appraisals and Case Management Services are covered under the TEMP Program. Services other than those listed above (i.e. dental, ambulance, home health, durable medical equipment, CRNA, or psychiatric services) may be covered with a Certificate of Medical Necessity in the provider's file that testifies that the pregnancy would have been adversely affected without the service. Proof of medical necessity must be retained in the patients file and be available upon request by the MO HealthNet Division. Inpatient services, including miscarriage or delivery, are not covered for TEMP participants. Other noncovered services for TEMP participants include; global prenatal care, postpartum care, contraceptive management, dilation and curettage and treatment of spontaneous/missed abortions or other abortions. 1.5.H(3) Full MO HealthNet Eligibility After TEMP
General Manual
A TEMP participant may apply for full MO HealthNet coverage and be determined eligible for the complete range of MO HealthNet-covered services. Regular MO HealthNet coverage may be backdated and may or may not overlap the entire TEMP eligibility period. Approved participants receive an approval letter that shows their eligibility and type of assistance coverage. These participants also receive an ID card within a few days of approval. The services that are not covered under the TEMP Program may be resubmitted under the new type of assistance using the participant's MO HealthNet identification number instead of the TEMP number. The resubmitted claims are then processed without TEMP restrictions for the dates of service that were not included under the TEMP period of eligibility. 26 Production - 04/30/2012
1.5.I
PROGRAM FOR ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE)
Missouri and the Centers for Medicare & Medicaid (CMS) have entered into a three-way program agreement with Alexian Brothers Community Services (ABCS) of St. Louis. PACE is an integrated service system that includes primary care, restorative therapy, transportation, home health care, inpatient acute care, and even long-term care in a nursing facility when home and community-based services are no longer appropriate. Services are provided in the PACE center, the home, or the hospital, depending upon the needs of the individual. Refer to Section 11.11.E. The target population for this program includes individuals age 55 and older, who are identified by the Missouri Department of Health and Senior Services, Division of Senior Services and Regulation through a health status assessment with specific types of eligibility categories and at least 24 points on the nursing home level of care assessment. These targeted individuals must reside in the St. Louis area within specific zip codes. Refer to Section 11.11.A. Lock-in information is available to providers through the Internet or Interactive Voice Response (IVR). Enrollment in a PACE program is always voluntary and participants have the option to disenroll and return to the fee-for-service system at any time. Refer to Section 11.11.D. 1.5.J MISSOURI'S BREAST AND CERVICAL CANCER TREATMENT (BCCT) ACT
The Breast and Cervical Cancer Mortality Prevention Act of 1990 (Public Law: 101-354) established the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), to reduce the morbidity and mortality rates of breast and cervical cancers. The NBCCEDP provides grants to states to carry out activities aimed at early screenings and detection of breast and/or cervical cancer, case management services, education and quality assurance. The Missouri Department of Health and Senior Services, Division of Chronic Disease Prevention and Health Promotion's grant application was approved by the Centers for Disease Control and Prevention (CDC) to provide funding to establish the Missouri Breast and Cervical Cancer Control Project (BCCCP), known as Show Me Healthy Women. Matching funds were approved by the Missouri legislation to support breast and cervical cancer screening and education for low-income Missouri women through the Show Me Healthy Women project. Additional federal legislation was signed allowing funded programs in the NBCCEDP to participate in a new program with the MO HealthNet Breast and Cervical Cancer Treatment (BCCT) Act. State legislation authorized matching funds for Missouri to participate. 27 Production - 04/30/2012
General Manual
Most women who are eligible for Show Me Healthy Women, receive a Show Me Healthy Women-paid screening and/or diagnostic service and are found to need treatment for either breast and/or cervical cancer, are eligible for MO HealthNet coverage. For more information, providers may reference the Show Me Healthy Women Provider Manual at http://www.dhss.mo.gov/BreastCervCancer/providerlist.pdf . 1.5.J(1) Eligibility Criteria
To qualify for MO HealthNet based on the need for BCCT, all of the following eligibility criteria must be met: Screened by a Missouri BCCCP Provider; Need for treatment for breast or cervical cancer including certain precancerous conditions; Under the age of 65 years old; Have a Social Security Number; Citizenship or eligible non-citizen status; Uninsured (or have health coverage that does not cover breast or cervical cancer treatment); A Missouri Resident. 1.5.J(2) Presumptive Eligibility
Presumptive Eligibility (PE) determinations are made by BCCCP MO HealthNet providers. When a BCCCP provider determines a woman is eligible for PE coverage, a BCCT Temporary MO HealthNet Authorization letter is issued and provides for temporary, limited MO HealthNet benefits. A MO HealthNet ID Card is issued and should be received in approximately five days. MO HealthNet coverage under PE begins on the date the BCCCP provider determines the woman is in need of treatment. This allows for minimal delays for women in receiving the necessary treatment. Women receiving coverage under Presumptive Eligibility are assigned ME code 83. PE coverage continues until the last day of the month that the regular MO HealthNet application is approved or BCCT is no longer required, whichever is later. 1.5.J(3) Regular BCCT MO HealthNet
The BCCT MO HealthNet Application must be completed by the PE eligible client and forwarded as soon as possible to a managed care Service Center or the local Family Support Division office to determine eligibility for regular BCCT MO General Manual Production - 04/30/2012 28
HealthNet benefits. The PE eligible client receives information from MO HealthNet for the specific services covered. Limited MO HealthNet benefits coverage under regular BCCT begins the first day of the month of application, if the woman meets all eligibility requirements. Prior quarter coverage can also be approved, if the woman was eligible. Coverage cannot begin prior to the month the BCCCP screening occurred. No coverage can begin prior to August 28, 2001 (although the qualifying screening may have occurred prior to August 28, 2001). MO HealthNet benefits are discontinued when the treating physician determines the client no longer needs treatment for the diagnosed condition or if MO HealthNet denies the BCCT application. Women approved for Regular BCCT MO HealthNet benefits are assigned ME code 84. 1.5.J(4) Termination of Coverage
MO HealthNet coverage is date-specific for BCCT cases. A date-specific termination can take effect in the future, up to the last day of the month following the month of the closing action. 1.5.K TICKET TO WORK HEALTH ASSURANCE PROGRAM
Implemented August 28, 2007, the Ticket to Work Health Assurance Program (TWHAP) eligibility groups were authorized by the federal Ticket to Work and Work Incentives Improvement Act of 1999 (Public Law 106-170) and Missouri Senate Bill 577 (2007). TWHAP is for individuals who have earnings and are determined to be permanently and totally disabled or would be except for earnings. They have the same MO HealthNet fee-forservice benefits package and cost sharing as the Medical Assistance for the Permanently and Totally Disabled (ME code 13). An age limitation, 16 through 64, applies. The gross income ceiling for this program is 300% of the Federal Poverty Level (FPL) for an individual or a Couple. Premiums are charged on a sliding scale based on gross income between 101% 300% FPL. Additional income and asset disregards apply for MO HealthNet. Proof of employment/self-employment is required. Eligible individuals are enrolled with ME code 85 for premium and ME code 86 for non-premium. Eligibility for the Ticket to Work Health Assurance Program is determined by the Family Support Division. 1.5.K(1) Disability
An individual must meet the definition of Permanent and Total Disability. The definition is the same as for Medical Assistance (MA), except earnings of the individual are not considered in the disability determination.
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1.5.K(2)
Employment
An individual and/or spouse must have earnings from employment or selfemployment. There is no minimum level of employment or earnings required. The maximum is gross income allowed is 250% of the federal poverty level, excluding any earned income of the worker with a disability between 250 and 300% of the federal poverty level. "Gross income" includes all income of the person and the person's spouse. Individuals with gross incomes in excess of 100% of the federal poverty level shall pay a premium for participation. 1.5.K(3) Premium Payment and Collection Process
An individual whose computed gross income exceeds 100%, but is not more than 300%, of the FPL must pay a monthly premium to participate in TWHAP. TWHAP premium amounts are based on a formula specified by State statute. On new approvals, individuals in the premium group must select the beginning date of coverage, which may be as early as the first month of the prior quarter (if otherwise applicable) but no later than the month following approval. If an individual is not in the premium group, coverage begins on the first day of the first month the client is eligible. Upon approval by Family Support Division, the MO HealthNet Division (MHD) sends an initial Invoice letter, billing the individual for the premium amount for any past coverage selected through the month following approval. Coverage does not begin until the premium payment is received. If the individual does not send in the complete amount, the individual is credited for any full month premium amount received starting with the month after approval and going back as far as the amount of premium paid allows. Thereafter, MHD sends a Recurring Invoice on the second working day of each month for the next month's premium. If the premium is not received prior to the beginning of the new month, the individual's coverage ends on the day of the last paid month. MHD sends a Final Recurring Invoice after the individual has not paid for three consecutive months. It is sent in place of the Recurring Invoice, on the second working day of the month for the next month's premium. The Final Recurring Invoice notifies the individual that the case will be closed if a payment is not received by the end of the month.
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MHD collects the premiums as they do for the Medical Assistance (MA) Spenddown Program and the managed care program. 1.5.K(4) Termination of Coverage
MO HealthNet coverage end dates are the same as for the Medical Assistance Program. TWHAP non-premium case end dates are date-specific. TWHAP premium case end dates are not date-specific. 1.5.L PRESUMPTIVE ELIGIBILITY FOR CHILDREN
The Balanced Budget Act of 1997 (The Act) created Section 1920A of the Social Security Act which gives states the option of providing a period of presumptive eligibility to children when a qualified entity determines their family income is below the state's applicable MO HealthNet or SCHIP limit. This allows these children to receive medical care before they have formally applied for MO HealthNet for Kids. Missouri selected this option and effective March 10, 2003, children under the age of 19 may be determined eligible for benefits on a temporary basis prior to having a formal eligibility determination completed. Presumptive eligible children are identified by ME code 87. These children receive the full range of MO HealthNet for Kids covered services subject to the benefits and limitations specified in each MO HealthNet provider manual. These children are NOT enrolled in managed care health plans but receive all services on a fee-for-service basis as long as they are eligible under ME code 87. 1.5.L(1) Eligibility Determination
The Act allows states to determine what type of Qualified Entities to use for Presumptive Eligibility determinations. Currently, Missouri is limiting qualified entities to children's hospitals. Designated staff of qualified entities make Presumptive Eligibility determinations for children by determining the family meets the income guidelines and contacting the MO HealthNet for Kids Phone Centers to obtain a MO HealthNet number. The family is then provided with a MO HealthNet Presumptive Eligibility Authorization (PC-2) notice that includes the MO HealthNet number and effective date of coverage. This notice guarantees a minimum of five days of coverage with day one being the beginning date. After the five days, providers must check eligibility as for any client. Coverage for each child under ME code 87 continues until the last day of the second month of Presumptive Eligibility, unless the Family Support Division determines eligibility or ineligibility for MO HealthNet for Kids prior to that day. Presumptive Eligibility
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coverage ends on the date the child is approved or rejected for a regular MO HealthNet Program. Presumptive Eligibility is limited to one period during a rolling 12 month period. Qualified entities making temporary eligibility determinations for children facilitate a formal application for MO HealthNet for Kids. Children who are then determined by the Family Support Division to be eligible for MO HealthNet for Kids are placed in the appropriate MO HealthNet eligibility category (ME code), and are subsequently enrolled with a MO HealthNet Managed Care health plan if residing in a managed care health plan area and under ME codes enrolled with managed care health plans. 1.5.L(2) MO HealthNet for Kids Coverage
Children determined presumptively eligible for MO HealthNet for Kids receive the same coverage during the presumptive period. The children active under Presumptive Eligibility for Children are not enrolled in managed care. While the children must obtain their presumptive determination from a Qualified Entity (QE), once eligible, they can obtain covered services from any enrolled MO HealthNet fee-for-service provider. Coverage begins on the date the QE makes the presumptive eligibility determination and coverage ends on the later of: the 5th day after the Presumptive Eligibility for Children determination date; the day a MO HealthNet for Kids application is approved or rejected; or if no MO HealthNet for Kids application is made, the last date of the month following the month of the presumptive eligibility determination. A presumptive eligibility period has no effect on the beginning eligibility date of regular MO HealthNet for Kids coverage. Prior quarter coverage may be approved. In many cases the MO HealthNet for Kids begin dates may be prior to the begin date of the presumptive eligibility period. 1.5.M MO HEALTHNET COVERAGE FOR INMATES OF A PUBLIC INSTITUTION
Changes to eligibility requirements may allow incarcerated individuals (both juveniles and adults), who leave the public institution to enter a medical institution or individuals who are under house arrest, to be determined eligible for temporary MO HealthNet coverage. Admittance as an inpatient in a hospital, nursing facility, juvenile psychiatric facility or intermediate care facility interrupts or terminates the inmate status. Upon an inmate's admittance, the Family Support Division office in the county in which the penal institution is General Manual Production - 04/30/2012 32
located may take the appropriate type of application for MO HealthNet benefits. The individual, a relative, an authorized representative, or penal institution designee may initiate the application. When determining eligibility for these individuals, the county Family Support Division office considers all specific eligibility groups, including children, pregnant women, and elderly, blind or disabled, to determine if the individual meets all eligibility factors of the program for which they are qualifying. Although confined to a public institution, these individuals may have income and resources available to them. If an individual is ineligible for MO HealthNet, the application is rejected immediately and the appropriate rejection notice is sent to the individual. MO HealthNet eligibility is limited to the days in which the individual was an inpatient in the medical institution. Once the individual returns to the penal institution, the county Family Support Division office verifies the actual inpatient dates in the medical institution and determines the period of MO HealthNet eligibility. Appropriate notification is sent to the individual. The approval notice includes the individual's specific eligibility dates and a statement that they are not currently eligible for MO HealthNet because of their status as an inmate in a public institution. Some individuals may require admittance into a long term care facility. If determined eligible, the period of MO HealthNet eligibility is based on the length of inpatient stay in the long term care facility. Appropriate MO HealthNet eligibility notification is sent to the individual. 1.5.M(1) MO HealthNet Coverage Not Available
Eligibility for MO HealthNet coverage does not exist when the individual is an inmate and when the facility in which the individual is residing is a public institution. An individual is an inmate when serving time for a criminal offense or confined involuntarily to a state or federal prison, jail, detention facility or other penal facility. An individual voluntarily residing in a public institution is not an inmate. A facility is a public institution when it is under the responsibility of a government unit, or a government unit exercises administrative control over the facility. MO HealthNet coverage is not available for individuals in the following situations: Individuals (including juveniles) who are being held involuntarily in detention centers awaiting trial;
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Inmates involuntarily residing at a wilderness camp under governmental control; Inmates involuntarily residing in half-way houses under governmental control; Inmates receiving care on the premises of a prison, jail, detention center, or other penal setting; or Inmates treated as outpatients in medical institutions, clinics or physician offices. 1.5.M(2) MO HealthNet Benefits
If determined eligible by the county Family Support Division office, full or limited MO HealthNet benefits may be available to individuals residing in or under the control of a penal institution in any of the following circumstances: Infants living with the inmate in the public institution; Paroled individuals; Individuals on probation; Individuals on home release (except when reporting to a public institution for overnight stay); or Individuals living voluntarily in a detention center, jail or county penal facility after their case has been adjudicated and other living arrangements are being made for them (for example, transfer to a community residence). All specific eligibility groups, including children, pregnant women, and elderly, blind or disabled are considered to determine if the individual meets all eligibility factors of the program for which they are applying. 1.5.N VOLUNTARY PLACEMENT AGREEMENT, OUT-OF- HOME CHILDREN'S SERVICES
With the 2004 passage of House Bill 1453, the Voluntary Placement Agreement (VPA) was introduced and established in statute. The VPA is predicated upon the belief that no parent should have to relinquish custody of a child solely in order to access clinically indicated mental health services. This is a written agreement between the Department of Social Services (DSS)/Children's Division (CD) and a parent, legal guardian, or custodian of a child under the age of eighteen (18) solely in need of mental health treatment. A VPA developed pursuant to a Department of Mental Health (DMH) assessment and certification of appropriateness authorizes the DSS/CD to administer the placement and out-of-home care for General Manual Production - 04/30/2012 34
a child while the parent, legal guardian, or custodian of the child retains legal custody. The VPA requires the commitment of a parent to be an active participant in his/her child's treatment 1.5.N(1) Duration of Voluntary Placement Agreement
The duration of the VPA may be for as short a period as the parties agree is in the best interests of the child, but under no circumstances shall the total period of time that a child remains in care under a VPA exceed 180 days. Subsequent agreements may be entered into, but the total period of placement under a single VPA or series of VPAs shall not exceed 180 days without express authorization of the Director of the Children's Division or his/her designee. 1.5.N(2) Covered Treatment and Medical Services
Children determined eligible for out-of-home care, (ME88), per a signed VPA, are eligible for a variety of children's treatment services, medical and psychiatric services. The CD worker makes the appropriate referrals to CD approved contractual treatment providers. Payment is made at the MO HealthNet or state contracted rates. Providers should contact the local CD staff for payment information. 1.5.N(3) Medical Planning for Out-of-Home Care
Medical planning for children in out-of-home care is a necessary service to ensure that children receive the needed medical care. The following includes several medical service alternatives for which planning is necessary: Routine Medical/Dental Care; Human Immunodeficiency Virus (HIV) Screening; Emergency and Extraordinary Medical/Dental Care (over $500.00); Children's Treatment Services; Medical/Dental Services Program; Bureau for Children with Special Health Care Needs; Department of Mental Health Services; Residential Care; Private Psychiatric Hospital Placement; or Medical Foster Care. 35 Production - 04/30/2012
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1.6
ELIGIBILITY PERIODS FOR MO HEALTHNET PARTICIPANTS
Most participants are eligible for coverage of their services on a fee-for-service basis for those retroactive periods of eligibility from the first of the month of application until approval, or until the effective date of their enrollment in a MO HealthNet managed care health plan. This is often referred to as the period of backdated eligibility. Eligibility for MO HealthNet participants (except ME codes 71, 72, 73, 74, 75 and 89) is from the first day of the month of application through the last day of each subsequent month for which they are eligible unless the individual is subject to the provisions of Day Specific Eligibility. Some MO HealthNet participants may also request and be approved for prior quarter coverage. Participants with ME codes 71, 72 and 89 are eligible for MO HealthNet benefits from the first day of the month of application and are subject to the provisions of Day Specific Eligibility. Codes 71 and 72 are eligible from date of application. Code 80 is Extended Women's Health Care and eligibility begins the beginning of the month following the 60 day post partum coverage period for MPW (if not insured). MO HealthNet for Kids participants with ME codes 73, 74, and 75 who must pay a premium for coverage are eligible the later of 30 days after the date of application or the date the premium is paid. Participants with an ME code 75 are not subject to the provisions of Day Specific Eligibility. The 30 day waiting period does not apply to children with special health care needs. Codes 73 and 74 are eligible on the date of application or date premium is paid, whichever is later. Code 75 is eligible for coverage the later of 30 days after date of application or date premium is paid. All three codes are subject to day specific eligibility (coverage ends date case/eligibility is closed). MO HealthNet participants with ME code 83 are eligible for coverage beginning on the day the BCCCP provider determines the woman is in need of treatment for breast or cervical cancer. Presumptive Eligibility coverage continues until the last day of the month that the regular MO HealthNet application is approved or BCCT is no longer required, whichever is last. MO HealthNet participants with ME code 84 are eligible for coverage beginning the 1st day of the month of application. Prior quarter coverage may also be approved, if the woman is eligible. Coverage cannot begin prior to the month the BCCCP screening occurred. No coverage can begin prior to August 28, 2001. MO HealthNet children with ME code 87 are eligible for coverage during the presumptive period (fee-for-service only). Coverage begins on the date of the presumptive eligibility determination and ends on the later of 5th day after the eligibility determination or the day a MO HealthNet for Kids application is approved or rejected or if no MO HealthNet for Kids application is made, the last day of the month following the month of the presumptive eligibility determination.
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For those participants who reside in an MO HealthNet managed care county and are approved for a category of assistance included in MO HealthNet managed care, the reimbursement is fee-forservice or covered services for the period from the date of eligibility until enrollment in a managed care health plan. Once a participant has been notified they are eligible for assistance, they have 15 days to select a managed care health plan or have a managed care health plan assigned for them. After they have selected the managed care health plan, they are not actually enrolled in the managed care health plan for another 15 days. The ID Card is mailed out within a few days of the caseworkers eligibility approval. Participants may begin to use the ID Card when it is received. Providers should honor the approval/replacement/case action letter until a new card is received. MO HealthNet and managed care participants should begin using their new ID Card when it is received. 1.6.A DAY SPECIFIC ELIGIBILITY
Certain MO HealthNet participants are subject to the provisions of Day Specific Eligibility. This means that some MO HealthNet participants lose eligibility at the time of case closure, which may be anytime in the month. Prior to implementation of Day Specific Eligibility participants in all categories of assistance retained eligibility through the last date of the month if they were eligible on the first of the month. As of January 1, 1997, this varies for certain MO HealthNet participants. As with all MO HealthNet services, the participant must be eligible on the date of service. When the participant is in a Day Specific Eligibility category of assistance, the provider is not able to check eligibility on the Internet or IVR for a future date during the current month of eligibility. In order to convey to a provider that a participants eligibility is day specific, the MO HealthNet Division provides a verbal message on the IVR system. The Internet also advises of day specific eligibility. Immediately following the current statement, The participant is eligible for service on MONTH, DAY, YEAR through MONTH, DAY, YEAR with a medical eligibility code of XX, the IVR says, This participant is subject to day specific eligibility. The Internet gives this information in the same way as the IVR. If neither the Internet or IVR contains a message that the participant is subject to day specific eligibility, the participants eligibility continues through the last day of the current month. Providers are able to check eligibility for future dates for the participants who are not subject to day specific eligibility. It is important to note that the message regarding day specific eligibility is only a reminder to providers that the participants type of assistance is such that should his/her eligibility end, it 37 General Manual Production - 04/30/2012
may be at any time during that month. The Internet and IVR will verify the participants eligibility in the usual manner. Providers must also continue to check for managed care health plan enrollment for those participants whose ME codes and county are included in managed care health plan enrollment areas, because participants enrollment or end dates can occur any date in the month. 1.6.B SPENDDOWN
In the MO HealthNet for the Aged, Blind, and Disabled (MHABD) Program some individuals are eligible for MO HealthNet benefits only on the basis of meeting a periodic spenddown requirement. Effective October 1, 2002, eligibility for MHABD spenddown is computed on a monthly basis. If the individual is eligible for MHABD on a spenddown basis, MO HealthNet coverage for the month begins with the date on which the spenddown is met and ends on the last day of that month when using medical expenses to meet spenddown. MO HealthNet coverage begins and ends without the case closing at the end of the monthly spenddown period. The MO HealthNet system prevents payment of medical services used to meet an individual's spenddown amount. The individual may choose to meet their spenddown by either of the following options: submitting incurred medical expenses to their Family Support Division (FSD) caseworker; or paying the monthly spenddown amount to the MO HealthNet Division (MHD). Individuals have the option of changing the method in which their spenddown is met each month. A choice is made to either send the payment to MHD or to send bills to the FSD caseworker. For those months that the individual does not pay-in or submit bills, no coverage is available. 1.6.B(1) Notification of Spenddown Amount
MHD mails a monthly invoice to active spenddown cases on the second working day of each month. The invoice is for the next month's spenddown amount. The invoice gives the participant the option of paying in the spenddown amount to MHD or submitting bills to FSD. The invoice instructs the participant to call the MHD Premium Collections Unit at 1 (877) 888-2811 for questions about a payment. MHD stops mailing monthly invoices if the participant does not meet the spenddown for 6 consecutive months. MHD resumes mailing invoices the month 38 Production - 04/30/2012
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following the month in which the participant meets spenddown by bills or pay-in for the current month or past months. 1.6.B(2) Notification of Spenddown on New Approvals
On new approvals, the FSD caseworker must send an approval letter notifying the participant of approval for spenddown, but MO HealthNet coverage does not begin until the spenddown is met. The letter informs the participant of the spenddown amount and the months for which coverage may be available once spenddown is met. If the caseworker has already received bills to meet spenddown for some of the months, the letter includes the dates of coverage for those months. MHD sends separate invoices for the month of approval and the month following approval. These invoices are sent on the day after the approval decision. Notification of the spenddown amount for the months prior to approval is only sent by the FSD caseworker. 1.6.B(3) Meeting Spenddown with Incurred Expenses
If the participant chooses to meet spenddown for a month using incurred medical expenses, MO HealthNet coverage begins on the date the incurred expenses equal the spenddown amount. The bills do not have to have been paid. In order to determine whether or not the participant has met spenddown, the FSD caseworker counts the full amount of the valid medical expenses the participant incurred to establish eligibility for spenddown coverage. The caseworker does not try to estimate amounts, or deduct estimated amounts, to be paid by the participant's insurance from the amount of an incurred expenses. The QMB Program provides MO HealthNet payment of the Medicare premium, and coinsurance and deductibles for all Medicare covered services. Therefore, the cost of Medicare covered services cannot be used to meet spenddown for participants approved for QMB. Upon receipt of verification that spenddown has been met with incurred expenses for a month, FSD sends a Notification of Spenddown Coverage letter to inform the participant spenddown was met with the incurred expenses. The letter informs the participant of the MO HealthNet start date and the amount of spenddown met on the start date.
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1.6.B(4)
Preventing MO HealthNet Payment of Expenses Used to Meet Spenddown
On spenddown cases, MO HealthNet only reimburses providers for covered medical expenses that exceed a participant's spenddown amount. MO HealthNet does not pay the portion of a bill used to meet the spenddown. To prevent MO HealthNet from paying for an expense used to meet spenddown, MHD withholds the client liability amount of spenddown met on the first day of coverage for a month. The MHD system tracks the bills received for the first day of coverage until the bills equal the participant's remaining spenddown liability. For the first day of coverage, MHD denies or splits (partially pays) the claims until the participant's liability for that first day is reduced to zero. After MHD has reduced the liability to zero for the first day of coverage, other claims submitted for that day of spenddown coverage are paid up to the MO HealthNet rate. Claims for all other days of spenddown coverage process in the same manner as those of non-spenddown participants. MHD notifies both the provider and the participant of any claim amount not paid due to the bill having been used to meet spenddown. When a participant has multiple expenses on the day spenddown is met and the total expenses exceed the remaining spenddown, the liability amount may be withheld from the wrong claim. This can occur if Provider A submits a claim to MHD and Provider B does not (either because the bill was paid or it was a non-MO HealthNet covered service). Since the MHD system can only withhold the participant liability from claims submitted, the liability amount is deducted from the bill of the Provider A. Provider B's bill may have been enough to reduce the liability to zero, which would have allowed MO HealthNet to pay for Provider A's claim. MHD Participants Services Unit authorizes payment of the submitted claim upon receipt of verification of other expenses for the day which reduced the liability to zero. The Participant Services Unit may request documentation from the case record of bills FSD used to meet spenddown on the day it was met. 1.6.B(5) Spenddown Pay-In Option
The pay-in option allows participants to meet spenddown requirements by making a monthly payment of the spenddown amount to MHD. Participants who choose to pay-in may pay by sending a check (or money order) each month to MHD or having the spenddown amount automatically withdrawn from a bank account each month. When a participant pays in, MHD creates a coverage period that begins on the first day of the month for which the participant is paying. If the participant pays 40 Production - 04/30/2012
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for the next month prior to the end of the current month, there is no end date on the coverage period. If a payment has been missed, the coverage period is not continuous. Participants are given the option of having the spenddown amount withdrawn from an existing bank account. Withdrawals are made on the 10th of each month for the following month's coverage. The participant receives a monthly notification of withdrawal from MHD. In some instances, other state agencies, such as Department of Mental Health, may choose to pay the spenddown amount for some of their clients. Agencies interested in this process work with MHD to identify clients the agency intends to pay for and establish payment options on behalf of the client. 1.6.B(6) Prior Quarter Coverage
The eligibility determination for prior quarter MO HealthNet coverage is separate from the eligibility determination for current MO HealthNet coverage. A participant does not have to be currently eligible for MO HealthNet coverage to be eligible for prior quarter coverage. Prior quarter coverage can begin no earlier than the first day of the third month prior to the month of the application and can extend up to but not including the first day of the month of application. The participant must meet all eligibility requirements including spenddown/non-spenddown during the prior quarter. If the participant becomes eligible for assistance sometime during the prior quarter, the date on which eligibility begins depends on whether the participant is eligible as a non-spenddown or spenddown case. MO HealthNet coverage begins on the first day in which spenddown is met in each of the prior months. Each of the three prior quarter month's medical expenses are compared to that month's spenddown separately. Using this process, it may be that the individual is eligible for one, two or all three months, sometimes not consecutively. As soon as the FSD caseworker receives bills to meet spenddown for a prior quarter month, eligibility is met. 1.6.B(7) MO HealthNet Coverage End Dates
MO HealthNet coverage is date-specific for MO HealthNet for the Aged, Blind, and Disabled (MHABD) non-spenddown cases at the time of closing. A datespecific closing can take effect in the future, up to the last day of the month following the month of closing. For MHABD spenddown cases MO HealthNet eligibility and coverage is not date-specific at the time of the closing. When an General Manual Production - 04/30/2012 41
MHABD spenddown case is closed, MO HealthNet eligibility continues through the last day of the month of the closing. If MO HealthNet coverage has been authorized by pay-in or due to incurred expenses, it continues through the last day of the month of the closing. 1.6.C PRIOR QUARTER COVERAGE
Eligibility determination for prior quarter Title XIX coverage is separate from the eligibility determination of current Title XIX coverage. An individual does not have to be currently eligible for Title XIX coverage to be eligible for prior quarter coverage and vice versa. Eligible individuals may receive Title XIX coverage retroactively for up to 3 months prior to the month of application. This 3-month period is referred to as the prior quarter. The effective date of prior quarter coverage for participants can be no earlier than the first day of the third month prior to the month of the application and can extend up to, but not include, the first day of the month of application. MO HealthNet for Kids (ME codes 71-75) who meet federal poverty limit guidelines and who qualify for coverage because of lack of medical insurance are not eligible to receive prior quarter coverage. The individual must have met all eligibility factors during the prior quarter. If the individual becomes eligible for assistance sometime during the prior quarter, eligibility for Title XIX begins on the first day of the month in which the individual became eligible or, if a spenddown case, the date in the prior 3-month period on which the spenddown amount was equaled or exceeded. Example of Prior Quarter Eligibility on a Non-Spenddown Case: An individual applies for assistance in June. The prior quarter is March through May. A review of the eligibility requirements during the prior quarter indicates the individual would have been eligible on March 1 because of depletion of resources. Title XIX coverage begins March 1 and extends through May 31 if an individual continues to be eligible during April and May. 1.6.D EMERGENCY MEDICAL CARE FOR INELIGIBLE ALIENS
The Social Security Act provides MO HealthNet coverage for emergency medical care for ineligible aliens, who meet all eligibility requirements for a federally funded MO HealthNet program except citizenship/alien status. Coverage is for the specific emergency only. Providers should contact the local Family Support Division office and identify the services and the nature of the emergency. State staff identify the emergency nature of the claim and
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add or deny coverage for the period of the emergency only. Claims are reimbursed only for the eligibility period identified on the participant's eligibility file. An emergency medical condition is defined as follows: After sudden onset, the medical condition (including emergency labor and delivery) manifests itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in: Placing the patients health in serious jeopardy; or Serious impairment to bodily functions; or Serious dysfunction of any bodily organ or part. NOTE: All labor and delivery is considered an emergency for purposes of this eligibility provision.
1.7
PARTICIPANT ELIGIBILITY LETTERS AND CLAIMS CORRESPONDENCE
It is common for MO HealthNet participants to be issued an eligibility letter from the Family Support Division or other authorizing entity that may be used in place of an ID card. Participants who are new approvals or who need a replacement card are given an authorization letter. These letters are valid proof of eligibility in lieu of an ID Card. Dates of eligibility and most restrictions are contained in these letters. Participants who are enrolled or who will be enrolled in a managed care health plan may not have this designation identified on the letter. It is important that the provider verify the managed care enrollment status for participants who reside in a managed care service area. If the participant does not have an ID Card or authorization letter, the provider may also verify eligibility by contacting the IVR or the Internet if the participants MO HealthNet number is known. Refer to Section 3.3.A The MO HealthNet Division furnishes MO HealthNet participants with written correspondence regarding medical services submitted as claims to the division. Participants are also informed when a prior authorization request for services has been made on their behalf but denied. 1.7.A NEW APPROVAL LETTER
An Approval Notice (IM-32, IM-32 MAF, IM-32 MC, IM-32 MPW or IM-32 PRM, IM-32 QMB) is prepared when the application is approved. Coverage may be from the first day of the month of application or the date of eligibility in the prior quarter until the last day of the month in which the case was approved or the last day of the following month if approval occurs late in the month. Approval letters may be used to verify eligibility for services until the ID Card is received. The letter indicates whether an individual will be enrolled with a 43 General Manual Production - 04/30/2012
MO HealthNet managed care health plan. It also states whether the individual is required to pay a copay for certain services. Each letter is slightly different in content. Spenddown eligibility letters cover the date spenddown is met until the end of the quarter in which the case was approved. The eligibility letters contain Yes/No boxes to indicate LockIn, Hospice or QMB. If the Yes box is checked, the restrictions apply. 1.7.A(1) Eligibility Letter for Reinstated TANF (ME 81) Individuals
Reinstated Temporary MO HealthNet for Needy Families (TMNF) individuals have received a letter from the Family Support Division that serves as notification of temporary medical eligibility. They may use this letter to contact providers to access services. 1.7.A(2) BCCT Temporary MO HealthNet Authorization Letter
Presumptive Eligibility (PE) determinations are made by Breast and Cervical Cancer Control Project (BCCCP) MO HealthNet providers. When a BCCCP provider determines a woman is eligible for PE coverage, a BCCT Temporary MO HealthNet Authorization letter is issued which provides for temporary, full MO HealthNet benefits. A MO HealthNet ID Card is issued and should be received in approximately five days. MO HealthNet coverage under PE begins on the date the BCCCP provider determines the woman is in need of treatment. 1.7.A(3) Presumptive Eligibility for Children Authorization PC-2 Notice
Eligibility determinations for Presumptive Eligibility for Children are limited to qualified entities approved by the state. Currently only children's hospitals are approved. Upon determination of eligibility, the family is provided with a Presumptive Eligibility Authorization (PC-2) notice that includes the MO HealthNet number and effective date of coverage. This notice guarantees a minimum of five days of coverage with day one being the beginning date. After the five days, providers should be checking eligibility as for any client. 1.7.B REPLACEMENT LETTER
A participant may also have a replacement letter, which is the MO HealthNet Eligibility Authorization (IM-29, IM-29 QMB and IM-29 TEMP), from the Family Support Division county office as proof of MO HealthNet eligibility in lieu of a MO HealthNet ID card. This letter is issued when a card has been lost or destroyed. There are check-off boxes on the letter to indicate if the letter is replacing a lost card or letter. A provider should use this letter to verify eligibility as they would the ID Card. Participants 44 General Manual Production - 04/30/2012
who live in a managed care service area may not have their managed care health plan identified on the letter. Providers need to contact the IVR or the Internet to verify the managed care health plan enrollment status. A replacement letter is only prepared upon the request of the participant. 1.7.C NOTICE OF CASE ACTION
A Notice of Case Action (IM-33) advises the participant of application rejections, case closings, changes in the amount of cash grant, or ineligibility status for MO HealthNet benefits resulting from changes in the participants situation. This form also advises the participant of individuals being added to a case and authorizes MO HealthNet coverage for individuals being added. 1.7.D PARTICIPANT EXPLANATION OF MO HEALTHNET BENEFITS
The MO HealthNet Division randomly selects 300 MO HealthNet participants per month to receive a Participant Explanation of MO HealthNet Benefits (PEOMB) for services billed or managed care health plan encounters reported. The PEOMB contains the following information: Date the service was provided; Name of the provider; Description of service or drug that was billed or the encounter reported; and Information regarding how the participant may contact the Participant Services Unit by toll-free telephone number and by written correspondence. The PEOMB sent to the participant clearly indicates that it is not a bill and that it does not change the participants MO HealthNet. The PEOMB does not report the capitation payment made to the managed care health plan in the participants behalf. 1.7.E PRIOR AUTHORIZATION REQUEST DENIAL
When the MO HealthNet Division must deny a Prior Authorization Request for a service that is delivered on a fee-for-service basis, a letter is sent to the participant explaining the reason for the denial. The most common reasons for denial are: Prior Authorization Request was returned to the provider for corrections or additional information. Service or item requested does not require prior authorization. 45 Production - 04/30/2012
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Authorization has been granted to another provider for the same service or item. Our records indicate this service has already been provided. Service or item requested is not medically necessary. The Prior Authorization Request Denial letter gives the address and telephone number that the participant may call or write to if they feel the MO HealthNet Division was wrong in denying the Prior Authorization Request. The participant must contact the MO HealthNet Division, Participant Services Unit, within 90 days of the date on the letter, if they want the denial to be reviewed. Participants enrolled in a managed care health plan do not receive the Prior Authorization Request Denial letter from the MO HealthNet Division. They receive notification from the managed care health plan and can appeal the decision from the managed care health plan. The participant's member handbook tells them how to file a grievance or an appeal. 1.7.F PARTICIPANT SERVICES UNIT ADDRESS AND TELEPHONE NUMBER
A participant may send written correspondence to: Participant Services Agent P.O. Box 3535 Jefferson City, MO 65102 The participant may also call the Participant Services Unit at (800) 392-2161 toll free, or (573) 751-6527. Providers should not call the Participant Services Unit unless a call is requested by the state.
1.8
TRANSPLANT PROGRAM
The MO HealthNet Program provides limited coverage and reimbursement for the transplantation of human organs or bone marrow/stem cell and related medical services. Current policy and procedure is administered by the MO HealthNet Division with the assistance of its Transplant Advisory Committee. 1.8.A COVERED ORGAN AND BONE MARROW/STEM CELL TRANSPLANTS
With prior authorization from the MO HealthNet Division, transplants may be provided by MO HealthNet approved transplant facilities for transplantation of the following: Bone Marrow/Stem Cell Heart Kidney General Manual Production - 04/30/2012 46
Liver Lung Small Bowel Multiple organ transplants involving a covered transplant 1.8.B PATIENT SELECTION CRITERIA
The transplant prior authorization process requires the transplant facility or transplant surgeon to submit documentation that verifies the transplant candidate has been evaluated according to the facilitys Patient Selection Protocol and Patient Selection Criteria for the type of transplant to be performed. The patient must have been accepted as a transplant candidate by the facility before prior authorization requests can be considered for approval by the MO HealthNet Division. Bone Marrow/Stem Cell transplant candidates must also meet the general diagnosis and donor guidelines established by the Bone Marrow/Stem Cell Transplant Advisory Committee. All transplant requests for authorization are reviewed on a case-by-case basis. If the request is approved, an agreement is issued to the transplant facility that must be signed and returned to the MO HealthNet Division. 1.8.C CORNEAL TRANSPLANTS
Corneal transplants are covered for eligible MO HealthNet participants and do not require prior authorization. Corneal transplants have certain restrictions that are discussed in the physician and hospital manuals. 1.8.D ELIGIBILITY REQUIREMENTS
For the transplant facility or related service providers to be reimbursed by MO HealthNet, the transplant patient must be eligible for MO HealthNet on each date of service. A participant must have an ID card or eligibility letter to receive MO HealthNet benefits. Human organ and bone marrow/stem cell transplant coverage is restricted to those participants who are eligible for MO HealthNet. Transplant coverage is NOT available for participants who are eligible under a state funded MO HealthNet ME code. (See Section 1.1). Individuals whose type of assistance does not cover transplants should be referred to their local Family Support Division office to request application under a type of assistance that covers transplants. In this instance the MO HealthNet Division Transplant Unit should be 47 Production - 04/30/2012
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advised immediately. The MO HealthNet Division Transplant Unit works with the Family Support Division to expedite the application process. 1.8.E MANAGED CARE PARTICIPANTS
Managed care members receive a transplant as a fee-for-service benefit reimbursed by the MO HealthNet Division. The transplant candidate is allowed freedom of choice of Approved MO HealthNet Transplant Facilities The transplant surgery, from the date of the transplant through the date of discharge and related transplant services (procurement, physician, lab services, etc.) are not the managed care health plans responsibility. The transplant procedure is prior authorized by the MO HealthNet Division. Claims for the pretransplant assessment and care are the responsibility of the managed care health plan and must be authorized by the MO HealthNet managed care health plan. Any outpatient, inpatient, physician and related support services rendered prior to the date of the actual transplant surgery must be authorized by the managed care health plan and are the responsibility of the managed care health plan. The managed care health plan is responsible for post-transplant follow-up care. In order to assure continuity of care, follow-up services must be authorized by the managed care health plan. Reimbursement for those authorized services is made by the managed care health plan. Reimbursement to non-health plan providers must be no less than the current MO HealthNet FFS rate. The MO HealthNet Division only reimburses providers for those charges directly related to the transplant including the organ or bone marrow/stem cell procurement costs, actual inpatient transplant surgery costs, postsurgery inpatient hospital costs associated with the transplant surgery, and the transplant physicians charges and other physicians services associated with the patients transplant. 1.8.F MEDICARE COVERED TRANSPLANTS
Kidney, heart, lung, liver and certain bone marrow/stem cell transplants are covered by Medicare. If the patient has both Medicare and MO HealthNet coverage and the transplant is covered by Medicare, the Medicare Program is the first source of payment. In this case the requirements or restrictions imposed by Medicare apply and MO HealthNet reimbursement is limited to applicable deductible and coinsurance amounts. Medicare restricts coverage of heart, lung and liver transplants to Medicare-approved facilities. In Missouri, St. Louis University Hospital, Barnes-Jewish Hospital in St. Louis, St. General Manual Production - 04/30/2012 48
Lukes Hospital in Kansas City, and the University of Missouri Hospital located in Columbia, Missouri are Medicare-approved facilities for coverage of heart transplants. Barnes-Jewish Hospital and St. Louis University are also Medicare-certified liver transplant facilities. Barnes-Jewish Hospital is a Medicare approved lung transplant facility. Potential heart, lung and liver transplant candidates who have Medicare coverage or who will be eligible for Medicare coverage within six months from the date of imminent need for the transplant should be referred to one of the approved Medicare transplant facilities. MO HealthNet only considers authorization of a Medicare-covered transplant in a non-Medicare transplant facility if the Medicare beneficiary is too ill to be moved to the Medicare transplant facility.
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Section 2 - Provider Conditions of Participation
SECTION 2 - PROVIDER CONDITIONS OF PARTICIPATION

2.1 PROVIDER ELIGIBILITY ...........................................................................................................2 QMB-ONLY PROVIDERS.......................................................................................................2 NON-BILLING MO HEALTHNET PROVIDER.....................................................................2 PROVIDER ENROLLMENT ADDRESS ................................................................................2 ELECTRONIC CLAIM/ATTACHMENTS SUBMISSION AND INTERNET AUTHORIZATION ..................................................................................................................3 2.2 2.3 NOTIFICATION OF CHANGES .................................................................................................3 RETENTION OF RECORDS .......................................................................................................3 ADEQUATE DOCUMENTATION..........................................................................................4
2.1.A 2.1.B 2.1.C 2.1.D
2.3.A 2.4 2.5 2.6 2.7 2.8 2.9
NONDISCRIMINATION POLICY STATEMENT ....................................................................4 STATES RIGHT TO TERMINATE RELATIONSHIP WITH A PROVIDER .....................4 FRAUD AND ABUSE.....................................................................................................................5 OVERPAYMENTS.........................................................................................................................6 POSTPAYMENT REVIEW ..........................................................................................................6 PREPAYMENT REVIEW .............................................................................................................7
SECTION 2-PROVIDER CONDITIONS OF PARTICIPATION
2.1
PROVIDER ELIGIBILITY
To receive MO HealthNet reimbursement, a provider of services must have entered into, and maintain, a valid participation agreement with the MO HealthNet Division as approved by the Missouri Medicaid Audit and Compliance Unit (MMAC). Authority to take such action is contained in 13 CSR 70-3.020. Each provider type has specific enrollment criteria, e.g., licensure, certification, Medicare certification, etc., which must be met. Refer to Section 13, Benefits and Limitations, for specific enrollment criteria. 2.1.A QMB-ONLY PROVIDERS
Providers who want to enroll in MO HealthNet to receive payments for only the Qualified Medicare Beneficiary (QMB) services must submit a copy of their state license and documentation of their Medicare ID number. They must also complete a short enrollment form. For a discussion of QMB covered services refer to Section 1. 2.1.B NON-BILLING MO HEALTHNET PROVIDER
MO HealthNet managed care health plan providers who have a valid agreement with one or more managed care health plans but who are not enrolled as a participating MO HealthNet provider may access the Internet or interactive voice response (IVR) system if they enroll with MO HealthNet as a Non-Billing MO HealthNet Provider. Providers are issued a provider identifier that permits access to the Internet or IVR; however, it is not valid for billing MO HealthNet on a fee-for-service basis. Information regarding enrollment as a Non-Billing MO HealthNet Provider can be obtained by contacting the Provider Enrollment Unit at: mmac.providerenrollment@dss.mo.gov. 2.1.C PROVIDER ENROLLMENT ADDRESS
Specific information about MO HealthNet participation requirements and enrollment can be obtained from: Provider Enrollment Unit Missouri Medicaid Audit and Compliance Unit P. O. Box 6500 Jefferson City, Missouri 65102 mmac.providerenrollment@dss.mo.gov
Section 2 - Provider Conditions of Participation 2.1.D ELECTRONIC CLAIM/ATTACHMENTS SUBMISSION AND INTERNET AUTHORIZATION
A provider wishing to submit claims or attachments electronically or access the Internet web site, www.emomed.com, must be enrolled as an electronic billing provider. Providers wishing to enroll as an electronic billing provider may contact the Wipro Infocrossing Help Desk at (573) 635-3559 or the Provider Enrollment Unit at: mmacproviderenrollment@dss.mo.gov. Providers wishing to access the Internet web site, www.emomed.com, must complete the online Application for MO HealthNet Internet Access Account. Please reference http://manuals.momed.com/Application.html and click on the Apply for Internet Access link. Providers are unable to access www.emomed.com without proper authorization. An authorization is required for each individual user.
2.2
NOTIFICATION OF CHANGES
Change of provider address. This is necessary to ensure that all checks and correspondence are received promptly. Indication of change of address on a claim form is not sufficient. Change of ownership of business. A new participation agreement is required. Change of Licensure. Change of direct deposit information.
A provider must notify the Provider Enrollment Unit within five (5) days by certified mail of:
2.3
RETENTION OF RECORDS
MO HealthNet providers must retain for 5 years (7 years for the Nursing Home, CSTAR and Community Psychiatric Rehabilitation Programs), from the date of service, fiscal and medical records that coincide with and fully document services billed to the MO HealthNet Agency, and must furnish or make the records available for inspection or audit by the Department of Social Services, Missouri Medicaid Audit and Compliance Unit, or its representative upon request. Failure to furnish, reveal and retain adequate documentation for services billed to MO HealthNet may result in recovery of the payments for those services not adequately documented and may result in sanctions to the providers participation in the MO HealthNet Program. This policy continues to apply in the event of the providers discontinuance as an actively participating MO HealthNet provider through change of ownership or any other circumstance.
2.3.A
ADEQUATE DOCUMENTATION
All services provided must be adequately documented in the medical record. 13 CSR 703.030, Section(2)(A) defines adequate documentation and adequate medical records as follows: Adequate documentation means documentation from which services rendered and the amount of reimbursement received by a provider can be readily discerned and verified with reasonable certainty. Adequate medical records are records which are of the type and in a form from which symptoms, conditions, diagnoses, treatments, prognosis and the identity of the patient to which these things relate can be readily discerned and verified with reasonable certainty. All documentation must be made available at the same site at which the service was rendered.
2.4
NONDISCRIMINATION POLICY STATEMENT
Providers must comply with the 1964 Civil Rights Act, as amended; Section 504 of the Rehabilitation Act of 1973; the Age Discrimination Act of 1975; the Omnibus Reconciliation Act of 1981 and the Americans with Disabilities Act of 1990 and all other applicable Federal and State Laws that prohibit discrimination in the delivery of services on the basis of race, color, national origin, age, sex, handicap/disability or religious beliefs. Further, all parties agree to comply with Title VII of the Civil Rights Act of 1964 which prohibits discrimination in employment on the basis of race, color, national origin, age, sex, handicap/disability, and religious beliefs.
2.5
STATES RIGHT TO TERMINATE RELATIONSHIP WITH A PROVIDER
Providers of services and supplies to MO HealthNet participants must comply with all laws, policies, and regulations of Missouri and the MO HealthNet Division, as well as policies, regulations, and laws of the federal government. A provider must also comply with the standards and ethics of his or her business or profession to qualify as a participant in the program. The Missouri Medicaid Audit and Compliance Unit may terminate or suspend providers or otherwise apply sanctions of administrative actions against providers who are in violation of MO HealthNet Program requirements. Authority to take such action is contained in 13 CSR 70-3.030.
2.6
FRAUD AND ABUSE
The Department of Social Services, Missouri Medicaid Audit and Compliance Unit is charged by federal and state law with the responsibility of identifying, investigating, and referring to law enforcement officials cases of suspected fraud or abuse of the Title XIX Medicaid Program by either providers or participants. Section 1909 of the Social Security Act contains federal penalty provisions for fraudulent acts and false reporting on the part of providers and participants enrolled in MO HealthNet. Fraud is defined as an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him or herself or some other person. It includes any act that constitutes fraud under applicable Federal and State laws, regulations and policies. Abuse is defined as provider, supplier, and entity practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes participant practices that result in unnecessary costs to the Medicaid program. Frequently cited fraudulent or abusive practices include, but are not limited to, overcharging for services provided, charging for services not rendered, accepting bribes or kickbacks for referring patients, and rendering inappropriate or unnecessary services. The penalties for such acts range from misdemeanors to felonies with fines not to exceed $25,000 and imprisonment up to 5 years, or both. Procedures and mechanisms employed in the claims and payment surveillance and audit program include, but are not limited to, the following: Review of participant profiles of use of services and payment made for such. Review of provider claims and payment history for patterns indicating need for closer scrutiny. Computer-generated listing of duplication of payments. Computer-generated listing of conflicting dates of services. Computer-generated overutilization listing. Internal checks on such items as claims pricing, procedures, quantity, duration, deductibles, coinsurance, provider eligibility, participant eligibility, etc. Medical staff review and application of established medical services parameters.
Section 2 - Provider Conditions of Participation Field auditing activities conducted by the Missouri Medicaid Audit and Compliance Unit or its representatives, which include provider and participant contacts. In cases referred to law enforcement officials for prosecution, the Missouri Medicaid Audit and Compliance Unit has the obligation, where applicable, to seek restitution and recovery of monies wrongfully paid even though prosecution may be declined by the enforcement officials.
2.7
OVERPAYMENTS
The Missouri Medicaid Audit and Compliance Unit routinely conduct postpayment reviews of MO HealthNet claims. If during a review an overpayment is identified, the Missouri Medicaid Audit and Compliance Unit is charged with recovering the overpayment pursuant to 13 CSR 70-3.030. The Missouri Medicaid Audit and Compliance Unit maintains the position that all providers are held responsible for overpayments identified to their participation agreement regardless of any extrinsic relationship they may have with a corporation or other employing entity. The provider is responsible for the repayment of the identified overpayments. Missouri State Statute, Section 208.156, RSMo (1986) may provide for appeal of any overpayment notification for amounts of $500 or more. An appeal must be filed with the Administrative Hearing Commission within 30 days from the date of mailing or delivery of the decision, whichever is earlier; except that claims of less than $500 may be accumulated until such claims total that sum and, at which time, the provider has 90 days to file the petition. If any such petition is sent by registered mail or certified mail, the petition will be deemed filed on the date it is mailed. If any such petition is sent by any method other than registered mail or certified mail, it will be deemed filed on the date it is received by the Commission. Compliance with this decision does not absolve the provider, or any other person or entity, from any criminal penalty or civil liability that may arise from any action that may be brought by any federal agency, other state agency, or prosecutor. The Missouri Department of Social Services, Missouri Medicaid Audit and Compliance Unit, has no authority to bind or restrict in any way the actions of other state agencies or offices, federal agencies or offices, or prosecutors.
2.8
POSTPAYMENT REVIEW
Services reimbursed through the MO HealthNet Program are subject to postpayment reviews to monitor compliance with established policies and procedures pursuant to Title 42 CFR 456.1 through 456.23. Non-compliance may result in monetary recoupments according to 13 CSR 703.030 (5) and the provider may be subjected to prepayment review on all MO HealthNet claims.
2.9
PREPAYMENT REVIEW
MMAC may conduct prepayment reviews for all providers in a program, or for certain services or selected providers. When a provider has been notified that services are subject to prepayment review, the provider must follow any specific instructions provided by MMAC in addition to the policy outlined in the provider manual. In the event of prepayment review, the provider must submit all claims on paper. Claims subject to prepayment review are sent to the fiscal agent who forwards the claims and attachments to the MMAC consultants. MMAC consultants conduct the prepayment review following the MO HealthNet Divisions guidelines and either recommend approval or denial of payment. The claim and the recommendation for approval or denial is forwarded to the MO HealthNet fiscal agent for final processing. Please note, although MMAC consultants recommend payment for a claim, this does not guarantee the claim is paid. The claim must pass all required MO HealthNet claim processing edits before actual payment is determined. The final payment disposition on the claim is reported to the provider on a MO HealthNet Remittance Advice.
Section 3 - Provider and Participant Services
SECTION 3 - PROVIDER AND PARTICIPANT SERVICES

3.1 PROVIDER SERVICES ............................................................................................................... 2 WIPRO INFOCROSSING HELP DESK ................................................................................. 2
3.1.A 3.2 3.3
PROVIDER ENROLLMENT UNIT ........................................................................................... 2 PROVIDER RELATIONS COMMUNICATION UNIT ........................................................... 2
3.3.A INTERACTIVE VOICE RESPONSE (IVR) SYSTEM ........................................................... 3 3.3.A(1) Using the Telephone Key Pad ........................................................................................... 6 3.3.B 3.3.C MO HEALTHNET SPECIALIST ............................................................................................ 6 INTERNET............................................................................................................................... 6
3.3.D WRITTEN INQUIRIES ........................................................................................................... 7 3.4 3.5 3.6 PROVIDER EDUCATION UNIT ................................................................................................ 8 PARTICIPANT SERVICES ......................................................................................................... 8 FORMS ........................................................................................................................................... 9 RISK APPRAISAL FORM ...................................................................................................... 9
3.6.A 3.7 3.8
CLAIM FILING METHODS ....................................................................................................... 9 CLAIM ATTACHMENT SUBMISSION VIA THE INTERNET ............................................ 9
SECTION 3 - PROVIDER AND PARTICIPANT SERVICES 3.1 PROVIDER SERVICES
The MO HealthNet Division has staff to assist providers and potential providers with questions regarding enrollment, claims filing, payment problems, participant eligibility verification, prior authorization status, etc. Assistance can be obtained by contacting the appropriate unit. 3.1.A WIPRO INFOCROSSING HELP DESK
Wipro Infocrossing provides a help desk for use by fee-for-service providers, electronic billers and managed health care plan staff. The dedicated telephone number is (573) 6353559. The responsibilities of the help desk include: front-line assistance to providers and billing staff in establishing required electronic claim formats for claim submission as well as assistance in the use and maintenance of billing software developed by the MO HealthNet Division. front-line assistance accessibility to electronic claim submission for all providers via the Internet. front-line assistance to managed health care plans in establishing required electronic formats, network communications and ongoing operations. front-line assistance to providers in submitting claim attachments via the Internet.
3.2
PROVIDER ENROLLMENT UNIT
The Provider Enrollment Unit mails provider enrollment packets and processes enrollment applications and change requests. Information regarding provider participation requirements and enrollment application packets can be obtained at mmac.providerenrollment@dss.mo.gov.
3.3
PROVIDER RELATIONS COMMUNICATION UNIT
This unit responds to specific provider inquiries concerning MO HealthNet eligibility, claim filing instructions, billing errors, etc. Routine questions, in most cases, can be handled by telephone and email. Providers should submit complex inquiries in writing. A copy of a lost Remittance Advice can be obtained by contacting the Provider Relations Communication Units number (573) 751-2896. A minimal copy fee is required prior to release of the replacement. An old or lost RA can be requested at the billing web site at www.emomed.com. In the section "File Management" you can request and print a current RA by clicking on "Printable 2 Production - 04/30/2012
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Section 3 - Provider and Participant Services Remittance Advice". To retrieve an older RA click on "Request Aged RA's", fill out the required information and submit. The RA will be under "Printable Aged RA's" the next day. The requested RA will remain in the system for 5 days. Providers can access information through various methods, including the interactive voice response (IVR) system, Internet (www.emomed.com), Family Support Division, and written inquiries, which are described in this section. 3.3.A INTERACTIVE VOICE RESPONSE (IVR) SYSTEM
The interactive voice response (IVR) system at (573) 751-2896 allows an active MO HealthNet provider five inquiry options: 1. 2. 3. 5. 0. Participant eligibility Last two check amounts Claim status MO HealthNet informational message Speak to Medicaid Specialist
This system requires a touch-tone phone and is limited to use by active MO HealthNet providers or inactive providers inquiring on dates of service during their period of enrollment as an active MO HealthNet provider. The 10-digit NPI number must be entered each time any of the IVR options are accessed. The provider should listen to all eligibility information, particularly the suboptions. Option 1. Participant Eligibility The caller is prompted to supply the following information: Providers NPI number MO HealthNet participant's ID, Social Security Number or casehead ID Date of birth (if inquiry by Social Security Number) Dependant date of birth (if inquiry by casehead ID) First date of service (mm/dd/yy) Last date of service (mm/dd/yy)
For eligibility inquiries, the caller can inquire by individual date of service or a span of dates. Inquiry for a span of dates may not exceed 31 days. The caller may inquire on future service dates for the current month only. The caller may not inquire on dates that exceed one year prior to the current date. The caller is limited to ten inquiries per call. 3 Production - 04/30/2012
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Section 3 - Provider and Participant Services The caller is given standard MO HealthNet eligibility coverage information including ME code, date of birth, date of death (if applicable), county of eligibility, nursing home name and level of care (if applicable), and informational messages about the participant's eligibility or benefits. The IVR also tells the caller whether the participant has any service restrictions based on the participant's eligibility under QMB or the Presumptive Eligibility (TEMP) Program. Please reference the provider manual for a description of these services. Hospice beneficiaries are identified along with the name and telephone number of the providers of service. Refer to Section 1 for more detailed information on participant eligibility. Once standard MO HealthNet eligibility information is given, the IVR gives the caller the option to listen to additional eligibility information through a sub-menu. The sub-menu options include: 1 2 3 4 5 6 7 8 9 0 Managed care enrollment and health plan name and telephone number Eye exam and eyeglass information Third party liability information Medicare Part A, Part B and/or QMB coverage MO HealthNet ID, participant name, spelling of participant name and repeat of eligibility information Repeat of confirmation number Inquiry on another participant Return to the main menu End the call Transfer to a MO HealthNet hotline specialist
MO HealthNet eligibility information is confidential and must be used only for the purpose of providing services and for filing MO HealthNet claims. Option 2. Last Two Check Amounts The caller is prompted to supply their NPI number. The caller is given the last two remittance advice (RA) dates, RA numbers and check amounts. Check amount inquiries are limited to ten provider numbers per call. The caller is told if the provider for which the inquiry being made is eligible to bill their claims electronically.
Option 3. Claim Status The caller is prompted to supply the following: Providers NPI number Participant ID First date of service (mm/dd/yy) Claim type (optional), valid values are: zero (0) - any claim type One (1) - medical Two (2) - inpatient Three (3) - outpatient Four (4) - dental Five (5) - home health Six (6) - drug Seven (7) - nursing home Eight (8) - Medicare crossover The caller is provided the status of the most current claim that matches the date of service and claim type entered. The caller is told whether the claim is paid, denied, approved to pay or being processed. The caller is given the amount paid, RA date and the internal control number (ICN). In cases where a claim has been denied, the IVR reads an explanation of the EOB assigned to the denied claim. Claim status inquiries are limited to ten inquiries per call. Option 5. MO HealthNet Informational Message The caller is prompted to supply their MO HealthNet provider number. The caller is given the option to select from a list of informational messages. The IVR tells the caller to which MO HealthNet Program or topic each informational message pertains. When a particular message option is selected, a detailed message is read to the caller by the IVR. The informational messages available through this option may include, but are not limited to, changes or additions to the MO HealthNet Program, areas of interest for specific provider types, changes to the managed care program, and special instructions for receiving additional information. The messages are similar to the types of informational messages occasionally appearing on the cover page of provider remittance advices. If no informational messages are currently available on the message area, callers are not able to select option 5 from the main menu. General Manual Production - 04/30/2012 5
Section 3 - Provider and Participant Services 3.3.A(1) Using the Telephone Key Pad
Both alphabetic and numeric entries may be required on the telephone key pad. In some cases, the IVR instructs the caller which numeric values to key to match alphabetic entries. Please listen and follow the directions given by the IVR as it prompts the caller for the various information required by each option. Once familiar with the IVR, the caller does not have to wait for the entire voice prompt. The caller can enter responses before the prompts are given. If needed information is not available through the above options, the IVR allows the caller to request to speak to a MO HealthNet hotline specialist. Please allow for a 15 to 20 second waiting period for the IVR to complete the call transfer process. If all specialists are busy, the call is put into a queue and will be answered in the order it was received. 3.3.B MO HEALTHNET SPECIALIST
Specialists are on duty between the hours of 8:00AM and 5:00PM, Monday through Friday (except holidays) to provide information not available through the interactive voice response (IVR) system. The IVR number is (573) 751-2896. Providers are urged to: Review the provider manual and bulletins before calling the IVR. Have all material related to the problem (such as Remittance Advice, claim forms, and participant information) available for discussion. Have the providers NPI number available. Limit the call, if possible, to three questions or three to four minutes. The specialist will assist the provider until the problem is resolved or until it becomes apparent that a written inquiry is necessary to resolve the problem. Note the name of the specialist who answered the call. This saves a duplication of effort if the provider needs to clarify a previous discussion or to ask the status of a previous inquiry. INTERNET
3.3.C
Providers may submit claims via the Internet. The web site address is www.emomed.com. Providers are required to complete the on-line Application for MO HealthNet Internet Access Account. Please reference http://manuals.momed.com/Application.html and click on the Apply for Internet Access link. Providers are unable to access www.emomed.com without proper authorization. An authorization is required for each individual user. 6 Production - 04/30/2012
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Section 3 - Provider and Participant Services The current inquiry options available through the interactive voice response (IVR) system is offered, with the exception of procedure code inquiry. Functions include eligibility verification by participant ID, casehead ID and child's date of birth, or Social Security Number and date of birth, claim status and check inquiry. Eligibility verification can be performed on an individual basis or as a batch submission. Individual eligibility verifications occur in real-time similar to the IVR, which means a response is returned immediately. Batch eligibility verifications are returned to the user within 24 hours. Providers also have the capability to receive and download their Remittance Advice from the Internet. Access to this information is restricted to users with authorization. In addition to the Remittance Advice, the claim reason codes, remark codes and current fiscal year claims processing schedule is available on the Internet for viewing or downloading. Other options available on this web site include: claim submission; claim attachment submission; inquiries on claim status, attachment status, and check amounts; and credit adjustment(s). Refer to Section 1 for more detailed information on participant eligibility. 3.3.D WRITTEN INQUIRIES Letters directed to the Provider Relations Communication Unit are answered by trained MO HealthNet specialists. Written or telephone responses are provided to all inquiries. A provider who encounters a complex billing problem; numerous problems requiring detailed and lengthy explanation of such matters as policy, procedures, and coverage; or wishes to lodge a complaint should submit the inquiry or complaint in writing to: Provider Communications Unit MO HealthNet Division P.O. Box 5500 Jefferson City, MO 65102-5500 A written inquiry should state the problem as clearly as possible and should include the provider's name, NPI number, address, and telephone number. Written inquiries should also include the MO HealthNet participant's full name, MO HealthNet identification number, and birthdate. A copy of all pertinent information, such as Remittance Advice forms, invoices, participant information, form letters, and timely filing documentation must be included with the written inquiry.
3.4
PROVIDER EDUCATION UNIT
This unit serves as a major link of communication and assistance between The MO HealthNet Division and the provider community. Representatives can provide face-to-face assistance and personalized attention necessary to maintain clear, effective, and efficient provider participation in the MO HealthNet Program. Providers contribute to this process by identifying problems and difficulties encountered with MO HealthNet. Representatives are available to furnish assistance, training, and information to enhance provider participation in MO HealthNet. These representatives schedule seminars, workshops, computer-tocomputer trainings and both individual and associational meetings to provide instructions on procedures, policy changes, benefit changes, etc., which affect the provider community. Representatives are available, when in the state office, to talk with providers in person or by telephone. The Provider Education Unit is located at 615 Howerton Court, Jefferson City, Missouri. Providers may call (573) 751-6683 to arrange an appointment.
3.5
PARTICIPANT SERVICES
Providers may direct participants to the MO HealthNet Participant Services Unit for questions regarding such things as MO HealthNet-covered services, the denial or payment of claims filed with the MO HealthNet Program, and the location of participating providers in their areas of the state. This unit can be helpful, for example, when a participant moves to a new area of the state and needs the names of all physicians who are active MO HealthNet providers in the new area. Participants who have problems or questions concerning MO HealthNet should be directed to call (800) 392-2161 or to write: MO HealthNet Division Participant Services Unit P.O. Box 3535 Jefferson City, MO 65102 All calls or correspondence from providers are referred to the Provider Relations Communication Unit. Please do not give participants the Provider Relations telephone number.
3.6
PENDING CLAIMS
If payment or status information, for a submitted MO HealthNet claim, is not received within 60 days, providers may resubmit a new claim to the fiscal agent. However, providers should not
Section 3 - Provider and Participant Services resubmit a claim for a claim that remains in pending status. Resubmitting a claim in pending status will delay processing of claim. Refer to Section 17 for further discussion of the RA and Suspended Claims.
3.6
FORMS
All MO HealthNet forms necessary for claims processing are available for download on the MO HealthNet web site at www.dss.mo.gov/mhd/providers/index.htm. Choose the MO HealthNet forms link in the right column. 3.6.A RISK APPRAISAL FORM
See Section 13.66 of the Physician's Manual for information on the Risk Appraisal for Pregnant Women.
3.7
CLAIM FILING METHODS
Some providers may submit paper claims. All claim types may be submitted electronically through the MO HealthNet billing site at www.emomed.com. Most claims that require attachments may also be submitted at this site. Pharmacy claims may also be submitted electronically through a point of service (POS) system. Medical (CMS-1500), Inpatient and Outpatient (UB-04), Dental (ADA 2002, 2004), Nursing Home and Pharmacy (NCPDP) may also be submitted via the Internet. These methods are described in Section 15.
3.8
CLAIM ATTACHMENT SUBMISSION VIA THE INTERNET
The claim attachments available for submission via the Internet include: (Sterilization) Consent Form; Acknowledgment of Receipt of Hysterectomy Information; Medical Referral Form of Restricted Participant (PI-118) and Certificate of Medical Necessity (for Durable Medical Equipment providers only). These attachments may not be submitted via the Internet when additional documentation is required. The web site address for these submissions is www.emomed.com.
Section 4 - Timely Filing
SECTION 4 - TIMELY FILING

4.1 TIME LIMIT FOR ORIGINAL CLAIM FILING.....................................................................2 MO HEALTHNET CLAIMS...................................................................................................2 MEDICARE/MO HEALTHNET CLAIMS.............................................................................2 MO HEALTHNET CLAIMS WITH THIRD PARTY LIABILITY ........................................2
4.1.A 4.1.B 4.1.C 4.2
TIME LIMIT FOR RESUBMISSION OF A CLAIM ...............................................................3 CLAIMS FILED AND DENIED .............................................................................................3 CLAIMS FILED AND RETURNED TO PROVIDER ............................................................3 SECOND RESUBMISSIONS .................................................................................................4
4.2.A 4.2.B 4.2.C 4.3 4.4 4.5
CLAIMS NOT FILED WITHIN THE TIME LIMIT................................................................4 TIME LIMIT FOR FILING AN INDIVIDUAL ADJUSTMENT REQUEST FORM ...........4 DEFINITIONS ...............................................................................................................................5
Section 4 - Timely Filing
SECTION 4 - TIMELY FILING
4.1
TIME LIMIT FOR ORIGINAL CLAIM FILING

4.1.A MO HEALTHNET CLAIMS
Claims from participating providers who request MO HealthNet reimbursement must be filed by the provider and must be received by the state agency within 12 months from the date of service. The counting of the 12-month time limit begins with the date of service and ends with the date of receipt. Refer to Section 4.5, Definitions, for a detailed explanation of terms. 4.1.B MEDICARE/MO HEALTHNET CLAIMS
Claims that initially have been filed with Medicare within the Medicare timely filing requirement and that require separate filing of a claim with the MO HealthNet Division, (MHD) meet the timely filing requirement by being submitted by the provider and received by the state agency within 12 months from the date of service or 6 months from the date on Medicares provider notice of the allowed claim, whichever is later. Claims denied by Medicare must be filed by the provider and received by the state agency within 12 months from the date of service. The counting of the 12-month time limit begins with the date of service and ends with the date of receipt. The counting of the 6-month period begins with the date of adjudication of Medicare payment and ends with the date of receipt. Refer to Section 16 for billing instructions of Medicare/MO HealthNet (crossover) claims. 4.1.C MO HEALTHNET CLAIMS WITH THIRD PARTY LIABILITY
Claims for participants who have other insurance must first be submitted to the insurance company in most instances. Refer to Section 5 for exceptions to this rule. However, the claim must still meet the MO HealthNet timely filing guidelines outlined above. (Claim disposition by the insurance company after 1 year from the date of service does not serve to extend the filing requirement.) If the provider has not had a response from the insurance company prior to the 12-month filing limit, they should contact the Third Party Liability (TPL) Unit at (573) 751-2005 for billing instructions. It is recommended that providers wait no longer than 6 months after the date of service before contacting the TPL Unit. If the MO HealthNet Division waives the requirement that the third-party resource's adjudication must be attached to the claim, documentation indicating the third-party resource's adjudication of the claim must be kept in the provider's records and made available to the division at its request. The claim must meet the MO HealthNet timely filing requirement by being filed by the provider and received by the state agency within 12 months from the date of service.
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Section 4 - Timely Filing The 12 month initial filing rule may be extended if a third-party payer, after making a payment to a provider, being satisfied that the payment is correct, later reverses the payment determination, sometime after the 12 months from the date of service has elapsed, and requests the provider return the payment. Because a third-party resource was clearly available to cover the full amount of liability, and this was known to the provider, the provider may not have initially filed a claim with the MO HealthNet Division. Under this set of circumstances, the provider may file a claim with the MO HealthNet Division later than 12 months from the date of service. The provider must submit this type of claim to the Third Party Liability Unit at P.O. Box 6500, Jefferson City, MO 65102-6500 for special handling. The MO HealthNet Division may accept and pay this specific type of claim without regard to the 12 month timely filing rule; however, all claims must be filed for MO HealthNet reimbursement within 24 months from the date of service in order to be paid.
4.2
TIME LIMIT FOR RESUBMISSION OF A CLAIM
Claims that originally were submitted and received within 12 months from the date of service and that were denied or returned to the provider must be resubmitted and received within 24 months of the date of service. 4.2.A CLAIMS FILED AND DENIED
A copy of a Remittance Advice must be attached to a claim that was previously denied and is being resubmitted more than 12 months after the date of service. The Remittance Advice indicate that the claim had originally been filed timely. The Julian date within the internal control number (ICN) on the attached Remittance Advice and on the claim is the determinant for timely filing. Providers may enter the ICN number of the denied claim that was filed timely instead of attaching a copy of the Remittance Advice for the following claim types: CMS-1500enter the ICN in Field #22 UB-04enter the ICN in Field #64 Dental Claimenter the ICN in Remarks Field #35 Pharmacy Claimenter the ICN in Remarks Field #19 4.2.B CLAIMS FILED AND RETURNED TO PROVIDER
Some claims received by the fiscal agent cannot be processed because the wrong claim form is submitted or additional data is required. These claims are not processed through the system but are returned to the provider with a Return to Provider letter. When these claims are resubmitted more than 12 months after the date of service (and had been filed timely), a copy
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Section 4 - Timely Filing of the Return to Provider letter should be attached instead of the required Remittance Advice to document timely filing as explained in the previous paragraph. The date on the letter determines timely filing. 4.2.C SECOND RESUBMISSIONS
Claims may be resubmitted more than once. A resubmission filed beyond the 12-month filing limit must either include an attachment, a Remittance Advice or Return to Provider letter, or the claim must have the original ICN entered in the appropriate field (reference Section 4.2.A). Either the attachment or the ICN must indicate the claim had originally been filed within 12 months of the date of service. The same Remittance Advice, letter or ICN can be used for each resubmission of that claim.
4.3
CLAIMS NOT FILED WITHIN THE TIME LIMIT
In accordance with 13 CSR 70-3.100, claims that are not submitted in a timely manner as described in this section are denied. However, at any time in accordance with a court order, the MO HealthNet Division (MHD) may make payments to carry out a hearing decision, corrective action or court order to others in the same situation as those directly affected by it. MHD may make payment if a claim was denied due to state agency error or delay, as determined by the state agency. In order for payment to be made, the MHD must be informed of any claims denied due to MHD error or delay within 6 months from the date of the remittance advice on which the error occurred; or within 6 months of the date of completion or determination in the case of a delay; or 12 months from the date of service, whichever is longer.
4.4
TIME LIMIT FOR FILING AN INDIVIDUAL ADJUSTMENT REQUEST FORM
Adjustments to MO HealthNet payments are only accepted if filed within 24 months from the date of the Remittance Advice on which payment was made. If the processing of an adjustment necessitates filing a new claim, the timely limits for resubmitting the new, corrected claim is limited to 90 days from the date of the remittance advice indicating recoupment, or 12 months from the date of service, whichever is longer. Only adjustments that are the result of lawsuits or settlements are accepted beyond 24 months. When overpayments are discovered, it is always the providers responsibility to notify the state agency. When Individual Adjustment Request forms for overpayments are submitted 24 months after the date of the Remittance Advice on which payment was made, the provider is notified by letter that a recoupment will be made by deducting the amount of the overpayment from the next check written to him or her.
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Section 4 - Timely Filing Occasionally the claims-processing system is not able to process an Individual Adjustment Request form in the usual manner. In that situation, the provider is informed by letter that a recoupment of the paid claim will be made and that a new, corrected claim must be resubmitted. The timely filing limit for resubmitting the new, corrected claim is no more than 90 days from the date of the Remittance Advice indicating the recoupment or 12 months from the date of service, whichever is longer. A copy of the Remittance Advice indicating the recoupment must be attached to the new claim.
4.5
DEFINITIONS
Claim: Each individual line item of service on a claim form for which a charge is billed by a provider for all claim form types except inpatient hospital. An inpatient hospital service claim includes all the billed charges contained on one inpatient claim document. Date of Service: The date that serves as the beginning point for determining the timely filing limit. For such items as dentures, hearing aids, eyeglasses, and items of durable medical equipment such as an artificial larynx, braces, hospital beds, or wheelchairs, the date of service is the date of delivery or placement of the device or item. It applies to the various claim types as follows: Nursing Homes: The last date of service for the billing period indicated on the participant's detail record. Nursing Homes must bill electronically, unless attachments are required. Pharmacy: The date dispensed for each line item for each individual participant listed on the paper claim form, or on electronically submitted claims through point of service (POS) or the Internet. Outpatient Hospital: The ending date of service for each individual line item on the claim form. Professional Services: The ending date of service for each individual line item on the claim form. Dental: The date service was performed for each individual line item on the claim form. Inpatient Hospital: The through date of service in the area indicating the period of service. Date of Receipt: The date the claim is received by the fiscal agent. For a claim that is processed, this date appears as the Julian date in the internal control number (ICN). For a claim that is returned to the provider, this date appears on the Return to Provider letter. Date of Adjudication: The date that appears on the Remittance Advice indicating the determination of the claim. Internal Control Number (ICN): The 13-digit number printed by the fiscal agent on each document that processes through the claims processing system. The first two digits indicate the type
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Section 4 - Timely Filing of claim. The year of receipt is indicated by the 3rd and 4th digits, and the Julian date appears as the 5th, 6th, and 7th digits. For example, in the number 409516652006, 40 is a tape claim, 95 is the year 1995, and 166 is the Julian date for June 15. Julian Date: The number of a day of the year when the days of the year are numbered consecutively from 001 (January 1) to 365 (December 31) or 366 in a leap year. For example, in 1992, a leap year, June 15 is the 167th day of that year; thus, 167 is the Julian date for June 15, 1992. Date of Payment/Denials: The date on the Remittance Advice at the top center of each page under the words Remittance Advice. Twelve-Month Time Limit Unit: 366 days. Six-Month Time Limit: 181 days. Twenty-four-Month Time Limit: 731 days.
Section 5 - Third Party Liability
SECTION 5 - THIRD PARTY LIABILITY

5.1 GENERAL INFORMATION .......................................................................................................2 MO HEALTHNET IS PAYER OF LAST RESORT ...............................................................2 THIRD PARTY LIABILITY FOR MANAGED HEALTH CARE ENROLLEES .................3 PARTICIPANTS LIABILITY WHEN THERE IS A TPR ......................................................4 PROVIDERS MAY NOT REFUSE SERVICE DUE TO TPL ................................................5
5.1.A 5.1.B 5.1.C 5.1.D 5.2
HEALTH INSURANCE IDENTIFICATION ............................................................................5 TPL INFORMATION..............................................................................................................6 SOLICITATION OF TPR INFORMATION ...........................................................................6
5.2.A 5.2.B 5.3 5.4 5.5 5.6
INSURANCE COVERAGE CODES ...........................................................................................7 COMMERCIAL MANAGED HEALTH CARE PLANS ..........................................................8 MEDICAL SUPPORT...................................................................................................................8 PROVIDER CLAIM DOCUMENTATION REQUIREMENTS ..............................................9 EXCEPTION TO TIMELY FILING LIMIT ...........................................................................9 TPR CLAIM PAYMENT DENIAL .......................................................................................10
5.6.A 5.6.B 5.7 5.8 5.9
THIRD PARTY LIABILITY BYPASS .....................................................................................10 MO HEALTHNET INSURANCE RESOURCE REPORT (TPL-4) .....................................11 LIABILITY AND CASUALTY INSURANCE .........................................................................12 TPL RECOVERY ACTION ..................................................................................................12 LIENS ....................................................................................................................................13 TIMELY FILING LIMITS ....................................................................................................13 ACCIDENTS WITHOUT TPL ..............................................................................................13
5.9.A 5.9.B 5.9.C 5.9.D 5.10 5.11 5.12 5.13
RELEASE OF BILLING OR MEDICAL RECORDS INFORMATION .............................14 OVERPAYMENT DUE TO RECEIPT OF A THIRD PARTY RESOURCE ......................14 THE HEALTH INSURANCE PREMIUM PAYMENT (HIPP) PROGRAM.......................14 DEFINITIONS OF COMMON HEALTH INSURANCE TERMINOLOGY .......................15
SECTION 5-THIRD PARTY LIABILITY
5.1
GENERAL INFORMATION
The purpose of this section of the provider manual is to provide a good understanding of Third Party Liability (TPL) and MO HealthNet. The federal government defines a third party resource (TPR) as: Any individual, entity or program that is or may be liable to pay all or part of the expenditures for medical assistance furnished under a State Plan. The following is a list of common TPRs; however, the list should not be considered to be all inclusive. AssaultCourt Ordered Restitution AutomobileMedical Insurance CHAMPUS/CHAMPVA Health Insurance (Group or Private) Homeowners Insurance Liability & Casualty Insurance Malpractice Insurance Medical Support Obligations Medicare Owner, Landlord & Tenant Insurance Probate Product Liability Insurance Trust Accounts for Medical Services Covered by MO HealthNet Veterans Benefits Workers Compensation. 5.1.A MO HEALTHNET IS PAYER OF LAST RESORT
MO HealthNet funds are used after all other potential resources available to pay for the medical service have been exhausted. There are exceptions to this rule discussed later in this section. The intent of requiring MO HealthNet to be payer of last resort is to ensure that tax dollars are not expended when another liable party is responsible for all or a portion of the medical service charge. It is to the providers benefit to bill the liable TPR before billing MO HealthNet because many resources pay in excess of the maximum MO HealthNet allowable. Federal and state regulations require that insurance benefits or amounts resulting from litigation are to be utilized as the first source of payment for medical expenses incurred by MO HealthNet participants. See 42 CFR 433 subpart D and RSMo 208.215 for further
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Section 5 - Third Party Liability reference. In essence, MO HealthNet does not and should not pay a claim for medical expenses until the provider submits documentation that all available third party resources have considered the claim for payment. Exceptions to this rule are discussed later in this section of the provider manual. All TPR benefits for MO HealthNet covered services must be applied against the providers charges. These benefits must be indicated on the claim submitted to MO HealthNet. Subsequently, the amount paid by MO HealthNet is the difference between the MO HealthNet allowable and the TPR benefit amount, capping the payment at the MO HealthNet allowable. For example, a provider submits a charge for $100 to the MO HealthNet Program for which the MO HealthNet allowable is $80. The provider received $75 from the TPR. The amount MO HealthNet pays is the difference between the MO HealthNet allowable ($80) and the TPR payment ($75) or $5. 5.1.B THIRD PARTY LIABILITY FOR MANAGED HEALTH CARE ENROLLEES
Managed care health plans in the MO HealthNet Managed Care program must ensure that the health plan and its subcontractors conform to the TPL requirements specified in the managed care contract. The following outlines the agreement for the managed health care plans. The managed care health plan is responsible for performing third party liability (TPL) activities for individuals with private health insurance coverage enrolled in their managed care health plan. By law, MO HealthNet is the payer of last resort. This means that the managed care health plan contracted with the State of Missouri shall be used as a source of payment for covered services only after all other sources of payment have been exhausted. The two methods used in the coordination of benefits are cost avoidance and post-payment recovery (i.e., pay and chase). The managed care health plan shall act as an agent of the state agency for the purpose of coordination of benefits. The managed care health plan shall cost avoid all claims or services that are subject to payment from a third party health insurance carrier. If a third party health insurance carrier (other than Medicare) requires the managed care health plan member to pay any cost-sharing amount (such as copayment, coinsurance or deductible), the managed care health plan is responsible for paying the cost-sharing (even to an out-of-network provider). The managed care health plan's liability for such cost-sharing amounts shall not exceed the amount the managed care health plan would have paid under the managed care health plan's payment schedule.
Section 5 - Third Party Liability If a claim is cost-avoided, the establishment of liability takes place when the managed care health plan receives confirmation from the provider or the third party health insurance carrier indicating the extent of liability. If the probable existence of a Third Party Resource (TPR) cannot be established or third party benefits are not available at the time the claim is filed, the managed care health plan must pay the full amount allowed under the managed care health plan's payment schedule. The requirement to cost avoid applies to all covered services except claims for labor and delivery and postpartum care; prenatal care for pregnant women; preventative pediatric services; or if the claim is for a service provided to a managed care health plan member on whose behalf a child support enforcement order is in effect. The managed care health plan is required to provide such services and then recover payment from the third party health insurance carrier (pay and chase). In addition to coordination of benefits, the health plan shall pursue reimbursement in the following circumstances: Worker's Compensation Tort-feasors Motorist Insurance Liability/Casualty Insurance The managed care health plan shall immediately report to the MO HealthNet Division any cases involving a potential TPR resulting from any of the above circumstances. The managed care health plan shall cooperate fully with the MO HealthNet Division in all collection efforts. If the managed care health plan or any of its subcontractors receive reimbursement as a result of a listed TPR, that payment must be forwarded to the MO HealthNet Division immediately upon receipt. IMPORTANT: Contact the MO HealthNet Division, Third Party Liability Unit, at (573) 7512005 for questions about Third Party Liability. 5.1.C PARTICIPANTS LIABILITY WHEN THERE IS A TPR
The provider may not bill the participant for any unpaid balance of the total MO HealthNet covered charge when the other resource represents all or a portion of the MO HealthNet maximum allowable amount. The provider is not entitled to any recovery from the participant except for services/items which are not covered by the MO HealthNet Program or services/items established by a written agreement between the MO HealthNet participant and provider indicating MO HealthNet is not the intended payer for the specific service/item but rather the participant accepts the status and liability of a private pay patient.
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Section 5 - Third Party Liability Missouri regulation does allow the provider to bill participants for MO HealthNet covered services if, due to the participant's action or inaction, the provider is not reimbursed by the MO HealthNet Program. It is the providers responsibility to document the facts of the case. Otherwise, the MO HealthNet agency rules in favor of the participant. 5.1.D PROVIDERS MAY NOT REFUSE SERVICE DUE TO TPL
The Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 contained a number of changes affecting the administration of a states Medicaid TPL Program. A provision of this law implemented by Federal Regulations effective February 15, 1990, is described below: Under law and federal regulation, a provider may not refuse to furnish services covered under a states Medicaid plan to an individual eligible for benefits because of a third partys potential liability for the service(s). See 42 CFR 447.20(b). This provision prohibits providers from discriminating against a MO HealthNet participant based on the possible existence of a third party payer. A participant may not be denied services based solely on this criterion. Federal regulation does provide the state with authority to sanction providers who discriminate on this basis. A common misconception is that incorrect information regarding third party liability affects participant eligibility. Providers have refused services to participants until the third party information available to the state is either deleted or changed. Third party information reflects the participant's records at the time the MO HealthNet eligibility is verified and is used to notify providers there is probability of a third party resource. Current MO HealthNet third party information is used when processing provider claims. Therefore, incorrect third party information does not invalidate the participant's eligibility for services. The federal regulation cited in the paragraph above prohibits providers from refusing services because of incorrect third party information in the participant's records.
5.2
HEALTH INSURANCE IDENTIFICATION
Many MO HealthNet participants are dually eligible for health insurance coverage through a variety of sources. The provider should always question the participant or caretaker about other possible insurance coverage. While verifying participant eligibility, the provider is provided information about possible insurance coverage. The insurance information on file at the MO HealthNet Division (MHD) does not guarantee that the insurance(s) listed is the only resource(s) available nor does it guarantee that the coverage(s) remains available.
5.2.A
TPL INFORMATION
MO HealthNet participants may contact Participant Services, (800) 392-2161, if they have any questions concerning their MO HealthNet coverage. Providers may reference a point of service (POS) terminal, the Internet or they may call the interactive voice response (IVR) system at (573) 635-8908 for TPL information. Refer to Sections 1 and 3 for further information. In addition to the insurance company name, city, state and zip code, the Internet, IVR or POS terminal also gives a code indicating the type of insurance coverage available (see Section 5.3). For example, if 03 appears in this space, then the participant has hospital, professional and pharmacy coverage. If the participant does not have any additional health insurance coverage either known or unknown to the MO HealthNet agency, a provider not affected by the specified coverage, such as a dental provider, does not need to complete any fields relating to TPL on the claim form for services provided to that participant. 5.2.B SOLICITATION OF TPR INFORMATION
There may be coverage available to the participant that is not known to MHD. It is the providers responsibility and in his/her best interest to solicit TPR information from the participant or caretaker at the time service is provided whether or not MHD is aware of the availability of a TPR. The fact that the TPR information is unknown to MHD at the time service is provided does not release the liability of the TPR or the underlying responsibility of the provider to utilize those TPR benefits. A few of the more common health insurance resources are: If the participant is married or employed, coverage may be available through the participant's or spouses employment. If the participant is a foster child, the natural parent may carry health insurance for that child. The noncustodial parent may have insurance on the child or may be ordered to provide health insurance as part of his/her child support obligation. CHAMPUS/CHAMPVA or veterans benefits may provide coverage for families of active duty military personnel, retired military personnel and their families, and for disabled veterans, their families and survivors. A veteran may have additional medical coverage if the veteran elected to be covered under the Improved Pension Program, effective in 1979. If the participant is 65 or over, it is very likely that they are covered by Medicare. To meet Medicare Part B requirements, individuals need only be 65 (plus a residency
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Section 5 - Third Party Liability requirement for aliens or refugees) and the Part B premium be paid. Individuals who have been receiving kidney dialysis for at least 3 months or who have received a kidney transplant may also be eligible for Medicare benefits. (For Medicare related billings, see the Medicare Crossover Section in this manual.) If the participant is disabled, coverage may exist under Medicare, Workers Compensation, or other disability insurance carriers. If the participant is an over age disabled dependent (in or out of school), coverage may exist as an over age dependent on most group plans. If the participant is in school, coverage may exist through group plans. A relative may be paying for health insurance premiums on behalf of the participant.
5.3
INSURANCE COVERAGE CODES
Listed below are the codes that identify the type of insurance coverage the participant has: AC AM CA CC DE DM HH HI HO HP IN MA MB MD MH Accident Ambulance Cancer Nursing Home Custodial Care Dental Durable Medical Equipment Home Health Inpatient Hospital Outpatient Hospitalincludes outpatient and other diagnostic services Hospice Hospital Indemnityrefers to those policies where benefits cannot be assigned and it is not an income replacement policy Medicare Supplement Part A Medicare Supplement Part B Physiciancoverage includes services provided and billed by a health care professional Medicare Replacement HMO
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PS RX SC SU VI
Psychiatricphysician coverage includes services provided and billed by a health care professional Pharmacy Nursing Home Skilled Care Surgical Vision
5.4
COMMERCIAL MANAGED HEALTH CARE PLANS
Employers frequently offer commercial managed health care plans to their employees in an effort to keep insurance costs more reasonable. Most of these policies require the patient to use the plans designated health care providers. Other providers are considered out-of-plan and those services are not reimbursed by the commercial managed health care plan unless a referral was made by the commercial managed health care plan provider or, in the case of emergencies, the plan authorized the services (usually within 48 hours after the service was provided). Some commercial managedcare policies pay an out-of-plan provider at a reduced rate. At this time, MO HealthNet reimburses providers who are not affiliated with the commercial managed health care plan. The provider must attach a denial from the commercial managed-care plan to the MO HealthNet claim form for MO HealthNet to consider the claim for payment. Frequently, commercial managed health care plans require a copayment from the patient in addition to the amounts paid by the insurance plan. MO HealthNet does not reimburse copayments. This copayment may not be billed to the MO HealthNet participant or the participant's guardian caretaker. In order for a copayment to be collected the parent, guardian or responsible party must also be the subscriber or policyholder on the insurance policy and not a MO HealthNet participant.
5.5
MEDICAL SUPPORT
It is common for courts to require (usually in the case of divorce or separation) that the noncustodial parent provide medical support through insurance coverage for their child(ren). Medical support is included on all administrative orders for child support established by the Family Support Division. At the time the provider obtains MO HealthNet and third party resource information from the childs caretaker, the provider should ask whether this type of resource exists. Medical support is a primary resource. There are new rules regarding specific situations for which the provider can require the MO HealthNet agency to collect from the medical support resource. Refer to Section 5.7 for details.
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Section 5 - Third Party Liability It must be stressed that if the provider opts not to collect from the third party resource in these situations, recovery is limited to the MO HealthNet payment amount. By accepting MO HealthNet reimbursement, the provider gives up the right to collect any additional amounts due from the insurance resource. Federal regulation requires any excess amounts collected by the MO HealthNet agency be distributed to the participant/policyholder.
5.6
PROVIDER CLAIM DOCUMENTATION REQUIREMENTS
MO HealthNet is not responsible for payment of claims denied by the third party resource if all required forms were not submitted to the TPR, if the TPRs claim filing instructions were not followed, if the TPR needs additional information to process the claim or if any other payment precondition was not met. Postpayment review of claims may be conducted to verify the validity of the insurance denial. The MO HealthNet payment amount is recovered if the denial is related to reasons noted above and MO HealthNet paid the claim. MO HealthNet's timely filing requirements are not extended due to difficulty in obtaining the necessary documentation from the third party resource for filing with MO HealthNet. Refer to Section 4 regarding timely filing limitations. If the provider or participant is having difficulty obtaining the necessary documentation from the third party resource, the provider should contact Program Relations, (573) 751-2896, or the TPL Unit directly, (573) 751-2005, for further instructions. Because difficulty in obtaining necessary TPR documentation does not extend MO HealthNet's timely filing limitations, please contact the TPL Unit or Provider Relations early to obtain assistance. 5.6.A EXCEPTION TO TIMELY FILING LIMIT
The 12-month initial filing rule can be extended if a third party payer, after making a payment to a provider, being satisfied that the payment is proper and correct, later reverses the payment determination, sometimes after 12 months have elapsed, and requests the provider to return the payment. Because TPL was clearly available to cover the full amount of liability, and this was known to the provider, the provider may not have initially filed a claim with the State agency. The problem occurs when the provider, after having repaid the third party, wishes to file the claim with MO HealthNet, and is unable to do so because more than 12 months have elapsed since the date of service. Under this set of circumstances, the provider may file a claim with the MO HealthNet agency later than 12 months from the date of service. The provider must submit this type of claim to the Third Party Liability Unit at P.O. Box 6500, Jefferson City, MO 65102-6500 for special handling. The state may accept and pay this type of claim without regard to the 12-month rule; however, the 24-month rule as found in 45 CFR 95.7 still applies.
5.6.B
TPR CLAIM PAYMENT DENIAL
If the participant eligibility file indicates there is applicable insurance coverage relating to the providers claim type and a third party payment amount is not indicated on the claim, or documentation is not attached to indicate a bonafide denial of payment by the insurance company, the claim is denied for MO HealthNet payment. A bonafide denial is defined as an explanation of benefits from an insurance plan that clearly states that the submitted services are not payable for reasons other than failure to meet claim filing requirements. For instance, a denial from a TPR stating the service is not covered by the plan, exceeds usual and customary charges, or was applied to a deductible are all examples of bonafide denials. The MO HealthNet agency must be able to identify that the denial originated from the TPR and the reason for the denial is clearly stated. If the insurance company uses denial codes, be sure to include the explanation of that code. A handwritten note from the provider or from an unidentifiable source is not a bonafide denial. The claim is denied if the Other accident box in Field #10 of the CMS-1500 claim form is marked and the eligibility file indicates there is an insurance coverage code of 40. MO HealthNet denies payment if the claim does not indicate insurance payment or there is no bonafide TPR denial attached to the claim. Do not mark this box unless the services are applicable to an accident. To avoid unnecessary delay in payment of claims, it is extremely important to follow the claim completion instructions relating to third party liability found in the provider manual. Incorrect completion of the claim form may result in denial or a delay in payment of the claim.
5.7
THIRD PARTY LIABILITY BYPASS
There are certain claims that are not subjected to Third Party Liability edits in the MO HealthNet payment system. These claims are paid subject to all other claim submission requirements being met. MO HealthNet seeks recovery from the third party resource after MO HealthNet reimbursement has been made to the provider. If the third party resource reimburses MO HealthNet more than the maximum MO HealthNet allowable, by federal regulation this overpayment must be forwarded to the participant/policyholder. The provider may choose not to pursue the third party resource and submit a claim to MO HealthNet. The providers payment is limited to the maximum MO HealthNet allowable. The following services bypass Third Party Liability edits in the MO HealthNet claims payment system: The claim is for personal care or homemaker/chore services.
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Section 5 - Third Party Liability The claim is for adult day health care. The claim is for mentally retarded/developmentally disabled (MRDD) waiver services. The claim is for a child who is covered by a noncustodial parents medical support order. The claim is related to preventative pediatric care for those participants under age 21 and has one of the following PRIMARY diagnosis codes: V01-V07.9 V20-V20.2 V70.0 V72.0-V72.3 V73-V75.9 V77.0-V77.7 V78.2-V78.3 V79.2-V79.3 V79.8 V82.3-V82.4 EPS
The claim relates to prenatal care for pregnant women and has one of the following: A. PRIMARY diagnosis codes: V22-V23.9 V28-V28.9 **640-648.9 **651-658.9 **673-673.8 **675-676.9 **671-671.9
** Diagnosis codes require fourth and fifth digits. Claim is exempt from TPL denial only if the fifth digit is 3.
OR B. Procedure Codes: Global DeliveryVaginal 59400 --------------59425, Global Prenatal 59426 59510 --------------Global Cesarean
5.8
MO HEALTHNET INSURANCE RESOURCE REPORT (TPL-4)
Many times a provider may learn of a change in insurance information prior to MO HealthNet as the provider has an immediate contact with their patients. If the provider learns of new insurance information or of a change in the TPL information, they may submit the information to the MO HealthNet agency to be verified and updated to the participant's eligibility file. The provider may report this new information to the MO HealthNet agency using the MO HealthNet Insurance Resource Report. Complete the form as fully as possible to facilitate the verification of the
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Section 5 - Third Party Liability information. Do not attach claims to process for payment. They cannot be processed for payment due to the verification process. Please allow six to eight weeks for the information to be verified and updated to the participant's eligibility file. Providers wanting confirmation of the states response should indicate so on the form and ensure the name and address information is completed in the spaces provided.
5.9
LIABILITY AND CASUALTY INSURANCE
Injuries resulting from an accident/incident (i.e., automobile, work-related, negligence on the part of another person) often place the provider in the difficult position of determining liability. Some situations may involve a participant who: is a pedestrian hit by a motor vehicle; is a driver or passenger in a motor vehicle involved in an accident; is employed and is injured in a work-related accident; is injured in a store, restaurant, private residence, etc., in which the owner may be liable. The state monitors possible accident-related claims to determine if another party may be liable; therefore, information given on the claim form is very important in assisting the state in researching accident cases. 13 CSR 4.030 and 13 CSR 4.040 requires the provider to report the contingent liability to the MO HealthNet Division. Often the final determination of liability is not made until long after the accident. In these instances, claims for services may be billed directly to MO HealthNet prior to final determination of liability; however, it is important that MO HealthNet be notified of the following: details of the accident (i.e., date, location, approximate time, cause); any information available about the liability of other parties; possible other insurance resources; if a lien was filed prior to billing MO HealthNet. This information may be submitted to MO HealthNet directly on the claim form, by calling the TPL Unit, (573) 751-2005, or by completing the Accident Report. Providers may duplicate this form as needed. 5.9.A TPL RECOVERY ACTION
Accident-related claims are processed for payment by MO HealthNet. The Third Party Liability Unit seeks recovery from the potentially liable third party on a postpayment basis. Once MO HealthNet is billed, the MO HealthNet payment precludes any further recovery
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Section 5 - Third Party Liability action by the provider. The MO HealthNet provider may not then bill the participant or his/her attorney. 5.9.B LIENS
Providers may not file a lien for MO HealthNet covered services after they have billed MO HealthNet. If a lien was filed prior to billing MO HealthNet, and the provider subsequently receives payment from MO HealthNet, the provider must file a notice of lien withdrawal for the covered charges with a copy of the withdrawal notice forwarded to: MO HealthNet Division Third Party Liability Unit P.O. Box 6500 Jefferson City, MO 65102-6500. 5.9.C TIMELY FILING LIMITS
MO HealthNet timely filing rules are not extended past specified limits, if a provider chooses to pursue the potentially liable third party for payment. If a court rules there is no liability or the provider is not reimbursed in full or in part because of a limited settlement amount, the provider may not bill the participant for the amounts in question even if MO Healthnet's timely filing limits have been exceeded. 5.9.D ACCIDENTS WITHOUT TPL
MO HealthNet should be billed directly for services resulting from accidents that do not involve any third party liability or where it is probable that MO HealthNet is the only coverage available. Examples are: An accidental injury (e.g., laceration, cut, broken bone) occurs as a result of the participant's own action. A MO HealthNet participant is driving (or riding in) an uninsured motor vehicle that is involved in a one vehicle accident and the participant or driver has no uninsured motorists insurance coverage. If the injury is obviously considered to be no-fault then it should be clearly stated. Providers must be sure to fill in all applicable blocks on the claim form concerning accident information.
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5.10 RELEASE OF BILLING OR MEDICAL RECORDS INFORMATION

The following procedures should be followed when a MO HealthNet participant requests a copy of the providers billing or medical records for a claim paid by or to be filed with MO HealthNet. If an attorney is involved, the provider should obtain the full name of the attorney. In addition, the provider should obtain the name of any liable party, the liable insurance company name, address and policy number. Prior to releasing bills or medical records to the participant, the provider must either contact the MO HealthNet Division, Third Party Liability Unit, P.O. Box 6500, Jefferson City, MO 65102-6500, (573) 751-2005, or complete a MO HealthNet Accident Report or MO HealthNet Insurance Resource Report as applicable. If the participant requires copies of bills or medical records for a reason other than third party liability, it is not necessary to contact the Third Party Liability Unit or complete the forms referenced above. Prior to releasing bills or medical records to the participant, the provider must stamp or write across the bill, Paid by MO HealthNet or Filed with MO HealthNet in compliance with 13 CSR 70-3.040.
5.11 OVERPAYMENT DUE TO RECEIPT OF A THIRD PARTY RESOURCE

If the provider receives payment from a third party resource after receiving MO HealthNet reimbursement for the covered service, the provider must promptly submit an Individual Adjustment Request form to MO HealthNet for the partial or full recovery of the MO HealthNet payment. The amount to be refunded must be the full amount of the other resource payment, not to exceed the amount of the MO HealthNet payment. Refer to Section 6 for information regarding adjustments.
5.12 THE HEALTH INSURANCE PREMIUM PAYMENT (HIPP) PROGRAM

The Health Insurance Premium Payment (HIPP) Program is a MO HealthNet Program that pays for the cost of health insurance premiums for certain MO HealthNet participants. The program purchases health insurance for MO HealthNet-eligible participants when it is determined cost effective. Cost effective means that it costs less to buy the health insurance to cover medical care than to pay for the same services with MO HealthNet funds. The HIPP Program cannot find health insurance policies for MO HealthNet participants, rather it purchases policies already available to participants through employers, former employers, labor unions, credit unions, church affiliations,
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Section 5 - Third Party Liability other organizations, or individual policies. Certain participants may have to participate in this program as a condition of their continued MO HealthNet eligibility. Other participants may voluntarily enroll in the program. Questions about the program can be directed to: MO HealthNet Division TPL Unit - HIPP Section P.O. Box 6500 Jefferson City, MO 65102-6500 or by calling (573) 751-2005.
5.13 DEFINITIONS OF COMMON HEALTH INSURANCE TERMINOLOGY

COINSURANCE: Coinsurance is a percentage of charges for a specific service, which is the responsibility of the beneficiary when a service is delivered. For example, a beneficiary may be responsible for 20 percent of the charge of any primary care visits. MO HealthNet pays only up to the MO HealthNet allowable minus any amounts paid by the third party resource regardless of any coinsurance amount. COMPREHENSIVE INSURANCE PLAN: The comprehensive plan is also sometimes called a wraparound plan. Despite the name, comprehensive plans do not supply coverage as extensive as that of traditional insurance. Instead these plans are labeled comprehensive because they have no separate categories of insurance coverage. A comprehensive plan operates basically like a full major medical plan, with per-person and per-family deductibles, as well as coinsurance requirements. COPAYMENT: Copayments are fixed dollar amounts identified by the insurance policy that are the responsibility of the patient; e.g., $3 that a beneficiary must pay when they use a particular service or services. MO HealthNet cannot reimburse copayment amounts. An insurance plans copayment requirements should not be confused with the MO HealthNet cost sharing (copayment, coinsurance, shared dispensing fee) requirements established for specific MO HealthNet services. DEDUCTIBLE: Deductibles are amounts that an individual must pay out-of-pocket before third party benefits are made available to pay health care costs. Deductibles may be service specific and apply only to the use of certain health care services, or may be a total amount that must be paid for all service use, prior to benefits being available. MO HealthNet pays only up to the MO HealthNet allowable regardless of the deductible amount. FLEXIBLE BENEFIT OR CAFETERIA PLANS: Flexible benefit plans operate rather like a defined contribution pension plan in that the employer pays a fixed and predetermined amount.
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Section 5 - Third Party Liability Employees generally share some portion of the plans premium costs and thus are at risk if costs go up. Flexible benefit plans allow employees to pick what benefits they want. Several types of flexible programs exist, and three of the more popular forms include modular packages, coreplus plans, and full cafeteria plans. Modular plans offer a set number of predetermined policy options at an equal dollar value but includes different benefits. Core-plus plans have a set core of employer-paid benefits, which usually include basic hospitalization, physician, and major medical insurance. Other benefit options, such as dental and vision, can be added at the employees expense. Full cafeteria plans feature employer-paid benefit dollars which employees can use to purchase the type of coverage desired. MANAGED CARE PLANS: Managed care plans generally provide full protection in that subscribers incur no additional expenses other than their premiums (and a copay charge if specified). These plans, however, limit the choice of hospitals and doctors. Managed care plans come in two basic forms. The first type, sometimes referred to as a staff or group model health maintenance organization, encompasses the traditional HMO model used by organizations like Kaiser Permanente or SANUS. The physicians are salaried employees of the HMO, and a patients choice of doctors is often determined by who is on call when the patient visits. The second type of managed care plan is known as an individual (or independent) practice association (IPA) or a preferred provider organization (PPO), each of which is a network of doctors who work individually out of their own offices. This arrangement gives the patient some degree of choice within the group. If a patient goes outside the network, however, the plan reimburses at a lower percentage. Generally an IPA may be prepaid, while a PPO is similar to a traditional plan, in that claims may be filed and reimbursed at a predetermined rate if the services of a participating doctor are utilized. Some IPAs function as HMOs. SELF-INSURANCE PLANS: An alternative to paying premiums to an insurance company or managed-care plan is for an employer to self-insure. One way to self-insure is to establish a section 501(c)(9) trust, commonly referred to as a VEBA (Voluntary Employee Benefit Association). The VEBA must represent employees interest, and it may or may not have employee representation on the board. It is, in effect, a separate entity or trust devoted to providing life, illness, or accident benefits to members. A modified form of self-insurance, called minimum premium, allows the insurance company to charge only a minimum premium that includes a specified percentage of projected annual premiums, plus administrative and legal costs (retention) and a designated percentage of the annual premium. The employer usually holds the claim reserves and earns the interest paid on these funds.
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Section 5 - Third Party Liability Claims administration may be done by the old insurance carrier, which virtually guarantees replication of the former insurance programs administration. Or the self-insurance program can be serviced through the employers own benefits office, an option commonly employed by very large companies of 10,000 or more employees. The final option is to hire an outside third-party administrator (TPA) to process claims. TRADITIONAL INSURANCE PLAN: Provides first-dollar coverage with usually three categories of benefits: (1) hospital, (2) medical/surgical, and (3) supplemental major medical, which provides for protection for medical care not covered under the first two categories. Variations and riders to these plans may offer coverage for maternity care, prescription drugs, home and office visits, and other medical expenses.
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Section 6 - Adjustments
SECTION 6 - ADJUSTMENTS
6.1 6.2 GENERAL REQUIREMENTS .....................................................................................................2 INSTRUCTIONS FOR COMPLETING THE INDIVIDUAL ADJUSTMENT REQUEST FORM ..........................................................................................................................3 6.2.A INSTRUCTIONS FOR COMPLETION OF INDIVIDUAL ADJUSTMENTS VIA THE INTERNET................................................................................................................................5 6.3 EXPLANATION OF THE ADJUSTMENT TRANSACTIONS ................................................6
SECTION 6-ADJUSTMENTS 6.1 GENERAL REQUIREMENTS
Providers who are paid incorrectly for a claim may use the most current Individual Adjustment Request form to request an adjustment. Providers may submit paper individual adjustment requests however MO HealthNets preferred method is via the Internet. Medicare crossover claims must be adjusted (voided/replaced) via the internet. Adjustments may not be requested when the net difference in payment is less than $4.00, or $.25 for pharmacy, per claim. If the adjustment is due to an insurance payment, or involves Medicare, the $4.00, or $.25, minimum limitation does not apply. Medicare crossover claims must be done via the internet, reference Bulletin dated 07/01/05. For crossover claims past MO HealthNets timely filing guidelines, see Section 4 for requirements for adjustments and claim resubmissions. In some instances, more than one change may be necessary on a claim. ALL the changes to the claim must be addressed on the same Individual Adjustment Request form. Specify all the changes required, addressing each change separately. Field #15 of the form may be used to provide additional information. More than one claim cannot be processed per Individual Adjustment Request form. Each adjustment request addresses one particular claim. A separate Individual Adjustment Request form must be completed for each claim that requires changes, even if the changes or errors are of a similar nature or are for the same patient. Providers submitting adjustment requests for change of procedure codes must provide documentation for these changes. A copy of the original claim and the medical or operative report must be attached, along with any other information pertaining to the claim. When providers submit paper adjustments that do not have the required fields completed, the adjustment will be recouped and providers are required to resubmit the claim for payment. If an adjustment does not appear on a Remittance Advice within 90 days of submission, a copy of the original Individual Adjustment Request and attachments should be resubmitted. Photocopies are acceptable. Mark this copy with the word TRACER. Submitting another request without indicating it as a TRACER can further delay processing. Adjustments for claim credits submitted via the Internet get an immediate adjudication. Reference Claim Management after submission to confirm the acceptance and indicate the status of the adjustment. If the Internal Control Number (ICN) on the credit adjustment is not valid, the confirmation file indicates such. If no confirmation is received, the provider should resubmit the claim credit.
Section 6 - Adjustments If a claim has been adjusted but the payment is still incorrect, another adjustment may be requested. The Internal Control Number (ICN) from the most recent payment must be used on the Individual Adjustment Request (the ICN begins with a 50 or 55). See Section 4 for timely filing requirements for adjustments and claim resubmissions. Individual Adjustment Requests are to be submitted to the address shown on the form: MO HealthNet Division Adjustment Unit P.O. Box 6500 Jefferson City, MO 65102 Individual Adjustment Requests are not accepted by telephone. Individual adjustments may be done via the Internet. The web site address is www.emomed.com. Providers wishing to access the Internet web site, www.emomed.com, must complete the on-line Application for MO HealthNet Internet Access Account. Please reference http://dss.missouri.gov/mhd/ and click on the Apply for Internet Access link. Providers are unable to access www.emomed.com without proper authorization. An authorization is required for each individual user. NOTE: Providers must be enrolled as an electronic billing provider. See Section 2.1.D.
6.2
INSTRUCTIONS FOR COMPLETING THE INDIVIDUAL ADJUSTMENT REQUEST FORM
Fields with an asterisk (*) are required information and must be completed. Check the appropriate box at the top of the form indicating whether the adjustment is to correct an overpayment or underpayment. FIELD NUMBER & NAME 1. Claim Copy 2. Remittance Advice Copy INSTRUCTIONS FOR COMPLETION A copy of the original claim may be attached to the adjustment to assist in processing. A copy of that Remittance Advice page must be attached to the Individual Adjustment Request form. Enter the 13-digit ICN from the Remittance Advice for the claim in question. Enter the eight-digit MO HealthNet ID number as printed on the Remittance
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*3. Internal Control Number (ICN) *4. Participant MO HealthNet Number
Section 6 - Adjustments Advice. *5. Provider Label Place the provider label in this space. If a provider does not use the label, they must enter their provider number, name, and address in this space. Use of the provider label saves time and helps eliminate errors. Enter the participants name as shown on the ID card. Enter the Remittance Advice date. Enter the page number from the upper right corner of the Remittance Advice that pertains to the claim in question. Under Information on Remittance Advice enter the incorrect quantity or units as shown on the Remittance Advice. Under Corrected Information enter the corrected quantity or units. Under Information on Remittance Advice enter incorrect national drug code (NDC) or procedure code shown on the Remittance Advice. Under Corrected Information enter the corrected NDC or procedure code. Under Information on Remittance Advice enter the service date as it appears on the Remittance Advice. Under Corrected Information enter the corrected date of service. Under Information on Remittance Advice enter the billed amount as it appears on the Remittance Advice. Do not put the payment amount in this location. Under Corrected Information enter the corrected billed amount. Under Information on Remittance Advice enter the paid amount as it appears on the Remittance Advice. Under Corrected
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*6. Participant Name 7. Remittance Advice Date R.A. Page Number
8. Qty/Units
9. NDC/Procedure Code
*10. Service Date(s)
11. Billed Amount
12. Paid Amount
Section 6 - Adjustments Information, the correct payment amount may be entered. 13. Patient Surplus (Nursing Home, Mental Health Facilities, and Hospice) For correction of patient surplus (participant liability) amount, enter the patient surplus shown on the Remittance Advice under Information on Remittance Advice. Enter the corrected patient surplus under Corrected Information. For other resource payment, enter the amount paid by the other resource under Corrected Information and give the name of the source. Enter the specific reason for this request, if not specified elsewhere, and any other information pertinent to this claim. This field may be used to provide additional information for any of the previous lines, or additional pages may be attached. Do not use a second Individual Adjustment Request as the second page. The signature of the provider or other authorized party is entered on this line. The date the request is completed is entered on this line.
14. Other Resources (TPL) (Identify Source)
*15. Other/Remarks
*16. Providers Signature Date

* Required field.
6.2.A
INSTRUCTIONS FOR COMPLETION OF INDIVIDUAL ADJUSTMENTS VIA THE INTERNET
When a provider bills electronically it is expected that the adjustments or voids will be done electronically. To do these on line the provider logs onto the MO HealthNet billing site at www.emomed.com. The provider enters the participant DCN and DOS in the search box and clicks on the highlighted ICN of the claim to be adjusted. The provider then clicks on Void to delete a paid claim or Replacement if corrections/additions need to be made to a paid claim. If the provider is still billing paper claims they may still send in paper adjustment forms. Electronic claims over two years old may not be adjusted on line.
6.3
1.
EXPLANATION OF THE ADJUSTMENT TRANSACTIONS

An adjustment that credits the original payment and then repays the claim based on the adjusted information appears on the Remittance Advice as a two-step transaction consisting of two ICNs. An ICN that credits (recoups) the original paid amount and An ICN that repays the claim with the corrected payment amount. 2. An adjustment that credits or recoups the original payment but does not repay the claim (resulting in zero payment) appears on the Remittance Advice with one ICN that credits (recoups) the original paid amount.
There are two (2) types of adjustment transactions:
NOTE: If a provider submits an on-line adjustment, the provider should not send in a check and paper adjustment for the same adjustment.
Section 7 - Medical Necessity
SECTION 7 - MEDICAL NECESSITY

7.1 CERTIFICATE OF MEDICAL NECESSITY ............................................................................2 CERTIFICATE OF MEDICAL NECESSITY FOR DURABLE MEDICAL EQUIPMENT PROVIDERS .....................................................................................................3 7.2 INSTRUCTIONS FOR COMPLETING THE CERTIFICATE OF MEDICAL NECESSITY ....................................................................................................................................3
7.1.A
SECTION 7-MEDICAL NECESSITY
7.1
CERTIFICATE OF MEDICAL NECESSITY
The MO HealthNet Program requires that the Certificate of Medical Necessity form accompany claims for reimbursement for certain procedures, services or circumstances. Section 13, Benefits and Limitations, identifies circumstances for which a Certificate of Medical Necessity form is required for each program. Additional information regarding the use of this form may also be found in Section 14, Special Documentation Requirements. Listed below are several examples of claims for payment that must be accompanied by a completed Certificate of Medical Necessity form. This list is not all inclusive. Claims for services that are performed as emergency procedures which, under nonemergency circumstances, require special documentation such as a Prior Authorization Request. Claims for inpatient hospital private rooms unless all patient rooms in the facility are private. Claims for services for TEMP participants that are not covered by the TEMP Program but without which the pregnancy would be adversely affected. Claims for specific durable medical equipment. Use of this form for other than the specified conditions outlined in the providers manual has no bearing on the payment of a claim. The medical reason why the item, service, or supplies were needed must be stated fully and clearly on the Certificate of Medical Necessity form. The form must be related to the particular patient involved and must detail the risk to the patient if the service(s) had not been provided. The Certificate of Medical Necessity form must be either submitted electronically with the electronic claim or submitted on paper attached to the original claim form. For information regarding submission of the Certificate of Medical Necessity for claims submitted by a Durable Medical Equipment provider see Section 7.1.A. If a claim is resubmitted, the provider must again attach a copy of the Certificate of Medical Necessity form. Medical consultants and medical review staff review the Certificate of Medical Necessity form and the claim form to make a determination regarding payment of the claim. If the medical necessity of the service is supported by the documentation, the claim is approved for further processing. If medical necessity is not documented or supported, the claim is denied for payment.
7.1.A
CERTIFICATE OF MEDICAL NECESSITY FOR DURABLE MEDICAL EQUIPMENT PROVIDERS
The Certificate of Medical Necessity for durable medical equipment should not be submitted with a claim form. This attachment may be submitted via the Internet (see Section 3.8 and Section 23) or mailed to: Wipro Infocrossing P.O. Box 5900 Jefferson City, MO 65102 If the Certificate of Medical Necessity is approved, the approved time period is six months from the prescription date. Any claim matching the criteria (including the type of service) on the Certificate of Medical Necessity for the approved time period can be processed for payment without a Certificate of Medical Necessity attached. This includes all monthly claim submissions and any resubmissions.
7.2
INSTRUCTIONS FOR COMPLETING THE CERTIFICATE OF MEDICAL NECESSITY

INSTRUCTIONS FOR COMPLETION Enter last name, first name and middle initial as shown on the ID card. Enter the 8-digit MO HealthNet ID number exactly as it appears on the particpants ID card or letter of eligibility. Enter the appropriate CPT-4 code, CDT-3 code, revenue code or HCPCS procedure code (maximum of 6 procedure/revenue codes allowed per claim, 1 code per line). For each procedure/revenue code listed, describe in detail the service or item being provided. For each procedure/revenue code listed, state clearly the medical necessity for this service/item.
FIELD NUMBER & NAME 1. Patient Name 2. MO HealthNet ID Number
3. Procedure/Revenue Codes
4. Description of Item/Service
5. Reason for Service
6. Months Item Needed (DME only) 7. Name and Signature of Prescriber
For each procedure code listed, enter the amount of time the item is necessary (Durable Medical Equipment Program only). The prescriber's signature, when required, must be an original signature. A stamp, facsimile, or the signature of a prescriber's employee is not acceptable. A signature is not required here if the prescriber is the provider (Fields #12 thru #14). Enter the NPI number if the prescriber participates in the MO HealthNet Program. Enter the date the service or item was prescribed or identified by the prescriber as medically necessary in month/date/year numeric format, if required by program. This date must be prior to or equal to the date of service. Enter the appropriate ICD-9 code(s) that prompted the request for this service or item, if required by program. Enter the participant's prognosis and the anticipated results of the requested service or item. Enter provider's name, address, and telephone number or use provider label. Enter provider's NPI number. The provider must sign here with an original signature. This certifies that the information given on the form is true, accurate and complete.
8. Prescriber's MO HealthNet Provider Identifier 9. Date Prescribed
10. Diagnosis
11. Prognosis
12. Provider Name and Address 13. MO HealthNet Provider Identifier 14. Provider Signature
Section 8 - Prior Authorization
SECTION 8 - PRIOR AUTHORIZATION

8.1 8.2 8.3 8.4 8.5 BASIS ...............................................................................................................................................2 PRIOR AUTHORIZATION GUIDELINES ................................................................................2 PROCEDURE FOR OBTAINING PRIOR AUTHORIZATION..............................................3 EXCEPTIONS TO THE PRIOR AUTHORIZATION REQUIREMENT ...............................4 INSTRUCTIONS FOR COMPLETING THE PRIOR AUTHORIZATION REQUEST FORM ..............................................................................................................................................5 8.6 PRIOR AUTHORIZATION (PA) REQUEST .............................................................................6 WHEN TO SUBMIT A PRIOR AUTHORIZATION (PA) REQUEST ....................................6
8.6.A 8.7
MO HEALTHNET AUTHORIZATION DETERMINATION .................................................7 A DENIAL OF PRIOR AUTHORIZATION REQUESTS .......................................................8 MO HEALTHNET AUTHORIZATION DETERMINATION EXPLANATION....................8
8.7.A 8.7.B 8.8
REQUEST FOR CHANGE (RFC) OF PRIOR AUTHORIZATION (PA) REQUEST ..........9 WHEN TO SUBMIT A REQUEST FOR CHANGE (RFC) ......................................................9
8.8.A 8.9
DEPARTMENT OF HEALTH AND SENIOR SERVICES (DHSS) ......................................10
8.10 OUT-OF-STATE, NON-EMERGENCY SERVICS .................................................................11 8.10.A EXCEPTIONS TO OUT-OF-STATE PRIOR AUTHORIZATION (PA) REQUESTS ......11
SECTION 8-PRIOR AUTHORIZATION
8.1
BASIS
Under the MO HealthNet Program, certain covered services and equipment require approval from the Department of Social Services, MO HealthNet Division, prior to provision of the service as a condition of reimbursement. Prior authorization is used to promote the most effective and appropriate use of available services and to determine the medical necessity of the service. Please refer to Sections 13 and 14 for program-specific information regarding prior authorization.
8.2
PRIOR AUTHORIZATION GUIDELINES
Providers are required to seek prior authorization for certain specified services before delivery of the services. In addition to services that are available through the traditional MO HealthNet Program, expanded services are available to children 20 years of age and under through the Healthy Children and Youth (HCY) Program. Some expanded services also require prior authorization. Certain services require prior authorization only when provided in a specific place or when they exceed certain limits. These limitations are explained in detail in Sections 13 and 14 of the applicable provider manuals. The following general guidelines pertain to all prior authorized services: A Prior Authorization (PA) Request must be completed and mailed to the appropriate address. Unless otherwise specified in Sections 13 and 14 of the manual, mail requests to: Infocrossing Healthcare Services P.O. Box 5700 Jefferson City, MO 65102 A PA Request form can be printed and completed by hand or the form can be completed in Adobe and then printed. To enter information into a field, either click in the field or tab to the field and complete the information. When all the fields are finished, print the PA Request and send to the address listed above. The provider performing the service must submit the Prior Authorization Request form. Sufficient documentation or information must be included with the request to determine the medical necessity of the service. The service must be ordered by a physician, nurse practitioner, dentist, or other appropriate health care provider.
Section 8 - Prior Authorization Do not request prior authorization for services to be provided to an ineligible person. (see Sections 1 and 13). Expanded HCY (EPSDT) services are limited to participants 20 years of age and under and are not reimbursed for participants 21 and over even if prior authorized. See Section 20 for specific criteria and guidelines regarding prior authorization of noncovered services through the Exceptions Process for participants 21 and over. Prior authorization does not guarantee payment if the participant is or becomes enrolled in managed care and the service is a covered benefit. Payment is not made for services initiated before the approval date on the Prior Authorization Request form or after the authorization deadline. For services to continue after the expiration date of an existing Prior Authorization Request, a new Prior Authorization Request must be completed and mailed.
8.3
PROCEDURE FOR OBTAINING PRIOR AUTHORIZATION
Complete the Prior Authorization Request form describing in detail those services or items requiring prior authorization and the reason the services or items are needed. With the exception of x-rays, dental molds, and photos, documentation submitted with the Prior Authorization Request is not returned. Providers should retain a copy of the original Prior Authorization Request and any supporting documentation submitted for processing. Instructions for completing the Prior Authorization Request form are on the back of the form. Unless otherwise stated in Section 13 or 14 of the provider manual, mail the Prior Authorization Request form and any required attachments to: Infocrossing Healthcare Services P.O. Box 5700 Jefferson City, Missouri 65102 The appropriate program consultant reviews the request. A MO HealthNet Authorization Determination is returned to the provider with any stipulations for approval or reason for denial. If approved, services may not exceed the frequency, duration or scope approved by the consultant. If the service or item requested is to be manually priced, the consultant enters the allowed amount on the MO HealthNet Authorization Determination. The provider should keep the approved MO HealthNet Authorization Determination for their files; do not return it with the claim. After the authorized service or item is provided, the claim form must be completed and submitted in the usual manner. Providers are cautioned that an approved authorization approves only the medical necessity of the service and does not guarantee payment. Claim information must still be complete and correct, and the provider and the participant must both be eligible at the time the service is rendered or item delivered. Program restrictions such as age, category of
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Section 8 - Prior Authorization assistance, managed care, etc., that limit or restrict eligibility still apply and services provided to ineligible participants are not reimbursed. If the request for authorization of services is denied, the provider receives a MO HealthNet Authorization Determination (Reference Section 8.7). The participant is notified by letter each time a request for prior authorization is denied. (Reference Section 1 for a sample Prior Authorization Request Denial.)
8.4
EXCEPTIONS TO THE PRIOR AUTHORIZATION REQUIREMENT

Medicare crossovers when Medicare makes the primary reimbursement and MO HealthNet pays only the coinsurance and deductible. Procedures requiring prior authorization that are performed incidental to a major procedure. Services performed as an emergency. Emergency services are services required when there is a sudden or unforeseen situation or occurrence, or a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in: 1. Placing the patients health in serious jeopardy; or 2. Serious impairment to bodily functions; or 3. Serious dysfunction of any bodily organ or part. In the case of an emergency when prior authorization cannot be obtained before the service or item is rendered, the necessary and appropriate emergency service should be provided. Complete the claim form and write emergency across the top of the claim form. Do not submit a Prior Authorization Request form. Attach a Certificate of Medical Necessity form to the claim and submit it to the appropriate address (reference Section 15). The provider must state on the Certificate of Medical Necessity form, in detail, the reason for the emergency provision of service. (See Section 7 for information on completing a Certificate of Medical Necessity form.) Emergency requests are suspended and reviewed by the appropriate medical consultant. If the Certificate of Medical Necessity form is not attached or the reason does not substantiate the provision of the service on an emergency basis, the claim is denied. The participant was not eligible for MO HealthNet at the time of service, but eligibility was made retroactive to that time. Submit a claim along with a Certificate of Medical Necessity form to the appropriate address (reference Section 15). The provider must state on the Certificate of Medical Necessity form that the participant was not eligible on the date of
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Exceptions to prior authorization requirements are limited to the following:
Section 8 - Prior Authorization service, but has become eligible retroactively to that date. The provider must also include, in detail, the reason for the provision of service. (See Section 7 for information on completing a Certificate of Medical Necessity form.) Retroactive eligibility requests are suspended and reviewed by the appropriate medical consultant. If the Certificate of Medical Necessity form is not attached or the reason does not substantiate the provision of the service, the claim is denied.
8.5
INSTRUCTIONS FOR COMPLETING THE PRIOR AUTHORIZATION REQUEST FORM
Instructions for completing the Prior Authorization (PA) Request form are printed on the back of the form. Additional clarification is as follows: Section II, HCY Service Request, is applicable for participants 20 years of age and under and should be completed when the information is known. In Section III, Service Information, the gray area is for State Use only. Also, the PA Request forms must reflect the appropriate service modifier with procedure code and other applicable modifiers when requesting prior authorization for the services defined below: Service Modifier 26 54 55 80 AA NU QK QX QZ RP RR SG TC Definition Professional Component Surgical Care Only Postoperative Management Only Assistant Surgeon Anesthesia Service Performed Personally by Anesthesiologist New Equipment (required for DME service) Medical Direction of 2, 3, or 4 Concurrent Anesthesia Procedures Involving Qualified Individuals CRNA (AA) Service; with Medical Direction by a Physician CRNA Service; without Medical Direction by a Physician Replacement and Repair (required for DME service) Rental (required for DME service) Ambulatory Surgical Center (ASC) Facility Services Technical Component
Section V, Prescribing/Performing Practitioner, must be completed for services which require a prescription such as durable medical equipment, physical therapy, or for services
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Section 8 - Prior Authorization which are prescribed by a physician/practitioner that require prior authorization. Check the provider manual for additional instructions. The provider receives a MO HealthNet Authorization Determination (Refer to Section 8.7) indicating if the request has been approved or denied. Any comments made by the MO HealthNet/Mc+ consultant may be found in the comments section of the MO HealthNet Authorization Determination. The provider does not receive the Prior Authorization Request or a copy of the Prior Authorization Request form back. It is the providers responsibility to request prior authorization or reauthorization, and to notify the MO HealthNet Division of any changes in an existing period of authorization.
8.6
PRIOR AUTHORIZATION (PA) REQUEST
Providers are encouraged to follow the steps outlined on the back of the form to assure proper completion of an initial submission for prior authorization. Complete Section I. Complete Section II if the participant is under the age of 21 and the services requested are expanded Healthy Children and Youth services. Complete Section III. Field #24 in Section III, in addition to being used to document medical necessity, can also be used to identify unusual circumstances or to provide detailed explanations when necessary. Additional pages may be attached to the Prior Authorization Request for documentation. Place a provider label in Section IV or complete each field in that section. See Sections 13 and 14 of the provider manual to determine if a signature and date are required in this field. Requirements for signature are program specific. Section V is only required for certain programs. Refer to the program requirements in Sections 13 and 14 of the provider manual. 8.6.A WHEN TO SUBMIT A PRIOR AUTHORIZATION (PA) REQUEST
Providers may submit a PA Request to: Initiate the start of services that require prior authorization. Request continued services when services continue to be medically necessary beyond the current approved period of time.
Section 8 - Prior Authorization 1. The procedure for the services requested cannot overlap dates that are already approved and must be submitted far enough in advance to obtain approval prior to the expiration of the current approved PA Request. Correct a participant MO HealthNet number if the original PA Request had a number on it and services were approved. 1. When requesting a PA Request due to an error in the participant MO HealthNet number on the original PA Request, attach a copy of the MO HealthNet Authorization Determination giving original approval to the new request. 2. Fields #17 through #23 in Section III must be identical to the original approval. 3. The PA Request form should be clearly marked as a correction of the participant MO HealthNet number and the error must be explained in detail in Field #24 of Section III. 4. Mark the PA Request Special Handle at the top of the form. Change providers within a group during an approved authorization period. 1. When requesting a PA Request due to a change of provider within a group, attach a copy of the MO HealthNet Authorization Determination showing the approval to the new PA Request form. 2. Section III, Field #19 FROM must be the date the new provider begins services and field 20 THROUGH cannot exceed the through date of the previously approved PA Request. 3. The PA Request form should be clearly marked at the top change of provider, and the change must be explained in Field #24 of Section III. 4. Mark the PA Request Special Handle at the top of the form. Use Field #24 to provide a detailed explanation.
8.7
MO HEALTHNET AUTHORIZATION DETERMINATION
The MO HealthNet Authorization Determination is sent to the provider who submitted the Prior Authorization Request. The MO HealthNet Authorization Determination includes all data pertinent to the PA Request. The MO HealthNet Authorization Determination includes the PA number; the authorized provider number, name and address; the participant's DCN, name, and date of birth; the procedure code, the from and through dates (if approved), and the units or dollars (if approved); the status of the Prior Authorization Request on each detail line ("A"-approved; "C"-closed; "D"-denied; and "I"-incomplete); and the applicable Explanation of Benefit (EOB) reason(s), with the reason code description(s) on the reverse side of the determination.
8.7.A
A DENIAL OF PRIOR AUTHORIZATION REQUESTS
The MO HealthNet Authorization Determination indicates a denied authorization by reflecting a status on each detail line of "D" for a denial of the requested service or "I" for a denial due to incomplete information on the form. With either denial status, "D" or "I", a new Prior Authorization Request form must be submitted for the request to be reconsidered. 8.7.B MO HEALTHNET AUTHORIZATION DETERMINATION EXPLANATION
The following lists the fields found on the MO HealthNet Authorization Determination and an explanation of each field. FIELD NAME Date Request Number (No.) Receipt Date Service Provider Participant Procedure Code Modifier Authorization Dates Units Dollars Status EXPLANATION OF FIELD Date of the disposition letter Prior Authorization Number Date the PA Request was received by the fiscal agent Authorized provider number, name and address Participant's DCN, name, date of birth and sex The procedure code The modifier(s) The authorized from and thru dates The units requested, units authorized (if approved), units used The dollar amount requested, dollar amount authorized (if approved), dollar amount used The status codes of the PA Request The status codes are: AApproved CClosed DDenied IIncomplete Reason Comments The applicable Explanation of Benefit (EOB) reason(s) Comments by the consultant which may explain denials or
8
Section 8 - Prior Authorization make notations referencing specific procedure code(s) Physician/Provider Signature Date Reason Code Description Signature of provider when submitting a Request for Change (RFC) Date of providers signature when submitting a RFC Reason code description(s) listed in Reason field
8.8
REQUEST FOR CHANGE (RFC) OF PRIOR AUTHORIZATION (PA) REQUEST
To request a change to an approved PA Request, providers are required to make the applicable changes on the MO HealthNet Authorization Determination. Attach additional documentation per program requirement if the requested change is in frequency, amount, duration or scope or if it documents an error on the original request, e.g., plan of care, physician orders, etc. The amended MO HealthNet Authorization Determination must be signed and dated and submitted with applicable documentation to the address below. When changes to an approved PA Request are made on the MO HealthNet Authorization Determination, the MO HealthNet Authorization Determination is referred to as a Request For Change (RFC). Requests for reconsideration of any detail lines that reflect a "D" or "I" status must not be included on an RFC. Providers must submit a new PA Request form for reconsideration of denied detail lines. When an RFC is approved, a MO HealthNet Authorization Determination incorporating the requested changes is sent to the provider. When an RFC is denied, the MO HealthNet Authorization Determination sent to the provider indicates the same information as the original MO HealthNet Authorization Determination that notified the provider of approval, with an EOB stating that the requested changes were considered but were not approved. Providers must not submit changes to PA Requests until the MO HealthNet Authorization Determination from the initial request is received. Unless otherwise stated in Section 13 or 14 of the provider manual, PA Request forms and RFCs should be mailed to: Infocrossing Healthcare Services P. O. Box 5700 Jefferson City, MO 65102 8.8.A WHEN TO SUBMIT A REQUEST FOR CHANGE (RFC)
Providers may submit a RFC to: Correct a procedure code.

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Section 8 - Prior Authorization Correct a modifier. Add a new service to an existing plan of care. Correct or change the from or through dates. 1. The from date may not precede the approval date on the original request unless the provider can provide documentation that the original approval date was incorrect. 2. The through date cannot be extended beyond the allowed amount of time for the specific program. In most instances extending the end date to the maximum number of days allowed requires additional information or documentation. Increase or decrease requested units or dollars. 1. An increase in frequency and or duration in some programs require additional or revised information. Correct the provider number. The provider number can only be corrected if both of the following conditions are met: The number on the original request is in error; The provider was not reimbursed for any units on the initial Prior Authorization Request. Discontinue services for a participant.
8.9
DEPARTMENT OF HEALTH AND SENIOR SERVICES (DHSS)
PA Requests and RFCs for the Personal Care and Home Health Programs' services for children under the age of 21 must be submitted to DHSS, Bureau of Special Health Care Needs (BSHCN) for approval consideration. The BSHCN submits the request to Infocrossing Healthcare Services. The BSHCN staff continues to complete and submit PA Requests and RFCs for Private Duty Nursing and Physical Disabilities Waiver Programs' services. PA Requests and RFCs for AIDS Waiver and Personal Care Programs' services for individuals with HIV/AIDS continue to be completed and submitted by the DHSS, Section of STD/HIV contract case management staff. Personal Care and Aged and Disabled Waiver Programs' services continue to be authorized by DHSS, Division of Senior Services and Regulation staff through the Long Term Alternative Care Services (LTACS) system. The LTACS system has been upgraded to allow 12 detail lines of service information. Please reference the provider manual for further information.
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8.10 OUT-OF-STATE, NON-EMERGENCY SERVICS

All non-emergency, MO HealthNet covered services that are to be performed or furnished out-ofstate for eligible MO HealthNet participants and for which MO HealthNet is to be billed, must be prior authorized before the services are provided. Services that are not covered by the MO HealthNet Program are not approved. Out-of-state is defined as not within the physical boundaries of the State of Missouri nor within the boundaries of any state that physically borders on the Missouri boundaries. Border-state providers of services (those providers located in Arkansas, Illinois, Iowa, Kansas, Kentucky, Nebraska, Oklahoma and Tennessee) are considered as being on the same MO HealthNet participation basis as providers of services located within the State of Missouri. A Prior Authorization Request form is not required for out-of-state nonemergency services. To obtain prior authorization for out-of-state, nonemergency services, a written request must be submitted by a physician to: MO HealthNet Division Participant Services Unit P.O. Box 6500 Jefferson City, MO 65102 The request may be faxed to (573) 526-2471. The written request must include: 1. 2. 3. 4. A brief past medical history. Services attempted in Missouri. Where the services are being requested and who will provide them. Why services cant be done in Missouri.
NOTE: The out-of-state medical provider must agree to complete an enrollment application and accept MO HealthNet reimbursement. Prior authorization for out-of-state services expires 180 days from the date the specific service was approved by the state. 8.10.A EXCEPTIONS TO OUT-OF-STATE PRIOR AUTHORIZATION (PA) REQUESTS
The following are exempt from the out-of-state prior authorization requirement: 1. All Medicare/MO HealthNet crossover claims. 2. All Foster Care children living outside the State of Missouri. However, nonemergency services that routinely require prior authorization continue to require
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Section 8 - Prior Authorization prior authorization by out-of-state providers even though the service was provided to a Foster Care child. 3. Emergency ambulance services 4. Independent laboratory services
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Section 9 - Healthy Children and Youth Program
SECTION 9 - HEALTHY CHILDREN AND YOUTH PROGRAM

9.1 9.2 9.3 9.4 9.5 9.6 GENERAL INFORMATION .......................................................................................................4 PLACE OF SERVICE...................................................................................................................4 TYPE OF SERVICE (TEXT DEL. 9/04)......................................................................................5 DIAGNOSIS CODE.......................................................................................................................5 INTERPERIODIC SCREENS .....................................................................................................5 FULL HCY/EPSDT SCREEN ......................................................................................................6 QUALIFIED PROVIDERS .....................................................................................................7
9.6.A 9.7
PARTIAL HCY/EPSDT SCREENS ............................................................................................7 DEVELOPMENTAL ASSESSMENT ....................................................................................8 Qualified Providers ..........................................................................................................8
9.7.A
9.7.A(1) 9.7.B
UNCLOTHED PHYSICAL, ANTICIPATORY GUIDANCE, AND INTERVAL
HISTORY, LAB/IMMUNIZATIONS AND LEAD SCREEN................................................................9 9.7.B(1) 9.7.C Qualified Providers ..........................................................................................................9
VISION SCREENING .............................................................................................................9 Qualified Providers ........................................................................................................10
9.7.C(1) 9.7.D
HEARING SCREEN .............................................................................................................10 Qualified Providers ........................................................................................................10
9.7.D(1) 9.7.E
DENTAL SCREEN ...............................................................................................................11 Qualified Providers ........................................................................................................11
9.7.E(1) 9.7.F 9.8
ALL PARTIAL SCREENERS...............................................................................................11
LEAD RISK ASSESSMENT AND TREATMENTHEALTHY CHILDREN AND
YOUTH (HCY) ........................................................................................................................................12 9.8.A 9.8.B 9.8.C SIGNS, SYMPTOMS AND EXPOSURE PATHWAYS ......................................................12 LEAD RISK ASSESSMENT.................................................................................................15 MANDATORY RISK ASSESSMENT FOR LEAD POISONING .......................................15 Risk Assessment ............................................................................................................15 Determining Risk ...........................................................................................................15 Screening Blood Tests ...................................................................................................16
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9.8.C(1) 9.8.C(2) 9.8.C(3) General Manual
Production - 04/30/2012
Section 9 - Healthy Children and Youth Program 9.8.C(4) 9.8.D 9.8.E MO HealthNet Managed Care Health Plans ..................................................................17
LABORATORY REQUIREMENTS FOR BLOOD LEAD LEVEL TESTING ...................17 BLOOD LEAD LEVELRECOMMENDED INTERVENTIONS .....................................18 Blood Lead Level <10 g/dL.........................................................................................18 Blood Lead Level 10-19 g/dL .....................................................................................18 Blood Lead Level 20-44 g/dL .....................................................................................18 Blood Lead Level 45-69 g/dL .....................................................................................19 Blood Lead Level 70 g/dL or Greater .........................................................................20
9.8.E(1) 9.8.E(2) 9.8.E(3) 9.8.E(4) 9.8.E(5) 9.8.F 9.8.G
COORDINATION WITH OTHER AGENCIES ...................................................................20 ENVIRONMENTAL LEAD INVESTIGATION ..................................................................21 Environmental Lead Investigation .................................................................................21
9.8.G(1) 9.8.H 9.8.I 9.8.J 9.8.K
ABATEMENT .......................................................................................................................22 LEAD CASE MANAGEMENT ................................................................................................22 POISON CONTROL HOTLINE TELEPHONE NUMBER .....................................................22 MO HEALTHNET ENROLLED LABORATORIES THAT PERFORM BLOOD LEAD
TESTING ...............................................................................................................................................22 9.8.L OUT-OF-STATE LABS CURRENTLY REPORTING LEAD TEST RESULTS TO
THE MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES .....................................23 9.9 9.10 HCY CASE MANAGEMENT ....................................................................................................24 IMMUNIZATIONS .....................................................................................................................25 VACCINE FOR CHILDREN (VFC) .....................................................................................25
9.10.A 9.11 9.12
ASSIGNMENT OF SCREENING TIMES ...............................................................................25 PERIODICITY SCHEDULE FOR HCY (EPSDT) SCREENING SERVICES ....................25 DENTAL SCREENING SCHEDULE...................................................................................26 VISION SCREENING SCHEDULE .....................................................................................26 HEARING SCREENING SCHEDULE.................................................................................26
9.12.A 9.12.B 9.12.C 9.13
REFERRALS RESULTING FROM A FULL, INTERPERIODIC OR PARTIAL
SCREENING ............................................................................................................................................26 9.13.A PRIOR AUTHORIZATION FOR NON-STATE PLAN SERVICES (EXPANDED HCY
SERVICES) ...........................................................................................................................................27
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Section 9 - Healthy Children and Youth Program 9.14 9.15 9.16 9.17 9.18 PARTICIPANT NONLIABILITY .............................................................................................27 EXEMPTION FROM COST SHARING AND COPAY REQUIREMENTS ......................27 STATE-ONLY FUNDED PARTICIPANTS .............................................................................27 MO HEALTHNET MANAGED CARE ....................................................................................27 ORDERING HEALTHY CHILDREN AND YOUTH SCREENING AND HCY LEAD
SCREENING GUIDE..............................................................................................................................29
SECTION 9-HEALTHY CHILDREN AND YOUTH PROGRAM 9.1 GENERAL INFORMATION
The Healthy Children and Youth (HCY) Program in Missouri is a comprehensive, primary and preventive health care program for MO HealthNet eligible children and youth under the age of 21 years. The program is also known as Early Periodic Screening, Diagnosis and Treatment (EPSDT). The Social Security Act authorizes Medicaid coverage of medical and dental services necessary to treat or ameliorate defects and physical and mental illness identified by an HCY screen. These services are covered by Medicaid regardless of whether the services are covered under the state Medicaid plan. Services identified by an HCY screening that are beyond the scope of the Medicaid state plan may require a plan of care identifying the treatment needs of the child with regard to amount, duration, scope, and prognosis. Prior authorization (PA) of services may be required for service needs and for services of extended duration. Reference Section 13, Benefits and Limitations, for a description of requirements regarding the provision of services. Every applicant under age 21 (or his or her legal guardian) is informed of the HCY Program by the Family Support Division income-maintenance caseworker at the initial application for assistance. The participant is reminded of the HCY Program at each annual redetermination review. The goal of the Medicaid agency is to have a health care home for each childthat is, to have a primary care provider who manages a coordinated, comprehensive, continuous health care program to address the childs health needs. The health care home should follow the screening periodicity schedule, perform interperiodic screens when medically necessary, and coordinate the childs specialty needs.
9.2
PLACE OF SERVICE
03 11 12 21 22 25 71 72 99 School Office Home Inpatient Hospital Outpatient Hospital Birthing Center State or Local Public Health Clinic Rural Health Clinic Other
A full or partial HCY screen may be provided in the following places of service (POS):
9.3 9.4
TYPE OF SERVICE (text del. 9/04) DIAGNOSIS CODE
The Early Periodic Screening (V20.2 for children over 28 days old, V20.31 for a newborn fewer than 8 days old, and V20.32 for a newborn 8 to 28 days old) diagnosis code must appear as the primary diagnosis on a claim form submitted for HCY screening services. The appropriate HCY screening procedure code should be used for the initial HCY screen and all other full or partial screens.
9.5
INTERPERIODIC SCREENS
Medically necessary screens outside the periodicity schedule that do not require the completion of all components of a full screen may be provided as an interperiodic screen or as a partial screen. An interperiodic screen has been defined by the Centers for Medicare & Medicaid Services (CMS) as any encounter with a health care professional acting within his or her scope of practice. This screen may be used to initiate expanded HCY services. Providers who perform interperiodic screens may use the appropriate level of Evaluation/Management visit (CPT) procedure code, the appropriate partial HCY screening procedure code, or the procedure codes appropriate for the professionals discipline as defined in their provider manual. Office visits and full or partial screenings that occur on the same day by the same provider are not covered unless the medical necessity is clearly documented in the participants record. The diagnosis for the medical condition necessitating the interperiodic screening must be entered in the primary diagnosis field, and the appropriate screening diagnosis should be entered in the secondary diagnosis field. The interperiodic screen does not eliminate the need for full HCY screening services at established intervals based on the childs age. If all components of the full or unclothed physical are not met, the Reduced Preventative Screening codes must be billed. PROCEDURE CODE DESCRIPTION MO HEALTHNET MAXIMUM ALLOWABLE AMOUNT
99381 - 99385 ----------------- Preventative Screen; new patient ------------------------$23.00 99391 - 99395 ----------------- Preventative Screen; established patient ----------------$15.00
9.6
FULL HCY/EPSDT SCREEN

DESCRIPTION MO HEALTHNET MAXIMUM ALLOWABLE AMOUNT
PROCEDURE CODE
99381EP-99385EP 99391EP-99395EP 99381EPUC-99385EPUC 99391EPUC-99395EPUC
Full Medical Screening ------------------------------------$60.00
Full Medical Screening with Referral -------------------$60.00
A full HCY/EPSDT screen includes the following: A comprehensive unclothed physical examination; A comprehensive health and developmental history including assessment of both physical and mental health developments; Health education (including anticipatory guidance); Appropriate immunizations according to age;* Laboratory tests as indicated (appropriate according to age and health history unless medically contraindicated);* Lead screening according to established guidelines; Hearing screening; Vision screening; and Dental screening. It is not always possible to complete all components of the full medical HCY screening service. For example, immunizations may be medically contraindicated or refused by the parent/guardian. The parent/guardian may also refuse to allow their child to have a lead blood level test performed. When the parent/guardian refuses immunizations or appropriate lab tests, the provider should attempt to educate the parent/guardian with regard to the importance of these services. If the parent/guardian continues to refuse the service the childs medical record must document the reason the service was not provided. Documentation may include a signed statement by the parent/guardian that immunizations, lead blood level tests, or lab work was refused. By fully documenting in the childs medical record the reason for not providing these services, the provider may bill a full medical HCY screening service even though all components of the full medical HCY screening service was not provided.
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Section 9 - Healthy Children and Youth Program It is mandatory that the Healthy Children and Youth Screening guide be retained in the patients medical record as documentation of the service that was provided. The Healthy Children and Youth Screening guide is not all-inclusive; it is to be used as a guide to identify areas of concern for each component of the HCY screen. Other pertinent information can be documented in the comment fields of the guide. The screener must sign and date the guide and retain it in the patients medical record. The Title XIX participation agreement requires that providers maintain adequate fiscal and medical records that fully disclose services rendered, that they retain these records for 5 years, and that they make them available to appropriate state and federal officials on request. The Healthy Children and Youth Screening guide may be photocopied or obtained at no charge from the MO HealthNet Division. Providers must have this form in the medical record if billing the screening. The MO HealthNet Division is required to record and report to the Centers for Medicare & Medicaid Services all HCY screens and referrals for treatment. Reference Sections 13 and 15 for billing instructions. Claims for the full medical screening and/or full medical screening with referral should be submitted promptly within a maximum of 60 days from the date of screening. Office visits and screenings that occur on the same day by the same provider are not covered unless the medical necessity is clearly documented in the participants record and a Certificate of Medical Necessity form is attached to the claim when submitting for payment. * Reimbursement for immunizations and laboratory procedures is not included in the screening fee and
may be billed separately.
9.6.A
QUALIFIED PROVIDERS
The full screen must be performed by a MO HealthNet enrolled physician, nurse practitioner or nurse midwife*.
* only infants age 0-2 months; and females age 15-20 years
9.7
PARTIAL HCY/EPSDT SCREENS
Segments of the full medical screen may be provided by different providers. The purpose of this is to increase the access to care for all children and to allow providers reimbursement for those separate screens. When expanded HCY services are accessed through a partial or interperiodic screen, it is the responsibility of the provider completing the partial or interperiodic screening service to have a referral source to refer the child for the remaining components of a full screening service.
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Section 9 - Healthy Children and Youth Program Office visits and screenings that occur on the same day by the same provider are not covered unless the medical necessity is clearly documented in the participants record. The Healthy Children and Youth Screening guide provides age-specific guidelines for the screeners assistance. 9.7.A PROCEDURE CODE DEVELOPMENTAL ASSESSMENT DESCRIPTION MO HEALTHNET MAXIMUM ALLOWABLE AMOUNT
9942959 ------------------Developmental/Mental Health $15.00 partial screen--------------9942959UC --------------Developmental/Mental Health partial screen with Referral -------------------- $15.00 This screen includes the following: Assessment of social and language development. Age-appropriate behaviors are identified in the HCY Screening guide. Assessment of fine and gross motor skill development. Age-appropriate behaviors are identified in the HCY Screening guide. Assessment of emotional and psychological status. Some age-appropriate behaviors are found in the HCY Screening guide. 9.7.A(1) Qualified Providers
The Developmental/Mental Health partial screen may be provided by the following MO HealthNet enrolled providers: Physician, nurse practitioner or nurse midwife*; Speech/language therapist; Physical therapist; Occupational therapist; or Professional Counselors, Social Workers, and Psychologists. * only infants age 0-2 months; and females age 15-20 years
Section 9 - Healthy Children and Youth Program 9.7.B PROCEDURE CODE UNCLOTHED PHYSICAL, ANTICIPATORY GUIDANCE, AND INTERVAL HISTORY, LAB/IMMUNIZATIONS AND LEAD SCREEN DESCRIPTION MO HEALTHNET MAXIMUM ALLOWABLE AMOUNT
9938152EP-9938552EP HCY Unclothed Physical and 9939152EP-9939552EP History -------------------9938152EPUCHCY Unclothed Physical and 9938552EPUC ----------History with Referral --9939152EPUC9939552EPUC
$20.00 $20.00
The HCY unclothed physical and history includes the following: Check of growth chart; Examination of skin, head (including otoscopy and ophthalmoscopy), neck, external genitals, extremities, chest, hips, heart, abdomen, feet, and cover test; Appropriate laboratory; Immunizations; and Lead screening according to established guidelines. 9.7.B(1) Qualified Providers
The screen may be provided by a MO HealthNet enrolled physician, nurse practitioner or nurse midwife*. * Reimbursement for immunizations and laboratory procedures is not included in the screening fee and
9.7.C PROCEDURE CODE
VISION SCREENING DESCRIPTION MO HEALTHNET MAXIMUM ALLOWABLE AMOUNT $5.00

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9942952 ------------------Vision Screening --------
Section 9 - Healthy Children and Youth Program 9942952UC --------------Vision Screening with Referral ---------------- $5.00
This screen can include observations for blinking, tracking, corneal light reflex, pupillary response, ocular movements. To test for visual acuity, use the Cover test for children under 3 years of age. For children over 3 years of age utilize the Snellen Vision Chart. 9.7.C(1) Qualified Providers
The vision partial screen may be provided by the following MO HealthNet enrolled providers: Physician, nurse practitioner or nurse midwife*; Optometrist. * only infants age 0-2 months; and females age 15-20 years
9.7.D PROCEDURE CODE
HEARING SCREEN DESCRIPTION MO HEALTHNET MAXIMUM ALLOWABLE AMOUNT
99429EP-------------------HCY Hearing Screen ---------------------------$5.00 99429EPUC --------------HCY Hearing Screen with Referral -----------$5.00
This screen can range from reports by parents to assessment of the childs speech development through the use of audiometry and tympanometry. If performed, audiometry and tympanometry tests may be billed and reimbursed separately. These tests are not required to complete the hearing screen. 9.7.D(1) Qualified Providers
The hearing partial screen may be provided by the following MO HealthNet enrolled providers: Physician, nurse practitioner or nurse midwife*; Audiologist or hearing aid dealer/fitter; or Speech pathologist.
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* Reimbursement for immunizations and laboratory procedures is not included in the screening fee and
9.7.E PROCEDURE CODE
DENTAL SCREEN DESCRIPTION MO HEALTHNET MAXIMUM ALLOWABLE AMOUNT
99429 ----------------------HCY Dental Screen -----------------------------$20.00 99429UC ------------------HCY Dental Screen with Referral-------------$20.00
A dental screen is available to the HCY/EPSDT population on a periodicity schedule that is different from that of the full HCY/EPSDT screen. Children may receive age-appropriate dental screens and treatment services until they become 21 years old. A childs first visit to the dentist should occur no later than 12 months of age so that the dentist can evaluate the infants oral health, intercept potential problems such as nursing caries, and educate parents in the prevention of dental disease in their child. It is recommended that preventive dental services and oral treatment for children begin at age 6 to 12 months and be repeated every six months or as indicated. When a child receives a full medical screen by a physician, nurse practitioner or nurse midwife*, it includes an oral examination, which is not a full dental screen. A referral to a dental provider must be made where medically indicated when the child is under the age of 1 year. When the child is 1 year or older, a referral must be made, at a minimum, according to the dental periodicity schedule. The physician, nurse practitioner or nurse midwife may not bill the dental screening procedure 99429 or 99429UC separately. * only infants age 0-2 months; and females age 15-20 years
9.7.E(1)
Qualified Providers
A dental partial screen may only be provided by a MO HealthNet participating dentist. 9.7.F ALL PARTIAL SCREENERS
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Section 9 - Healthy Children and Youth Program The provider of a partial medical screen must have a referral source to send the participants for the remaining required components of the full medical screen and is expected to help make arrangements for this service.
9.8
LEAD RISK ASSESSMENT AND TREATMENTHEALTHY CHILDREN AND YOUTH (HCY)
The Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) has identified all children between 6 months and 72 months to be at risk for lead poisoning and has mandated they must receive a lead risk assessment as part of the HCY full or partial screening. A complete lead risk assessment consists of a verbal risk assessment and blood test(s) when indicated, and at the mandatory testing ages of 12 and 24 months. Lead risk assessment is included as a component of a full HCY medical screen, 99381EP through 99385EP and 99391EP through 99395EP, or a partial HCY screen, 9938152EP through 9938552EP and 9939152EP through 9939552EP, which also includes the following components: Interval History, Unclothed Physical, Anticipatory Guidance, Lab, and Immunization. See Section 9.7.B for additional information. CMS has also determined that there are no guidelines or policies for states or local health departments to refer to in determining that an area is a lead free zone. Until there is specific information or guidance from the Centers for Disease Control (CDC) on how lead free zones are determined, CMS will not recognize them in the context of screening Medicaid eligible children for lead poisoning. 9.8.A SIGNS, SYMPTOMS AND EXPOSURE PATHWAYS
The signs and symptoms of lead exposure and toxicity may vary because of differences in individual susceptibility. A continuum of signs and symptoms exist, ranging from asymptomatic persons to those with overt toxicity. Mild toxicity is usually associated with blood lead levels in the 35 to 50 g/dL range for children and in the 40 to 60 g/dL range for adults. Severe toxicity is frequently found in association with blood lead levels of 70 g/dL or more in children and 100 g/dL or more in adults. The following signs and symptoms and exposure pathways are provided to assist providers in identifying children who may have lead poisoning or be at risk of being poisoned.
SIGNS AND SYMPTOMS MILD TOXICITY Myalgia or paresthesia Mild fatigue
SEVERE TOXICITY Paresis or paralysis Encephalopathymay abruptly lead to 12

Irritability Lethargy Occasional abdominal discomfort MODERATE TOXICITY Arthralgia General fatigue Decrease in play activity Difficulty concentrating Muscular exhaustibility Tremor Headache Diffuse abdominal pain Vomiting Weight loss Constipation seizures, changes in level of consciousness, coma and death Lead line (blue-black) on gingival tissue Colic (intermittent, severe abdominal cramps)
EXPOSURE PATHWAYS OCCUPATIONAL Plumbers, pipe fitters Lead miners Lead smelters and refiners Auto repairers Glass manufacturers Shipbuilders Printers Plastic manufacturers Police Officers Steel welders and cutters Construction workers Bridge reconstruction workers Rubber products manufacturers Gas station attendants Battery manufacturers Chemical and chemical preparation Manufacturers Industrial machinery and equipment operators Firing Range Instructors ENVIRONMENTAL Lead-containing paint Soil/dust near industries, roadways, lead painted homes Plumbing leachate Ceramic ware Leaded gasoline
HOBBIES AND RELATED ACTIVITIES Glazed pottery making Target shooting at firing ranges Lead soldering (e.g., electronics) Painting Preparing lead shot, fishing sinkers, bullets Stained-glass making Car or boat repair Home remodeling SUBSTANCE USE Folk remedies Health foods Cosmetics Moonshine whiskey Gasoline huffing+
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Section 9 - Healthy Children and Youth Program Regardless of risk, all families must be given detailed lead poisoning prevention counseling as part of the anticipatory guidance during the HCY screening visit for children up to 72 months of age.
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9.8.B
LEAD RISK ASSESSMENT
The HCY Lead Risk Assessment Guide should be used at each HCY screening to assess the exposure to lead, and to determine the risk for high dose exposure. The HCY Lead Risk Assessment Guide is designed to allow the same document to follow the child for all visits from 6 months to 6 years of age. The HCY Lead Risk Assessment Guide has space on the reverse side to identify the type of blood test, venous or capillary, and also has space to identify the dates and results of blood lead levels. A comprehensive lead risk assessment includes both the verbal lead risk assessment and blood lead level determinations. Blood Lead Testing is mandatory at 12 and 24 months of age and if the child is deemed high risk. The HCY Lead Risk Assessment Guide is available for providers use. The tool contains a list of questions that require a response from the parent. A positive response to any of the questions requires blood lead level testing by capillary or venous method. 9.8.C MANDATORY RISK ASSESSMENT FOR LEAD POISONING
All children between the ages of 6 months and 72 months of age MUST receive a lead risk assessment as a part of the HCY full or partial screening. Providers are not required to wait until the next HCY screening interval and may complete the lead risk assessment at the next office visit if they choose. The HCY Lead Risk Assessment Guide and results of the blood lead test must be in the patients medical record even if the blood lead test was performed by someone other than the billing provider. If this information is not located in the medical record a full or partial HCY screen may not be billed. 9.8.C(1) Risk Assessment
Beginning at six months of age and at each visit thereafter up to 72 months of age, the provider must discuss with the childs parent or guardian childhood lead poisoning interventions and assess the childs risk for exposure by using the HCY Lead Risk Assessment Guide. 9.8.C(2) Determining Risk
Risk is determined from the response to the questions on the HCY Lead Risk Assessment Guide. This verbal risk assessment determines the child to be low risk or high risk.
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Section 9 - Healthy Children and Youth Program If the answers to all questions is no, a child is not considered at risk for high doses of lead exposure. If the answer to any question is yes, a child is considered at risk for high doses of lead exposure and a capillary or venous blood lead level must be drawn. Follow-up guidelines on the reverse side of the HCY Lead Risk Assessment Guide must be followed as noted depending on the blood test results. Subsequent verbal lead risk assessments can change a childs risk category. As the result of a verbal lead risk assessment, a previously low risk child may be recategorized as high risk. 9.8.C(3) Screening Blood Tests
The Centers for Medicare & Medicaid Services (CMS) requires mandatory blood lead testing by either capillary or venous method at 12 months and 24 months of age regardless of risk. If the answer to any question on the HCY Lead Risk Assessment Guide is positive, a venous or capillary blood test must be performed. If a child is determined by the verbal risk assessment to be high risk, a blood lead level test is required, beginning at six months of age. If the initial blood lead level test results are less than 10 micrograms per deciliter (g/dL) no further action is required. Subsequent verbal lead risk assessments can change a child's risk category. A verbal risk assessment is required at every visit prescribed in the EPSDT periodicity schedule through 72 months of age and if considered to be high risk must receive a blood lead level test, unless the child has already received a blood lead test within the last six months of the periodic visit. A blood lead test result equal to or greater than 10 g/dL obtained by capillary specimen (finger stick) must be confirmed using venous blood according to the time frame listed below: 10-19 g/dL- confirm within 2 months 20-44 g/dL- confirm within 2 weeks 45-69 g/dL- confirm within 2 days 70+ g/dL- IMMEDIATELY For future reference and follow-up care, completion of the HCY Lead Risk Assessment Guide is still required at these visits to determine if a child is at risk.
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9.8.C(4)
MO HealthNet Managed Care Health Plans
The MO HealthNet Managed Care health plans are responsible for mandatory risk assessment for children between the ages of 6 months and 72 months. MO HealthNet Managed Care health plans are also responsible for mandatory blood testing if a child is at risk or if the child is 12 or 24 months of age. MO HealthNet Managed Care health plans must follow the HCY Lead Risk Assessment Guide when assessing a child for risk of lead poisoning or when treating a child found to be poisoned. MO HealthNet Managed Care health plans are responsible for lead case management for those children with elevated blood lead levels. MO HealthNet Managed Care health plans are encouraged to work closely with the MO HealthNet Division and local public health agencies when a child with an elevated blood lead level has been identified. Referral for an environmental investigation of the child's residence must be made to the local public health agency. This investigation is not the responsibility of the MO HealthNet Managed Care health plan, but can be reimbursed by the MO HealthNet Division on a fee-for-service basis. 9.8.D LABORATORY REQUIREMENTS FOR BLOOD LEAD LEVEL TESTING
When performing a lead risk assessment in Medicaid eligible children, CMS requires the use of the blood lead level test at 12 and 24 months of age and when a child is deemed high risk. The erythrocyte protoporphyrin (EP) test is not acceptable as a blood lead level test for lead poisoning. The following procedure code must be used to bill the blood lead test: (Capillary specimen or venous blood samples.) PROCEDURE CODE DESCRIPTION MO HEALTHNET MAXIMUM ALLOWABLE AMOUNT
83655 ------------------ Lead, quantitative blood ------------------------$15.00 This code must be used by MO HealthNet enrolled laboratories. Laboratories must be CLIA certified to perform blood lead level tests. All blood lead level tests must be reported to the Missouri Department of Health and Senior Services as required in Missouri Code of State Regulations 19 CSR 20-20.
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9.8.E
BLOOD LEAD LEVELRECOMMENDED INTERVENTIONS 9.8.E(1) Blood Lead Level <10 g/dL
This level is NOT indicative of lead poisoning. No action required unless exposure sources change. Recommended Interventions: The provider should refer to Section 9.8.C(3) and follow the guidelines for risk assessment blood tests. 9.8.E(2) Blood Lead Level 10-19 g/dL
Children with results in this range are in the borderline category. The effects of lead at this level are subtle and are not likely to be measurable or recognizable in the individual child. Recommended Interventions: Provide family education and follow-up testing. *Retest every 2-3 months. If 2 venous tests taken at least 3 months apart both result in elevations of 15 g/dL or greater, proceed with retest intervals and follow-up guidelines as for blood lead levels of 20-44 g/dL. * Retesting must always be completed using venous blood.
9.8.E(3)
Blood Lead Level 20-44 g/dL
If the blood lead results are in the 20-44 g/dL range, a confirmatory venous blood lead level must be obtained within 2 weeks. Based upon the confirmation, a complete medical evaluation must be conducted. Recommended Interventions: Provide family education and follow-up testing. Assure coordination of care (case management) either through the MO HealthNet Managed Care health plan, provider or local public health agency. The provider assures medical management.
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Section 9 - Healthy Children and Youth Program Contact local public health agency to provide environmental investigation and to assure lead-hazard control. *Retest every 1-2 months until the blood lead level remains less than 15 g/dL for at least 6 months, lead hazards have been removed, and there are no new exposures. When these conditions are met, proceed with guidelines for blood lead levels 10-19 g/dL. * Retesting must always be completed using venous blood.
9.8.E(4)
Blood Lead Level 45-69 g/dL
These children require urgent medical evaluation. If the blood lead results are in the 45-69 g/dL range, a confirmatory venous blood lead level must be obtained within 48 hours. Children with symptomatic lead poisoning (with or without encephalopathy) must be referred to a setting that encompasses the management of acute medical emergencies. Recommended Interventions: Provide family education and follow-up testing. Assure coordination of care (case management) either through the MO HealthNet Managed Care health plan, provider or local public health agency. The provider assures medical management. Contact local public health agency to provide environmental investigation and to assure lead-hazard control. Within 48 hours begin coordination of care (case management), medical management, environmental investigation, and lead hazard control. A child with a confirmed blood lead level greater than 44 g/dL should be treated promptly with appropriate chelating agents and not returned to an environment where lead hazard exposure may continue until it is controlled. *Retest every 1-2 months until the blood lead level remains less than 15 g/dL for at least 6 months, lead hazards have been removed, and there are no new exposures.
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Section 9 - Healthy Children and Youth Program When these conditions are met, proceed with guidelines for blood lead levels 10-19 g/dL. * Retesting must always be completed using venous blood.
9.8.E(5)
Blood Lead Level 70 g/dL or Greater
Children with blood lead levels in this range constitute a medical emergency. If the blood lead results are in the 70 g/dL range, a confirmatory venous blood lead level must be obtained immediately. Recommended Interventions: Hospitalize child and begin medical treatment immediately. Begin coordination of care (case management), medical management, environmental investigation, and lead hazard control immediately. Blood lead levels greater than 69 g/dL must have an urgent repeat venous test, but chelation therapy should begin immediately (not delayed until test results are available.) *Retest every 1-2 months until the blood lead level remains less than 15 g/dL for at least 6 months, the lead hazards have been removed, and there are no new exposures. When these conditions are met, proceed with guidelines for blood lead levels 10-19 g/dL. * Retesting must always be completed using venous blood.
9.8.F
COORDINATION WITH OTHER AGENCIES
Coordination with local health departments, WIC, Head Start, and other private and public resources enables elimination of duplicate testing and ensures comprehensive diagnosis and treatment. Also, local public health agencies Childhood Lead Poisoning Prevention programs may be available. These agencies may have the authority and ability to investigate a lead-poisoned childs environment and to require remediation. Local public health agencies may have the authority and ability to investigate a lead poisoned childs environment. We encourage providers to note referrals and coordination with other agencies in the patients medical record.
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Section 9 - Healthy Children and Youth Program 9.8.G ENVIRONMENTAL LEAD INVESTIGATION
When two consecutive lab tests performed at least three months apart measure 15 g/dL or above, an environmental investigation must be obtained. Furthermore, where there is a reading above 10 g/dL, the child must be re-tested in accordance to the recommended interventions listed in Section 9.8.E. 9.8.G(1) Environmental Lead Investigation
Children who have a blood lead level 20 g/dL or greater or children who have had 2 blood lead levels greater than 15 g/dL at least 3 months apart should have an environmental investigation performed. The purpose of the environmental lead investigation is to determine the source(s) of hazardous lead exposure in the residential environment of children with elevated blood lead levels. Environmental lead investigations are to be conducted by licensed lead risk assessors who have been approved by the Missouri Department of Health and Senior Services. Approved licensed lead risk assessors shall comply with the Missouri Department of Health and Senior Services Lead Manual and applicable State laws. All licensed lead risk assessors must be registered with the Missouri Department of Health and Senior Services. Approved lead risk assessors who wish to receive reimbursement for MO HealthNet eligible children must also be enrolled as a MO HealthNet provider. Lead risk assessors must use their MO HealthNet provider number when submitting claims for completing an environmental lead investigation. The following procedure codes have been established for billing environmental lead investigations: T1029UATG T1029UA T1029UATF T1029UATS Initial Environmental Lead Investigation First Environmental Lead Reinvestigation Second Environmental Lead Reinvestigation Subsequent Environmental Lead Reinvestigation Certificate of Medical Necessity must be attached to claim for this procedure Federal Medicaid regulations prohibit Medicaid coverage of environmental lead investigations of locations other than the principle residence. The Missouri
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Section 9 - Healthy Children and Youth Program Department of Health and Senior Services recommend that all sites where the child may be exposed be assessed, e.g., day care, grandparents' home, etc. Federal Health Care Financing policy prohibits Medicaid paying for laboratory testing of paint, soil and water samples. Contact the local health department to arrange for environmental lead investigation services. 9.8.H ABATEMENT
Medicaid cannot pay for abatement of lead hazards. Lead risk assessors may be able to provide information and advice on proper abatement and remediation techniques. 9.8.I LEAD CASE MANAGEMENT
Children with 1 blood lead level of 20 g/dL or greater, or who have had 2 venous tests at least 3 months apart with elevations of 15 g/dL or greater must be referred for case management services through the HCY Program. In order to be reimbursed for these services the lead case management agency must be an enrolled provider with MO HealthNet Division. For additional information on Lead Case Management, go to Section 13.66.D of the Physician's Manual. 9.8.J POISON CONTROL HOTLINE TELEPHONE NUMBER
The statewide poison control hotline number is (800) 366-8888. This number may also be used to report suspected lead poisoning. The Department of Health and Senior Services, Section for Environmental Health, hotline number is (800) 392-0272. 9.8.K MO HEALTHNET ENROLLED LABORATORIES THAT PERFORM BLOOD LEAD TESTING
Kneibert Clinic, LLC PO Box PO Box 220 Poplar Bluff, MO 63902 LabCorp Holdings-Kansas City 1706 N. Corrington Kansas City, MO 64120 Physicians Reference Laboratory 7800 W. 110 St. Overland, MO 66210
Childrens Mercy Hospital 2401 Gillham Rd. Kansas City, MO 64108 Hannibal Clinic Lab 711 Grand Avenue Hannibal, MO 63401 Kansas City Health Department Lab 2400 Troost, LL#100 Kansas City, MO 64108
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Missouri State Public Health Laboratory 101 Chestnut St, Jefferson City, MO 65101 Springfield-Greene County Public Health 227 E. Chestnut Springfield, MO 65802 St. Lukes Hospital Dept. of Pathology 4401 Wornall Kansas City, MO University of MO-Columbia Hospital & Clinics One Hospital Drive Columbia, MO 65212 Quest Diagnostics 11636 administration St. Louis, MO 63146 St. Francis Medical Center 211 St. Francis Drive Cape Girardeau, MO 63703 St. Louis County Environmental Health Lab 111 S. Meramec Clayton, MO 63105
9.8.L
OUT-OF-STATE LABS CURRENTLY REPORTING LEAD TEST RESULTS TO THE MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
Esa 22 Alpha Rd. Chelmsford, MA 01824 Iowa Methodist Medical Center 1200 Pleasant St. Des Moines, IA 50309 Mayo Medical Laboratories 2050 Superior Dr. NW Rochester, MN 55901 Physicians Reference Laboratory 7800 W. 110th St. Overland Park, KS 66210 Tamarac Medical 7800 Broadway Ste. 2C Centennial, Co 80122
Arup Laboratories 500 Chipeta Way Salt Lake City, UT 84108 Iowa Hygenic Lab Wallace State Office Building Des Moines, IA 50307 Kansas Department of Health 619 Anne Ave. Kansas City, KS 66101 Leadcare, Inc. 52 Court Ave. Stewart Manor, NY 11530 Quincy Medical Group 1025 Main St. Quincy, IL 62301 Specialty Laboratories 2211 Michigan Ave. Santa Monica, CA 90404
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9.9
HCY CASE MANAGEMENT

DESCRIPTION MO HEALTHNET MAXIMUM ALLOWABLE AMOUNT
PROCEDURE CODE
T1016EP -------------T1016TSEP -----------
HCY Case Management-----------------------------------$12.50 HCY Case Management; Follow-up---------------------$10.00
For more information regarding HCY Case Management, refer to Section 13.66.D of the Physician's Manual.
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9.10 IMMUNIZATIONS
Immunizations must be provided during a full medical HCY screening unless medically contraindicated or refused by the parent or guardian of the patient. When an appropriate immunization is not provided, the patients medical record must document why the appropriate immunization was not provided. Immunization against polio, measles, mumps, rubella, pertussis, chicken pox, diphtheria, tetanus, haemophilus influenzae type b, and hepatitis B must be provided according to the Recommended Childhood Immunization Schedule found on the Department of Health and Senior Services' website at: http://www.dhss.mo.gov/Immunizations/index.html. 9.10.A VACCINE FOR CHILDREN (VFC)
For information on the Vaccine for Children (VFC) program, reference Section 13.13.A of the Physician Program.
9.11 ASSIGNMENT OF SCREENING TIMES

Participants under 21 years of age become eligible for the initial screening, as well as for the periodic screenings, at the time MO HealthNet eligibility is determined regardless of how old they are. A periodic screen should occur thereafter according to the established periodicity schedule. A notification letter is sent in the month the participant again becomes eligible for an HCY screening. The letter is to notify the participant that a screening is due.
9.12 PERIODICITY SCHEDULE FOR HCY (EPSDT) SCREENING SERVICES

The periodicity schedule represents the minimum requirements for frequency of full medical screening services. Its purpose is not to limit the availability of needed treatment services between the established intervals of the periodicity schedule. Children may be screened at any time the physician, nurse practitioner or nurse midwife* feels it is medically necessary to provide additional screening services. If it is medically necessary for a full medical screen (See Section 9.6 for procedure list) to occur more frequently than the suggested periodicity schedule, then the screen should be provided. There must, however, be documentation in the patients medical record that indicates the medical necessity of the additional full medical screening service. The HCY Program makes available to MO HealthNet participants under the age of 21 a full HCY screening examination during each of the age categories in the following periodicity schedule:
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Newborn (2-3) days By one Month 2-3 Months 4-5 Months 6-8 Months 9-11 Months 12-14 Months 15-17 Months 18-23 Months 24 Months
3 Years 4 Years 5 Years 6-7 Years 8-9 Years 10-11 Years 12-13 Years 14-15 Years 16-17 Years 18-19 Years 20 Years
* only infants age 0-2 months; and females age 15-20 years
9.12.A
DENTAL SCREENING SCHEDULE
Twice a year from age 6 months to 21 years. 9.12.B VISION SCREENING SCHEDULE
Once a year from age 3 to 21 years. 9.12.C HEARING SCREENING SCHEDULE
Once a year from age 3 to 21 years.
9.13 REFERRALS RESULTING FROM A FULL, INTERPERIODIC OR PARTIAL SCREENING

The full HCY screen is to serve as a complete screen and should not result in a referral for an additional partial screen for the component that identified a need for further assessment or treatment. A child referred as a result of a full screen should be referred for diagnostic or treatment services and not for additional screening except for dental (see Section 9.7.E). Diagnostic and treatment services beyond the scope of the Medicaid state plan may require a plan of care and prior authorization (see Section 9.13.A). Additional information regarding specialized services can be found in Section 13, Benefits and Limitations.
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9.13.A
PRIOR AUTHORIZATION FOR NON-STATE PLAN SERVICES (EXPANDED HCY SERVICES)
Medically necessary services beyond the scope of the traditional Medicaid Program may be provided when the need for these services is identified by a complete, interperiodic or partial HCY screening. When required, a Prior Authorization Request form must be submitted to the MO HealthNet Division. Refer to instructions found in Section 13 of the provider manual for information on services requiring prior authorization. Complete the Prior Authorization Request form in full, describing in full detail the service being requested and submit in accordance with requirements in Section 13 of the provider manual. Section 8 of the provider manual indicates exceptions to the prior authorization requirement and gives further details regarding completion of the form. Section 14 may also include specific requirements regarding the prior authorization requirement.
9.14 PARTICIPANT NONLIABILITY

MO HealthNet covered services rendered to an eligible participant are not billable to the participant if MO HealthNet would have paid had the provider followed the proper policies and procedures for obtaining payment through the MO HealthNet Program as set forth in 13 CSR 70-4.030.
9.15
EXEMPTION FROM COST SHARING AND COPAY REQUIREMENTS
Providers must refer to appropriate program manuals for specific information regarding cost sharing and copay requirements.
9.16 STATE-ONLY FUNDED PARTICIPANTS

Children eligible under a state-only funded category of assistance are eligible for all services including those available through the HCY Program to the same degree any other person under the age of 21 years is eligible for a service. Refer to Section 1 for further information regarding stateonly funded participants.
9.17 MO HEALTHNET MANAGED CARE

MO HealthNet Managed Care health plans are responsible for insuring that Early and Periodic, Screening, Diagnosis and Treatment (EPSDT) screens are performed on all MO HealthNet Managed Care eligibles under the age of 21.
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Section 9 - Healthy Children and Youth Program The Omnibus Budget Reconciliation Act of 1989 (OBRA-89) mandated that Medicaid provide medically necessary services to children from birth through age 20 years which are necessary to treat or ameliorate defects, physical or mental illness, or conditions identified by an EPSDT screen regardless of whether or not the services are covered under the Medicaid state plan. Services must be sufficient in amount, duration and scope to reasonably achieve their purpose and may only be limited by medical necessity. According to the MO HealthNet Managed Care contracts, the MO HealthNet Managed Care health plans are responsible for providing all EPSDT/HCY services for their enrollees. Missouri is required to provide the Centers for Medicare & Medicaid Services with screening and referral data each federal fiscal year (FFY). This information is reported to CMS on the CMS-416 report. Specific guidelines and requirements are required when completing this report. The health plans are not required to produce a CMS-416 report. Plans must report encounter data for HCY screens using the appropriate codes in order for the MO HealthNet Division to complete the CMS416 report. A full EPSDT/HCY screening must include the following components: a) A comprehensive unclothed physical examination b) A comprehensive health and developmental history including assessment of both physical and mental health development c) Health education (including anticipatory guidance) d) Appropriate immunizations according to age e) Laboratory tests as indicated (appropriate according to age and health history unless medically contraindicated) f) Lead screen according to established guidelines
g) Hearing screen h) Vision screen i) Dental screen
Partial screens which are segments of the full screen may be provided by appropriate providers. The purpose of this is to increase access to care to all children. Providers of partial screens are required to have a referral source for the full screen. (For the plan enrollees this should be the primary care physician). A partial screen does not replace the need for a full medical screen which includes all of the above components. See Section 9, page 5 through 8 for specific information on partial screens. Plans must use the following procedure codes, along with a primary diagnosis code of V20.2, V20.31, or V20.32 when reporting encounter data to the MO HealthNet Division on Full and Partial EPSDT/HCY Screens:
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Full Screen Unclothed Physical and History Developmental/Mental Health Hearing Screen Vision Screen Dental Screen
99381EP through 99385EP and 99391EP through 99395EP 99381 through 99385 and 99391 through 99395 9942959 9942959UC 99429EP 99429EPUC 9942952 9942952UC 99429 99429UC
The history and exam of a normal newborn infant and initiation of diagnostic and treatment programs may be reported by the plans with procedure code 99431. Normal newborn care in other than a hospital or birthing room setting may be reported by the plans with procedure code 99432. Both of the above newborn procedure codes are equivalent to a full HCY screening. Plans are responsible for required immunizations and recommended laboratory tests. Lab services are not part of the screen and are reported separately using the appropriate CPT-4 code. Immunizations are recommended in accordance with the Advisory Committee on Immunization Practices (ACIP) guidelines and an acceptable medical practice. If a problem is detected during a screening examination, the child must be evaluated as necessary for further diagnosis and treatment services. The MO HealthNet Managed Care health plan is responsible for the treatment services.
9.18 ORDERING HEALTHY CHILDREN AND YOUTH SCREENING AND HCY LEAD SCREENING GUIDE
The Healthy Children and Youth Screening and HCY Lead Screening Guide may be ordered from Infocrossing Healthcare Services, P.O. Box 5600, Jefferson City, Missouri 65102 by checking the appropriate item on the Forms Request. If a provider needs additional screening forms they can also make copies.
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Section 10 - Family Planning
SECTION 10 - FAMILY PLANNING

Family planning services are services relating to elective sterilizations and birth control products including drugs, diaphragms, Norplant Systems and IUDs. Section 10, The Family Planning Section, is not applicable to the following manuals: Adult Day Health Care Aged and Disabled Waiver AIDS Waiver Ambulance Comprehensive Day Rehabilitation Dental Durable Medical Equipment Environmental Lead Assessment Hearing Aid Hospice Nursing Home Optical Personal Care Private Duty Nursing Psychology/Counseling Rehabilitation Centers Therapy
Section 11 - MO HealthNet Managed Health Care Delivery System
SECTION 11 - MO HEALTHNET MANAGED HEALTH CARE DELIVERY SYSTEM

11.1 MO HEALTHNET 'S MANAGED CARE PROGRAM ............................................................2 11.1.A EASTERN MISSOURI PARTICIPATING MO HEALTHNET MANAGED CARE HEALTH PLANS ..................................................................................................................2 11.1.B CENTRAL MISSOURI PARTICIPATING MO HEALTHNET MANAGED CARE HEALTH PLANS ..................................................................................................................2 11.2 MO HEALTHNET MANAGED CARE HEALTH PLAN ENROLLMENT ...........................3 11.3 MO HEALTHNET MANAGED CARE HEALTH PLAN INCLUDED INDIVIDUALS.......4 11.4 MO HEALTHNET MANAGED CARE HEALTH PLAN EXCLUDED INDIVIDUALS .....4 11.5 MO HEALTHNET MANAGED CARE MEMBER BENEFITS...............................................5 11.6 STANDARD BENEFITS UNDER MO HEALTHNET MANAGED CARE PROGRAM .....6 11.6.A BENEFITS FOR CHILDREN AND WOMEN IN A MO HEALTHNET CATEGORY OF ASSISTANCE FOR PREGNANT WOMEN ........................................................................8 11.7 SERVICES PROVIDED OUTSIDE THE MO HEALTHNET MANAGED CARE PROGRAM .....................................................................................................................................9 11.8 QUALITY OF CARE ...................................................................................................................10 11.9 IDENTIFICATION OF MO HEALTHNET MANAGED CARE PARTICIPANTS ............11 11.9.A 11.10 11.11 NON-BILLING MO HEALTHNET PROVIDER ...............................................................11
EMERGENCY SERVICES .....................................................................................................11 PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) ......................12 PACE PROVIDER AND SERVICE AREA ........................................................................12 ELIGIBILITY FOR PACE ..................................................................................................13 INDIVIDUALS NOT ELIGIBLE FOR PACE ....................................................................13 LOCK-IN IDENTIFICATION OF PACE INDIVIDUALS.................................................13 PACE COVERED SERVICES ............................................................................................14
11.11.A 11.11.B 11.11.C 11.11.D 11.11.E
SECTION 11 - MO HEALTHNET MANAGED HEALTH CARE DELIVERY SYSTEM

MO HealthNet provides health care services to Managed Care eligibles who meet the criteria for enrollment through Managed Care arrangements, as follows: Under MO HealthNet's Managed Care Program certain eligible individuals are enrolled with a MO HealthNet managed care health plan. Managed Care has been implemented in three regions of the state: Eastern (St. Louis area), Central and Western (Kansas City area) regions.
11.1 MO HEALTHNET 'S MANAGED CARE PROGRAM

Managed Care eligibles who meet specific eligibility criteria receive services through a Managed Care health plan. The Managed Care Program replaces the process of direct reimbursement to individual providers by the MO HealthNet Division (MHD). Participants enroll in a Managed Care health plan that contracts with the state to provide a specific scope of benefits. Individuals who are included in the Managed Care Program have the opportunity to choose their own Managed Care health plan and primary care provider. 11.1.A EASTERN MISSOURI PARTICIPATING MO HEALTHNET MANAGED CARE HEALTH PLANS
The Eastern Missouri Managed Care Program (St. Louis area) began providing services to members on September 1, 1995. It includes the following counties: Franklin (036), Jefferson (050), St. Charles (092), St. Louis County (096) and St. Louis City (115). On December 1, 2000, 5 new counties were added to this region: Lincoln (057), St. Genevieve (095), St. Francois (094), Warren (109) and Washington (110). On January 1, 2008, the following three new counties were added to the Eastern region: Madison (062), Perry (079) and Pike (082). A listing of the health plans providing services for the Eastern region Managed Care Program can be found on the MHD website at http://www.dss.mo.gov/mhd/mc/pages/healthplan.htm. 11.1.B CENTRAL MISSOURI PARTICIPATING MO HEALTHNET MANAGED CARE HEALTH PLANS
The Central Missouri Managed Care region began providing services to members on March 1, 1996. It includes the following counties: Audrain (004), Boone (010), Callaway (014), Camden (015), Chariton (021), Cole (026), Cooper (027), Gasconade (037), Howard (045), Miller (066), Moniteau (068), Monroe (069), Montgomery (070), Morgan (071), Osage (076), Pettis (080), Randolph (088) and Saline (097). On January 1, 2008, ten new counties were added to this region: Benton (008), Laclede (053), Linn (058), Macon (061), Maries (063), Marion (064), Phelps (081), Pulaski (085), Ralls (087) and Shelby (102). General Manual Production - 04/30/2012 2
A listing of the health plans providing services for the Central region Managed Care Program can be found on the MHD website at http://www.dss.mo.gov/mhd/mc/pages/healthplan.htm. 11.1.C WESTERN MISSOURI PARTICIPATING MO HEALTHNET MANAGED CARE HEALTH PLANS The Western Missouri Managed Care Program (Kansas City area) began providing services to members on November 1, 1996. The Western Managed Care region includes the following counties: Cass (019), Clay (024), Jackson (048), Johnson (051), Lafayette (054), Platte (083) and Ray (089). St. Clair (093) and Henry (042) counties were incorporated into the Western region effective 2/1/99. On January 1, 2008 four new counties were added to this region: Bates (007), Cedar (020), Polk (084) and Vernon (108). A listing of the health plans providing services for the Western region Managed Care Program can be found on the MHD website at http://www.dss.mo.gov/mhd/mc/pages/healthplan.htm.
11.2 MO HEALTHNET MANAGED CARE HEALTH PLAN ENROLLMENT

The state has contracted with an independent enrollment agent to assist current and future MO HealthNet Managed Care participants to make an informed decision in the choice of a MO HealthNet Managed Care health plan that meets their needs. The Managed Care enrollment agent sends mailers/letters, etc., provides MO HealthNet Managed Care health plan option information, and has a hot line number available to participants in order to make the selection process easy and informative. Participants who are identified as eligible for inclusion in the MO HealthNet Managed Care Program are not enrolled with a MO HealthNet Managed Care health plan until 15 days after they actually select or are assigned to a Managed Care health plan. When the selection or assignment is in effect, the name of the MO HealthNet Managed Care health plan appears on the interactive voice response system/point of service/Internet information. If a MO HealthNet Managed Care health plan name does not appear for a particular date of service, the participant is in a fee-for-service status for each date of service that a MO HealthNet Managed Care health plan is not listed for the participant. "OPT" OUT POPULATIONS: The Department of Social Services is allowing participants, who are currently in the MO HealthNet Managed Care Program because they receive SSI disability payments, who meet the SSI disability definition as determined by the Department of Social Services, or who receive foster care assistance or adoption subsidy benefits, the option of choosing to receive services on a fee-for-service basis or through the MO HealthNet Managed Care Program. The option is entirely up to the participant, parent or guardian.
11.3 MO HEALTHNET MANAGED CARE HEALTH PLAN INCLUDED INDIVIDUALS

Refer to Section 1.5.C, MO HealthNet Managed Care Participants, and 1.1.A, Description of Eligibility Categories, for more information on Managed Care health plan members. Managed Care health plan members fall into 3 groups: Individuals with the following ME codes fall into Group 1: 05, 06, 10, 18, 19, 21, 24, 26, 40, 43, 44, 45, 60, 61 and 62. Individuals with the following ME codes fall into Group 4: 07, 08, 29, 30, 36, 37, 38, 50, 52, 56, 57, 63, 64, 66, 68, 69, 70 and 88. Individuals with the following ME codes fall into Group 5: 71, 72, 73, 74 and 75;
11.4 MO HEALTHNET MANAGED CARE HEALTH PLAN EXCLUDED INDIVIDUALS

The following categories of assistance/individuals are not included in the MO HealthNet Managed Care Program. Individuals who are eligible for both Medicare and MO HealthNet Individuals who are residents of a domiciliary, residential care facility or nursing home Individuals who are receiving MO HealthNet as a permanently and totally disabled individual Pregnant Women who are presumptively eligible under the Temporary Eligibility During Pregnancy (TEMP) program Individuals eligible for Blind Pension or Aid to the Blind Individuals in a state mental institution or institutional care facility AIDS Waiver Participants Missouri Children with Developmental Disabilities Waiver (ME Codes 33 and 34) Uninsured women losing their MO HealthNet eligibility 60 days after the birth of their child would be eligible under ME Code 80 for womens health services for one year plus 60 days, regardless of income level. Women eligible for Womens Health Services, 1115 Waiver Demonstration, ME code 89. These are uninsured women who are at least 18 to 55 years of age, with a net family income at or below 185% of the Federal Poverty Level (FPL), and with assets totaling less than $250,000. These women are eligible for womens health services as long as they continue to meet eligibility requirements. 4 Production - 04/30/2012
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Terminated Temporary Assistance for Needy Families (TANF) individuals who have had their medical eligibility temporarily reinstated. (ME code 81) Presumptive Eligibility for Children. (ME code 87) Voluntary Placement (ME Code 88) Children placed in foster homes or residential care by the Department of Mental Health (ME Codes 28, 49 and 67). Individuals eligible under ME Code 55 (Qualified Medicare Beneficiary - QMB). Children placed in residential care by their parents if eligible for MO HealthNet on the date of placement (ME code 65). Women eligible under ME Codes 83 and 84 (Breast and Cervical Cancer Treatment). Individuals eligible under ME Code 82 (MoRx).
11.5 MO HEALTHNET MANAGED CARE MEMBER BENEFITS

The MO HealthNet Managed Care health plans are required to provide health benefits to MO HealthNet Managed Care members for each date they are enrolled in the MO HealthNet Managed Care health plan. Managed Care members select a primary care provider (PCP) to provide routine care. MO HealthNet enrolled providers (also called MO HealthNet Managed Care approved providers) who provide services to a Managed Care member do not receive direct reimbursement from the state for Managed Care health plan benefits furnished while the participant is enrolled in a MO HealthNet Managed Care health plan. MO HealthNet enrolled providers who wish to provide services for MO HealthNet Managed Care members must contact the Managed Care health plans for participation agreements/contracts or prior authorization. The MO HealthNet Managed Care member must be told in advance of furnishing the service by the non Managed Care health plan provider that they are able to receive the service from the MO HealthNet Managed Care health plan at no charge. The participant must sign a statement that they have been informed that the service is available through the Managed Care health plan but is being provided by the non MO HealthNet Managed Care health plan provider and they are willing to pay for the service as a private pay patient. MO HealthNet Managed Care health plan members receive the same standard benefit package regardless of the MO HealthNet Managed Care health plan they select. Managed Care health plans must provide services according to guidelines specified in contracts. Managed Care members are eligible for the same range of medical services as under the fee-for-service program. The Managed Care health plans may provide services directly, through subcontracts, or by referring the Managed Care member to 5 Production - 04/30/2012
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a specialist. Services are provided according to the medical needs of the individual and within the scope of the Managed Care health plans administration of health care benefits. Some services continue to be provided outside the MO HealthNet Managed Care health plan with direct provider reimbursement by the MO HealthNet Division. Refer to Section 11.7.
11.6 STANDARD BENEFITS UNDER MO HEALTHNET MANAGED CARE PROGRAM

The following is a listing of the standard benefits under the comprehensive Managed Care Program. Benefits listed are limited to members who are eligible for the service. Inpatient hospital services Outpatient hospital services Emergency room services Ambulatory surgical center, birthing center Physician services (including advanced practice nurse and certified nurse midwife) Family planning (requires freedom of choice and may be accessed out of the Managed Care Health Plan) Laboratory, radiology and other diagnostic services Maternity services (A shorter length of hospital stay for services related to maternity and newborn care may be authorized if a shorter inpatient hospital stay meets with the approval of the attending physician after consulting with the mother and is in keeping with federal and state law. Home visits are required following early discharge. Reference Section 13.20 of the Home Health Manual for more information) Prenatal case management Home health services Emergency (ground or air) transportation Nonemergency medical transportation (NEMT), except for CHIP children in ME codes 73-75. Services of other providers when referred by the Managed Care member's primary care provider Hospice services Durable medical equipment (including but not limited to orthotic and prosthetic devices, respiratory equipment and oxygen, enteral and parenteral nutrition, wheelchairs, walkers, diabetic supplies and equipment) and medically necessary equipment and supplies used in 6 Production - 04/30/2012
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connection with physical, occupational, and speech therapies for all members with an Individualized Educational Program (IEP) or Individualized Family Service Plan (IFSP). Limited Podiatry services Dental services related to trauma to the mouth, jaw, teeth, or other contiguous sites as a result of injury. Dental services when the absence of dental treatment would adversely affect a preexisting medical condition. Personal care/advanced personal care Adult day health care Optical services include one comprehensive or limited eye examination every two years for refractive error, services related to trauma or treatment of disease/medical condition (including eye prosthetics), and one pair of eyeglasses every two years (during any 24 month period of time). Services provided by local public health agencies (may be provided by the MO HealthNet Managed Care health plan or through the local public health agency and paid by the MO HealthNet Managed Care health plan) Screening, diagnosis and treatment of sexually transmitted diseases HIV screening and diagnostic services Screening, diagnosis and treatment of tuberculosis Childhood immunizations Childhood lead poisoning prevention services, including screening, diagnosis and treatment Behavioral health and substance abuse services. Covered for children (except Group 4) and adults in all Managed Care regions without limits. Services shall include, but not be limited to: Inpatient hospitalization, when provided by an acute care hospital or a private or state psychiatric hospital Outpatient services when provided by a licensed psychiatrist, licensed psychologist, licensed clinical social worker, provisional licensed clinical social worker, licensed professional counselor, provisional licensed professional counselor, licensed psychiatric advanced practice nurse, licensed home health psychiatric nurse, or state certified behavioral health or substance abuse program Crisis intervention/access services Alternative services that are reasonable, cost effective and related to the member's treatment plan 7 Production - 04/30/2012
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Referral for screening to receive case management services. Behavioral health and substance abuse services that are court ordered, 96 hour detentions, and for involuntary commitments. Behavioral health and substance abuse services to transition the Managed Care member who received behavioral health and substance abuse services from an out-of-network provider prior to enrollment with the MO HealthNet Managed Care health plan. The MO HealthNet Managed Care health plan shall authorize out-of-network providers to continue ongoing behavioral health and substance abuse treatment, services, and items for new Managed Care members until such time as the new Managed Care member has been transferred appropriately to the care of an in-network provider. Early, periodic, screening, diagnosis and treatment (EPSDT) services also known as healthy children and youth (HCY) services for individuals under the age of 21. Services include but are not limited to: HCY screens including interval history, unclothed physical, anticipatory guidance, lab/immunizations, lead screening (verbal risk assessment and blood lead levels, [mandatory 6-72 months]), developmental screen and vision, hearing, and dental screens Orthodontics Private duty nursing Psychology/counseling services (Group 4 children in care and custody receive psychology/counseling services outside the Managed Care Health Plan). Refer to ME Codes listed for Group 4, Section 1.5.C Physical, occupational and speech therapy (IEP and IFSP services may be accessed out of the. MO HealthNet Managed Care health plan) Expanded services in the Home Health, Optical, Personal Care, Hearing Aid and Durable Medical Equipment Programs Transplant related services. The MO HealthNet Managed Care health plan is financially responsible for any inpatient, outpatient, physician, and related support services including presurgery assessment/evaluation prior to the date of the actual transplant surgery. The Managed Care health plan is responsible for the pre-transplant and post-transplant follow-up care. 11.6.A BENEFITS FOR CHILDREN AND WOMEN IN A MO HEALTHNET CATEGORY OF ASSISTANCE FOR PREGNANT WOMEN
A child is anyone less than twenty-one (21) years of age. For some members the age limit may be less than nineteen (19) years of age. Some services need prior approval before getting them. Women must be in a MO HealthNet category of assistance for pregnant women to get these extra benefits. 8 General Manual Production - 04/30/2012
Comprehensive day rehabilitation, services to help you recover from a serious head injury; Dental services All preventive, diagnostic, and treatment services as outlined in the MO HealthNet State Plan; Diabetes self management training for persons with gestational, Type I or Type II diabetes; Hearing aids and related services; Optical services to include one (1) comprehensive or one (1) limited eye examination per year for refractive error, one (1) pair of eyeglasses per year, and, for children under age twenty-one (21), HCY/EPSDT optical screen and services; Podiatry, medical services for your feet; Services that are included in the comprehensive benefit package, medically necessary, and identified in the IFSP or IEP (except for physical, occupational, and speech therapy services). Therapy services (physical, occupational, and speech) that are not identified in an IEP or IFSP. This includes maintenance, developmental, and all other therapies.
11.7 SERVICES PROVIDED OUTSIDE THE MO HEALTHNET MANAGED CARE PROGRAM

The following services are available to MO HealthNet Managed Care members outside the MO HealthNet Managed Care Program and are reimbursed to MO HealthNet approved providers on a feefor-service basis by the MO HealthNet Division: Abortion services (subject to MO HealthNet Program benefits and limitations) Physical, occupational and speech therapy services for children included in: the Individual Education Plan (IEP); or the Individual Family Service Plan (IFSP) Environmental lead assessments for children with elevated blood lead levels Community Psychiatric Rehabilitation program services Comprehensive substance treatment and rehabilitation (CSTAR) services Lab tests performed by the Department of Health and Senior Services as required by law (e.g., metabolic testing for newborns) 9 Production - 04/30/2012
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SAFE and CARE exams and related diagnostic studies furnished by a SAFE-CARE trained MO HealthNet approved provider MRDD waiver services for MRDD waiver participants included in all Managed Care regions. Bone marrow/stem cell and solid organ transplant services (corneal tissue transplants are covered as an outpatient benefit under the MO HealthNet Managed Care health plan). Services include the hospital stay from the date of transplant through the date of discharge, procurement, and physician services related to the transplant and procurement procedures. Pretransplant and post-transplant follow-up care after the inpatient transplant discharge are the responsibility of the MO HealthNet Managed Care health plan. Behavioral health services for MO HealthNet Managed Care children (group 4) in state care and custody Inpatient servicespatients with a dual diagnosis admission (physical and behavioral) have their hospital days covered by the MO HealthNet Managed Care Health Plan. Outpatient behavioral health visits are not the responsibility of the MO HealthNet Managed Care health plan for Group 4 members when provided by a: comprehensive substance treatment and rehabilitation (CSTAR) provider licensed psychiatrist
licensed psychologist, provisionally licensed psychologist, licensed clinical social worker, licensed master social worker, licensed professional counselor or provisionally licensed professional counselor Psychiatric Clinical Nurse Specialist, Psychiatric Mental Health Nurse Practitioner
state certified behavioral health or substance abuse program Missouri certified substance abuse counselor a qualified behavioral health professional in the following settings: federally qualified health center (FQHC) rural health clinic (RHC) Pharmacy services Home birth services Targeted Case Management for Behavioral Health Services
11.8 QUALITY OF CARE

The state has developed quality improvement measures for the MO HealthNet Managed Care health plan and will monitor their performance. 10 General Manual Production - 04/30/2012
11.9 IDENTIFICATION OF MO HEALTHNET MANAGED CARE PARTICIPANTS

Participants who are included in the MO HealthNet Managed Care Program are identified on the Internet or interactive voice response (IVR) system when verifying eligibility. The response received identifies the name and telephone number of the participants selected MO HealthNet Managed Care health plan. For MO HealthNet Managed Care members, the response also includes the identity of the MO HealthNet Managed Care member's primary care provider (PCP). Providers who need to contact the PCP, may contact the Managed Care health plan to confirm the PCP on the State's system has not recently changed. Participants who are eligible for the MO HealthNet Managed Care Program and enrolled with a MO HealthNet Managed Care health plan must have their basic benefit services provided by or prior authorized by the MO HealthNet Managed Care health plan. Refer to Section 1 for additional information on identification of participants in MO HealthNet Managed Care Programs. MO HealthNet Managed Care health plans may also issue their own individual Managed Care Health Plan ID cards. The individual must be eligible for managed health care and enrolled with the MO HealthNet Managed Care health plan on the date of service for the MO HealthNet Managed Care health plan to be responsible for services. Providers must verify the eligibility status and Managed Care health plan enrollment status on all MO HealthNet Managed Care participants before providing service. 11.9.A NON-BILLING MO HEALTHNET PROVIDER
MO HealthNet Managed Care health plan providers who have a valid agreement with one or more Managed Care health plans but who are not enrolled as a participating MO HealthNet provider may access the Internet or interactive voice response (IVR) only if they enroll with MO HealthNet as a Non-Billing MO HealthNet Provider. Providers are issued an atypical provider identifier that permits access to the Internet or IVR; however, it is not valid for billing MO HealthNet on a fee-for-service basis. Information regarding enrollment as a Non-Billing MO HealthNet Provider can be obtained by contacting the Provider Enrollment Unit at mmac.providerenrollment@dss.mo.gov.
11.10 EMERGENCY SERVICES

Emergency medical/behavioral health services means covered inpatient and outpatient services that are furnished by a provider that is qualified to furnish these services and are needed to evaluate or stabilize an emergency medical condition. Emergency medical condition for MO HealthNet Managed Care health plan members means medical or behavioral health condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent lay person, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following: General Manual Production - 04/30/2012 11
1. 2. 3. 4. 5. 6.
Placing the physical or behavioral health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; or Serious impairment of bodily functions; or Serious dysfunction of any bodily organ or part; or Serious harm to self or others due to an alcohol or drug abuse emergency; or Injury to self or bodily harm to others; or With respect to a pregnant woman having contractions: (1) that there is inadequate time to effect a safe transfer to another hospital before delivery or; (2) that transfer may pose a threat to the health or safety of the woman or the unborn.
Post stabilization care services means covered services, related to an emergency medical condition that are provided after a member is stabilized in order to maintain the stabilized conditions or to improve or resolve the member's condition.
11.11 PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE)

PACE is a comprehensive service delivery system and finance model for the frail elderly that replicates the original model pioneered at the San Francisco On Lok site in the early 1980s. The fully capitated service delivery system includes: primary care, restorative therapy, transportation, home health care, inpatient acute care, and nursing facility long-term care when home and community-based services are no longer appropriate. Services are provided at the PACE center, the home, in the hospital, or in a nursing facility, depending upon the needs of the individual. The goal is to maximize each participant's potential and continued residence in the home and community by providing preventive primary care and other support. Enrollment in the PACE program is always voluntary. Participants have the option to disenroll and return to the fee-for-service system at any time. A fully capitated PACE provider receives a monthly capitation from Medicare and/or MO HealthNet. All medical services that the individual requires while enrolled in the program are the financial responsibility of the fully capitated PACE provider. A successful PACE site serves 150 to 300 enrollees in a limited geographical area. The Balanced Budget Act of 1997 established PACE as a permanent provider under Medicare and allowed states the option to pay for PACE services under MO HealthNet. 11.11.A PACE PROVIDER AND SERVICE AREA Missouri and CMS have entered into a three-way program agreement with Alexian Brothers Community Services (ABCS) of St Louis. Services are provided to eligible individuals who reside in areas with the following zip codes: 63005 63034 General Manual Production - 04/30/2012 63011 63038 63017 63040 63021 63042 63025 63043 63026 63044 63031 63049 63033 63069 12
63074 63107 63115 63123 63131 63139
63088 63108 63116 63124 63132 63140
63101 63109 63117 63125 63133 63141
63102 63110 63118 63126 63134 63143
63103 63111 63119 63127 63135 63144
63104 63112 63120 63128 63136 63145
63105 63113 63121 63129 63137 63146
63106 63114 63122 63130 63138 63147
11.11.B ELIGIBILITY FOR PACE The PACE program is one more option along the continuum of long-term care services available under the Department of Health and Senior Services' (DHSS) "Missouri Care Options" (MCO) program, which offers a variety of home and community-based services to prevent or delay entry into a nursing facility. PACE targets individuals who require services above and beyond the standard package of in-home services available through MCO. The DHSS is the entry point for assessment for PACE program eligibility and referral to the PACE provider. Referrals for the program may be made to the DHSS office in St. Louis by calling (314) 340-7300. The target population for this program includes individuals age 55 and older, identified by DHSS through a health status assessment with a score of at least 21 points on the nursing home level of care assessment; and who reside in the service area. 11.11.C INDIVIDUALS NOT ELIGIBLE FOR PACE Individuals not eligible for PACE enrollment include: persons who are under age 55; persons residing in a State Mental Institution or Intermediate Care Facility for the Mentally Retarded (ICF/MR); persons enrolled in the Managed Care program; persons currently enrolled with a MO HealthNet hospice provider; 11.11.D LOCK-IN IDENTIFICATION OF PACE INDIVIDUALS When a DHSS-assessed individual meets the program criteria and chooses to enroll in the PACE program, the PACE provider has the individual sign an enrollment agreement and the DHSS locks the individual into the PACE provider for covered PACE services. Lock-in information is available to providers through the Internet and Interactive Voice Response (IVR) at (573) 6358908. A PACE Lock-In Provider is recognized by an "89" provider number. Enrollment in a PACE program is always voluntary and participants have the option to disenroll and return to the fee-for-service system at any time. 13 Production - 04/30/2012
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11.11.E PACE COVERED SERVICES Once the individual is locked into the PACE provider, the PACE provider is responsible for providing the following covered PACE services; physician, clinic, advanced practice nurse, and specialist (ophthalmology, podiatry, audiology, internist, surgeon, neurology, etc.); nursing facility services; physical, occupational, and speech therapies (group or individual); non-emergency medical transportation (including door-to-door services and the ability to provide for a companion to travel with the client when medically necessary); emergency transportation; adult day health care services; optometry and ophthalmology services including eye exams, eyeglasses, prosthetic eyes, and other eye appliances; audiology services including hearing aids and hearing aid services; dental services including dentures; mental health and substance abuse services including community psychiatric rehabilitation services; oxygen, prosthetic and orthotic supplies, durable medical equipment and medical appliances; health promotion and disease prevention services/primary medical care; in-home supportive care such as homemaker/chore, personal care and in-home nutrition; pharmaceutical services, prescribed drugs, and over the counter medications; medical and surgical specialty and consultation services; home health services; inpatient and outpatient hospital services; services for chronic renal dialysis chronic maintenance dialysis treatment, and dialysis supplies; emergency room care and treatment room services; laboratory, radiology, and radioisotope services, lab tests performed by DHSS and required by law; interdisciplinary assessment and treatment planning; 14 Production - 04/30/2012
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nutritional counseling; recreational therapy; meals; case management, care coordination; rehabilitation services; hospice services; ambulatory surgical center services; other services determined necessary by the interdisciplinary team to improve and maintain the participants overall health status. No fee-for-service claims are reimbursed by MO HealthNet for participants enrolled in PACE. Services authorized by MHD prior to the effective enrollment date with the PACE provider, are the responsibility of MHD. All other prior authorized services must be arranged for or provided by the PACE provider and are not reimbursed through fee-for-service.
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Section 12 - Reimbursement Methodology
SECTION 12 -REIMBURSEMENT METHODOLOGY

12.1 THE BASIS FOR ESTABLISHING A RATE OF PAYMENT ....................................... 2 12.2 BEHAVIORAL HEALTH SERVICES .............................................................................. 2 12.3 DETERMINING A FEE ...................................................................................................... 3 12.3.A ON-LINE FEE SCHEDULE ........................................................................................... 3 12.4 MEDICARE/MO HEALTHNET REIMBURSEMENT (CROSSOVER CLAIMS) ..... 3 12.5 RECIPIENT COST SHARING AND COPAY .................................................................. 4 12.6 A MO HEALTHNET MANAGED HEALTH CARE DELIVERY SYSTEM METHOD OF REIMBURSEMENT............................................................................... 4 12.6.A MANAGED HEALTH CARE ........................................................................................ 4 12.7 DIRECT DEPOSIT OPTION.............................................................................................. 5
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SECTION 12REIMBURSEMENT METHODOLOGY 12.1 THE BASIS FOR ESTABLISHING A RATE OF PAYMENT
The MO HealthNet Division is charged with establishing and administering the rate of payment for those medical services covered by the Missouri Title XIX Program. The Division establishes a rate of payment that meets the following goals: Ensures access to quality medical care for all participants by encouraging a sufficient number of providers; Allows for no adverse impact on private-pay patients; Assures a reasonable rate to protect the interests of the taxpayers; and Provides incentives that encourage efficiency on the part of medical providers.
Funds used to reimburse providers for services rendered to eligible participants are received in part from federal funds and supplemented by state funds to cover the costs. The amount of funding by the federal government is based on a percentage of the allowable expenditures. The percentage varies from program to program and in some cases different percentages for some services within the same program may apply. Funding from the federal government may be as little as 60% or as much as 90%; depending on the service and/or program. The balance of the allowable, (10-40%) is paid from state General Revenue appropriated funds. Total expenditures for MO HealthNet must be within the appropriation limits established by the General Assembly. If the expenditures do not stay within the appropriation limits set by the General Assembly and funds are insufficient to pay the full amount, then the payment for services may be reduced pro rata in proportion to the deficiency.
12.2 BEHAVIORAL HEALTH SERVICES

Reimbursement for Behavioral Health services is made on a fee-for-service basis. The maximum allowable fee for a unit of service has been determined by the State Agency to be a reasonable fee, consistent with efficiency, economy, and quality of care. Payment for covered services is the lower of the provider's actual billed charge (should be the provider's usual and customary charge to the general public for the service), or the maximum allowable per unit of service.
12.3 DETERMINING A FEE

Under a fee system each procedure, service, medical supply and equipment covered under a specific program has a maximum allowable fee established. In determining what this fee should be, the MO HealthNet Division uses the following guidelines: Recommendations from the State Medical Consultant and/or the provider subcommittee of the Medical Advisory Committee; Medicares allowable reasonable and customary charge payment or cost-related payment, if applicable; Charge information obtained from providers in different areas of the state. Charges refer to the usual and customary fees for various services that are charged to the general public. Implicit in the use of charges as the basis for fees is the objective that charges for services be related to the cost of providing the services.
The MO HealthNet Division then determines a maximum allowable fee for the service based upon the recommendations, charge information reviewed and current appropriated funds. 12.3.A ON-LINE FEE SCHEDULE
MO HealthNet fee schedules through the MO HealthNet Division are available athttp://dss.mo.gov/mhd/providers/index.htm. The on-line Fee Schedule identifies covered and non-covered procedure codes, restrictions, allowed units and the MO HealthNet allowable fee per unit. The on-line Fee Schedule is updated quarterly and is intended as a reference not a guarantee for payment. The on-line Fee Schedule allows for the downloading of individual files or the search for a specific fee schedule. Some procedure codes may be billed by multiple provider types. Categories within the Fee Schedule are set up by the service rendered and are not necessarily provider specific. Refer to Section 13 for program specific benefits and limitations.
12.4 MEDICARE/MO HEALTHNET REIMBURSEMENT (CROSSOVER CLAIMS)

For MO HealthNet participants who are also Medicare beneficiaries and receive services covered by the Medicare Program, MO HealthNet pays the deductible and coinsurance amounts otherwise charged to the participant by the provider. See Section 16 for a detailed explanation of these claims.
12.5 RECIPIENT COST SHARING AND COPAY

Certain MO HealthNet services are subject to participant cost sharing or copay. The cost sharing amount is paid by the participant at the time services are rendered. Services of the Physician Program described in this manual are subject to a cost sharing or copay amount. The provider must accept in full the amounts paid by the state agency plus any cost sharing or copay amount required of the participant. Refer to Section 13 for program specific information.
12.6 A MO HEALTHNET MANAGED HEALTH CARE DELIVERY SYSTEM METHOD OF REIMBURSEMENT

One method through which MO HealthNet provides services is a MO HealthNet Managed Health Care Delivery System. A basic package of services is offered to the participant by the health plan; however, some services are not included and are covered by MO HealthNet on a fee-for-service basis. Behavioral Health services are included as a plan benefit in MO HealthNet's Managed Care program for children under the age of 21. Children (category 4) in state care and custody are fee-for-service.
12.6.A MANAGED HEALTH CARE

Under a managed health plan, a basic set of services is provided either directly or through subcontractors. Managed health care plans are reimbursed at an established rate per member per month. Reimbursement is based on predicted need for health care and is paid for each participant for each month of coverage. Rather than setting a reimbursement rate for each unit of service, the total reimbursement for all enrollees for the month must provide for all needed health care to all participants in the group covered. The health plan is at risk for staying within the overall budgetthat is, within the negotiated rate per member per month multiplied by the number of participants covered. Some individual cases exceed the negotiated rate per member per month but many more cases cost less than the negotiated rate. The MO HealthNet Program utilizes the managed care delivery system for certain included MO HealthNet eligibles. Refer to Section 1 and Section 11 for a detailed description.
12.7 DIRECT DEPOSIT OPTION

The MO HealthNet Program requires providers have their MO HealthNet checks automatically deposited into their checking or savings accounts. Providers must complete the Application for Provider Direct Deposit form. Direct deposit begins following a submission of a properly completed application form to the MO HealthNet Division, the successful processing of a test transaction through the banking system and the authorization of the Division to make payment using the direct deposit option. The state conducts direct deposit through the automated clearing house system, utilizing an originating depository financial institution. The rules of the National Clearing House Association and its member local Automated Clearing House Association shall apply, as limited or modified by law. The Application for Provider Direct Deposit is available at the MHD website under MO HealthNet Forms. Please read the form and instructions carefully, Section C contains statements regarding legal obligations. This form must also be used if providers wish to change an account number or cancel their election to participate. Exact copies of the form may be used. One form must be completed for each provider NPI. The MO HealthNet Division will terminate or suspend the direct deposit for administrative or legal actions, including but not limited to: ownership change, duly executed liens or levies, legal judgments, notice of bankruptcy, administrative sanctions for the purpose of ensuring program compliance, death of a provider, and closure or abandonment of an account. The MO HealthNet Remittance Advice is available to view and print on the MO HealthNet Web portal at www.emomed.com.
Section 13 Benefits and Limitations
SECTION 13 BENEFITS AND LIMITATIONS

13.1 GENERAL INFORMATION .................................................................................6 13.1.A CHILDREN ......................................................................................................... 6 13.1.B ADULTS ............................................................................................................. 6 13.2 PATIENT ELIGIBILITY .......................................................................................6 13.3 PROVIDER PARTICIPATION REQUIREMENTS ................................................7 13.3.A MAXIMUM MONTHLY BILLABLE HOURS ................................................ 7 13.3.B PSYCHOLOGISTS AND PROVISIONALLY LICENSED PSYCHOLOGISTS (PLP) ................................................................................................................... 8 13.3.C LICENSED CLINICAL SOCIAL WORKERS AND LICENSED MASTER SOCIAL WORKERS (LCSW, LMSW) ............................................................. 8 13.3.D LICENSED OR PROVISIONALLY LICENSED PROFESSIONAL COUNSELORS (LPC or PLPC) ......................................................................... 9 13.3.E LICENSED PSYCHIATRISTS, PSYCHIATRIC CLINICAL NURSE SPECIALIST (PCNS), AND PSYCHIATRIC MENTAL HEALTH NURSE PRACTITIONERS (PMHNP) ............................................................................ 9 13.3.F NOTIFICATION OF PROVIDER CHANGES ................................................ 10 13.4 ADEQUATE DOCUMENTATION .......................................................................10 13.4.A DOCUMENTATION REQUIREMENTS ........................................................ 12 13.4.A(1) Diagnostic Assessment.............................................................................. 13 13.4.A(2) Plan Of Treatment Documentation ........................................................... 14 13.4.A(3) Progress Notes ........................................................................................... 15 13.4.A(4) Plan Of Treatment Review ........................................................................ 16 13.4.A(5) Aftercare Plan............................................................................................ 17 13.4.A(6) Pharmacologic Management CPT 90862............................................... 17 13.4.B RETENTION OF RECORDS ........................................................................... 18 13.5 PATIENT COST SHARING AND COPAY ...........................................................18 13.5.A PROVIDER RESPONSIBILITY TO COLLECT COPAYMENT ................... 18 1 Behavioral Health Services Manual
13.5.B PATIENT RESPONSIBILITY TO PAY COPAY ............................................ 19 13.5.B(1) Uncolleted Copay Amount ........................................................................ 19 13.5.C SERVICES REQUIRING A COPAY ............................................................... 19 13.5.D EXEMPTIONS TO THE COPAY REQUIREMENTS .................................... 20 13.5.E PROVIDER PARTICIPATION PRIVILEGES ................................................ 21 13.6 PATIENT NONLIABILITY .................................................................................21 13.7 EMERGENCY SERVICES ..................................................................................21 13.8 OUT-OF-STATE, NONEMERGENCY SERVICES ...............................................21 13.8.A EXCEPTIONS TO OUT-OF-STATE PRIOR AUTHORIZATION (PA) REQUESTS ....................................................................................................... 22 13.9 PRIOR AUTHORIZATION .................................................................................22 13.9.A REQUESTING PRIOR AUTHORIZATION ................................................... 23 13.9.B CLINICAL EXCEPTIONS ............................................................................... 25 13.9.C PRIOR AUTHORIZATION EXEMPTIONS ................................................... 25 13.9.D RESIDENTIAL CARE EXEMPTIONS ........................................................... 26 13.9.E PARTICIPANT APPEAL RIGHTS .................................................................. 26 13.10 SERVICES FOR ADULTS .................................................................................26 13.10.A PRIOR AUTHORIZATION GUIDELINES ADULTS ............................... 27 13.10.B ADULTS - CODES REQUIRING PRIOR AUTHORIZATION ................... 28 13.10.C ADULTS - CODES NOT REQUIRING PRIOR AUTHORIZATION .......... 29 13.11 SERVICES FOR CHILDREN AND YOUTH.......................................................33 13.11.A PRIOR AUTHORIZATION GUIDELINES - CHILDREN AND YOUTH .. 33 13.11.A(1) Prior Authorization For Children And Youth By Age Group Children Not In State Custudy Or Not Residing In Residential Care Facility ............. 34 13.11.A(2) Prior Authorization For Children and Youth By Age Group Foster Care (ME Code 07, 08, 37, and 38) Not Residing In Residential Care Facility .... 37 13.11.B CHILDREN AND YOUTH CODES REQUIRING PRIOR AUTHORIZATION .......................................................................................... 39
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13.11.C CHILDREN AND YOUTH CODES NOT REQUIRING PRIOR AUTHORIZATION .......................................................................................... 41 13.12 SCHOOL-BASED SERVICES ............................................................................45 13.12.A PROVIDER ENROLLMENT ......................................................................... 46 13.12.B TREATMENT PLAN...................................................................................... 46 13.12.C PROCEDURE CODES ................................................................................... 47 13.13 PROCEDURE CODE LIMITATIONS ................................................................48 13.13.A PROCEDURE CODES FOR LCSW, LMSW, LPC AND PLPC ................... 48 13.13.B PROCEDURE CODES FOR PSYCHOLOGISTS OR PROVISIONALLY LICENSED PSYCHOLOGISTS ...................................................................... 50 13.13.C PSYCHIATRISTS, PCNS, PMHNP, FQHC, AND RHC .............................. 51 13.14 TIME-BASED SERVICE LIMITATIONS...........................................................53 13.15 MUTUALLY EXCLUSIVE CODES ...................................................................54 13.16 POSTPAYMENT REVIEW................................................................................54 13.17 PREPAYMENT REVIEW PROCESS .................................................................54 13.18 DIAGNOSTIC ASSESSMENT ...........................................................................54 13.18.A PSYCHIATRIC DIAGNOSTIC INTERVIEW EXAMINATION (90801) ... 55 13.18.B INTERACTIVE PSYCHIATRIC DIAGNOSTIC INTERVIEW (90802) ..... 56 13.19 TESTING ..........................................................................................................56 13.20 INDIVIDUAL THERAPY ..................................................................................57 13.20.A INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE PSYCHOTHERAPY ......................................................................................... 57 13.20.B INTERACTIVE PSYCHOTHERAPY............................................................ 57 13.20.C INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE PSYCHOTHERAPY INPATIENT SETTING .............................................. 59 13.20.D INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE INPATIENT SETTING .......................................................................................................... 59 13.21 FAMILY THERAPY..........................................................................................60 3 Behavioral Health Services Manual
13.22 GROUP THERAPY ...........................................................................................60 13.23 CRISIS INTERVENTION ..................................................................................60 13.24 SMOKING CESSATION ...................................................................................61 13.24.A PROCEDURE CODES ................................................................................... 61 13.24.A(1) Physicians, Nurse Practitioners, Nurse Midwives, PCNS, PMHNP, Psychologists, and PLP (Psychologists and PLPs must use the AH modifier) ....................................................................................................................... 62 13.24.A(2) LCSWs, LMSWs, LPCs, and PLPCs (LCSWs and LMSWs must use the AJ modifier. LPCs and PLPCs must use the UD modifier) ......................... 62 13.24.B DIAGNOSIS CODES...................................................................................... 62 13.25 EPSDT/HCY SERVICES ...................................................................................63 13.25.A PARTIAL EPSDT/HCY SCREENS ............................................................... 63 13.25.A(1) EPSDT/HCY Partial Screen For Developmental Assessment ................ 63 13.25.A(2) Partial Screeners ...................................................................................... 63 13.26 NONCOVERED SERVICES ..............................................................................64 13.26.A NON-ALLOWED SERVICES ....................................................................... 64 13.26.B PSYCHOLOGICAL SERVICES IN A NURSING HOME ........................... 65 13.27 TELEHEALTH SERVICES ...............................................................................65 13.27.A TELEHEALTH COVERED SERVICES ....................................................... 65 13.27.B ELIGIBLE PROVIDERS ................................................................................ 66 13.27.C TELEHEALTH SERVICE REQUIREMENTS .............................................. 66 13.27.D REIMBURSEMENT ....................................................................................... 67 13.27.E PRIOR AUTHORIZATION AND UTILIZATION REVIEW ...................... 69 13.27.F DOCUMENTATION FOR THE ENCOUNTER ........................................... 69 13.27.G CONFIDENTIALITY AND DATA INTEGRITY/APPROVED MISSOURI TELEHEALTH NETWORK (MTN)................................................................ 69 13.27.H INFORMED CONSENT ................................................................................. 70 13.27.I MISSOURI TELEHEALTH NETWORK ........................................................ 70 13.28 MODIFIERS .....................................................................................................71 4 Behavioral Health Services Manual
13.29 FREQUENTLY USED PLACE OF SERVICE CODES ........................................71 13.29.A PLACE OF SERVICE CODE ......................................................................... 72 13.30 REFERRAL SERVICES ....................................................................................72 13.31 THIRD PARTY LIABILITY (TPL) ....................................................................73 13.31.A TPL BYPASS .................................................................................................. 73 13.31.B TPL LIABILITY INSURANCE REPORTING FORM .................................. 73 13.32 MANAGED CARE BEHAVIORAL HEALTH SERVICES ..................................74 13.33 REPORTING CHILD ABUSE CASES ................................................................74
SECTION 13BENEFITS AND LIMITATIONS 13.1 GENERAL INFORMATION

The Behavioral Health Services Manual contains policy and procedures for providing mental health services to children and adults. 13.1.A CHILDREN Medically necessary mental health services are available to MO HealthNet (MHD) eligible children under the age of 21 (0-20). MHD eligible children may receive behavioral health services when provided by a licensed Psychiatrist, licensed Psychiatric Clinical Nurse Specialist (PCNS), licensed Psychiatric Mental Health Nurse Practitioner (PMNHP), licensed or provisionally licensed Psychologist, Licensed Clinical Social Worker (LCSW), Licensed Master Social Worker (LMSW), or licensed or provisionally Licensed Professional Counselor (LPC or PLPC). MHD reimburses services provided in a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC). Services provided by LPCs and PLPCs are not considered a Rural Health Clinic Service. The Omnibus Budget Reconciliation Act of 1989 (OBRA-89) mandated that services purchased by MHD be medically necessary as determined through a Healthy Children and Young (HCY) screening. These services include behavioral health services. Senate Bill 765 of the 85th General Assembly provided state legislation for program implementation. Refer to Section 9 for complete information concerning the HCY program. 13.1.B ADULTS Medically necessary mental health services are available to MHD eligible adults age 21 and over through the Behavioral Health Services Program. MHD eligible adults, may receive behavioral health services when provided by a licensed Psychiatrist, a PCNS, a PMHNP, or licensed or provisionally licensed Psychologist. MHD reimburses services provided in an FQHC or an RHC setting when provided by a Psychiatrist, PCNS, PMHNP, licensed or provisionally licensed Psychologist, LCSW, or LMSW. Individually enrolled MHD LCSWs or LMSWs who are not part of a FQHC or RHC may not provide services to adults, 21 years and older.
13.2 PATIENT ELIGIBILITY

MHD pays for approved behavioral health services when furnished within the providers scope of practice. The patient must be eligible on the date the service is furnished. Patients may have specific limitations for behavioral health services according to the type of assistance for which they have been determined eligible and their age. It is the providers responsibility to determine the coverage benefits for a patient based on their type of assistance and age. The provider shall ascertain the patients MHD managed care or other lock-in status before any service is 6 Behavioral Health Services Manual
performed. The patients eligibility shall be verified in accordance with methodology outlined in Section1 and Section 3.
13.3 PROVIDER PARTICIPATION REQUIREMENTS

To be eligible to participate in the MHD Behavioral Health Services Program, the mental health provider must satisfy the following requirements:
Hold a valid current Missouri license if located in Missouri; or
Hold a corresponding valid current license if located outside the state of Missouri that meets the licensing criteria specified; Have a signed and accepted Participation Agreement in effect with the Missouri Department of Social Services, Missouri Medicaid Audit and Compliance (MMAC). The enrolled MHD provider shall agree to: Keep any records necessary to disclose the extent of services the provider furnishes to patients, and; On request furnish to the Medicaid agency or State Medicaid Fraud Control Unit any information regarding payments claimed by the provider for furnishing services under the plan. Additional information on provider conditions of participation can be found Section 2 of this provider manual. 13.3.A MAXIMUM MONTHLY BILLABLE HOURS Pursuant to 13 CSR 70-98.015, Section (3) Provider Participation, MHD implemented a limit of billable hours for Behavioral Health Services Program services to a maximum of one hundred fifty (150) hours in a single calendar month. Services provided to MHD participants and participants who are both MHD and Medicare eligible are counted toward the monthly one hundred fifty (150) hour limit. The Provider will be required to refund payment for MHD services when the provider has billed MHD for more than one hundred fifty (150) hours in a single calendar month, regardless of the type of service. In a group/clinic setting the monthly maximum billable hours (150) are calculated based on each individual performing provider, not the group/clinic billing provider. The limit applies to ALL behavioral health services provided in ALL settings, regardless of the patient age, placement or ME code.
13.3.B PSYCHOLOGISTS AND PROVISIONALLY LICENSED PSYCHOLOGISTS (PLP) A Psychologist or PLP may provide psychological services for children and adults. A Psychologist or PLP must have and maintain: A valid license or provisional license issued by the State Committee of Psychologists when practicing in Missouri; or A valid license or provisional license issued by the licensing authority of the state in which they practice. The provider's NPI must be on file with MHD. Services are submitted to MHD with the provider's NPI. Services provided in a group/clinic setting must be filed under the group/clinic NPI with the individual's NPI reported as the performing provider when the claim is submitted for reimbursement.
NOTE: A PLP must only provide services allowed under the provisional licensure. A PLP may not operate as an independent practitioner, receive direct payment from MHD or own their own business in the practice as a PLP. PLPs must submit a copy of their permanent license to the Missouri Medicaid Audit and Compliance Provider Enrollment Unit upon receipt. 13.3.C LICENSED CLINICAL SOCIAL WORKERS AND LICENSED MASTER SOCIAL WORKERS (LCSW, LMSW) LCSWs and LMSWs may be reimbursed for behavioral health services for children under 21. LCSWs and LMSWs who are members of an FQHC or an RHC may be reimbursed for behavioral health services for adults (age 21 and up) as part of the clinic. LCSWs and LMSWs must have and maintain: A valid license issued by the State Committee for Social Workers administered by the Division of Professional Registration if practicing in Missouri; or A valid license issued by the licensing authority of the state in which they practice; The provider's NPI must be on file with MHD. Services are submitted to MHD with the provider's NPI. Services provided in a group/clinic setting must be filed under the group/clinic NPI with the individual's NPI reported as the performing provider when the claim is submitted for reimbursement.
NOTE: An LMSW must only provide services allowed under the licensure. An LMSW may not operate as an independent practitioner, receive direct payment from MHD or own their own business in the practice as an LMSW. LMSW providers will be enrolled for a period of forty-eight (48) months to complete supervision requirements and obtain a license as a Clinical Social Worker. LMSW providers must submit a copy of the LCSW license to the Missouri Medicaid Audit and Compliance Provider Enrollment Unit upon 8 Behavioral Health Services Manual
receipt of license to be maintained as an MHD provider. LMSWs must follow the MHD policy for LCSWs. 13.3.D LICENSED OR PROVISIONALLY LICENSED PROFESSIONAL COUNSELORS (LPC or PLPC) LPCs and PLPCs may be reimbursed for behavioral health services for children under 21. LPCs and PLPCs may not be reimbursed for behavioral health services provided to adults, ages 21 and older. LPCs and PLPCs must have and maintain: A valid license or provisional license with the State Committee of Professional Counselors if practicing in Missouri; or A valid license or provisional license issued by the licensing authority of the state in which they practice. The provider's NPI must be on file with MHD. Services are submitted to MHD with the provider's NPI. Services provided in a group/clinic setting must be filed under the group/clinic NPI with the individual's NPI reported as the performing provider when the claim is submitted for reimbursement.
NOTE: A PLPC must only provide services allowed under the provisional licensure. A PLPC may not operate as an independent practitioner, receive direct payment from MHD or own their own business in the practice as a PLPC. PLPCs must submit a copy of their permanent license to the Missouri Medicaid Audit and Compliance Provider Enrollment Unit upon receipt of license to be maintained as an MHD provider. 13.3.E LICENSED PSYCHIATRISTS, PSYCHIATRIC CLINICAL NURSE SPECIALIST (PCNS), AND PSYCHIATRIC MENTAL HEALTH NURSE PRACTITIONERS (PMHNP) MHD reimburses Psychiatrists, PCNS, and PMHNPs for services provided to children and adults through the Behavioral Health Services Program. See Section 13.19.C for codes billable under the Behavioral Health Services Program. A Psychiatrist must have and maintain: A valid permanent license issued by the Division of Professional Registration, Board of Healing Arts.
A clinical nurse specialist with a specialty in Psychiatry (PCNS) must have and maintain: A valid RN license AND a valid Document of Recognition with a specialty in Psychiatry through the Missouri State Board of Nursing.
A mental health nurse practitioner with a specialty in Psychiatry (PMHNP) must have and maintain: A valid RN license AND Document of Recognition as an adult psychiatric mental health nurse practitioner, family psychiatric mental health nurse practitioner, or psychiatric mental health nurse practitioner.
For all provider types listed above, the provider's NPI must be on file with MHD. Services are submitted to MHD with the provider's NPI. Services provided in a group/clinic setting must be filed under the group/clinic NPI with the individual's NPI reported as the performing provider when the claim is submitted for reimbursement. 13.3.F NOTIFICATION OF PROVIDER CHANGES The MMAC Provider Enrollment Section must be notified in writing of any changes in provider records. The notification must include the provider's National Provider Identification (NPI), the requested changes, and the provider's signature. A provider must notify the MMAC Provider Enrollment Section promptly of: Change of provider address or pay to address, if different (necessary to ensure that all checks and correspondence are received promptly). Indication of change of address on a claim form is not sufficient. Change of ownership of business. (change of ownership form is required.) Change from Social Security number to a Tax Payer I.D. number. Change of Employment Address Change in EIN, CLIA, Medicare numbers, etc. Change in licensure or certification including but not limited to status. Mailing Address: MMAC Provider Enrollment Section Missouri Medicaid Audit and Compliance Unit P. O. Box 6500 Jefferson City, MO 65102 Email address: MMAC.providerenrollment@dss.mo.gov Refer to Section 2 of this manual for additional information.
13.4 ADEQUATE DOCUMENTATION

All services provided must be adequately documented in the medical record. The requirement to document services and to release records to representatives of the Department of Social Services or the U.S. Department of Health and Human Services is stated in the following documents, MO HealthNet state regulation (13 CSR 70-3) Conditions of Provider Participation, Reimbursement and Procedure of General Applicability. These requirements are also repeated in the Title XIX
Participation Agreement, which is a document signed by all providers upon enrollment as a MO HealthNet provider. The Code of State Regulation, 13 CSR 70-3.030, Section (2)(A) defines adequate documentation and adequate medical records as follows: Adequate documentation means documentation from which services rendered and the amount of reimbursement received by a provider can be readily discerned and verified with reasonable certainty. Adequate medical records are records which are of the type and in a form from which symptoms, conditions, diagnosis, treatments, prognosis and the identity of the patient to which these things relate can be readily discerned and verified with reasonable certainty. All documentation must be made available at the same site at which the service was rendered. An adequate and complete patient record is a record which is legible, which is made contemporaneously with the delivery of the service, which addresses the patient/client specifics, which include, at a minimum, individualized statements that support the assessment or treatment encounter, and shall include documentation of the following information: First name, and last name, and either middle initial or date of birth of the MO HealthNet participant An accurate, complete, and legible description of each service(s) provided Name, title, and signature of the MO HealthNet enrolled provider delivering the service. Inpatient hospital services must have signed and dated physician or psychologist orders within the patients medical record for the admission and for services billed to MO HealthNet. For patients registered on hospital records as outpatient, the patients medical record must contain signed and dated physician orders for services billed to MO HealthNet. Services provided by an individual under the direction or supervision are not reimbursed by MO HealthNet. Services provided by a person not enrolled with MO HealthNet are not reimbursed by MO HealthNet The name of the referring entity, when applicable The date of service (month/day/year) For those MO HealthNet programs and services that are reimbursed according to the amount of time spent in delivering or rendering a service(s) (except for services identified by the American Medical Association Current Procedural Terminology procedure codes 99291-99292 and targeted case management services administered through the Department of Mental Health and as specified under 13 CSR 70-91.010 Personal Care Program (4)(A)) the actual begin and end time taken to deliver the service (for example, 4:00-4:30 p.m.) must be documented The setting in which the service was rendered The plan of treatment, evaluation(s), test(s), findings, results, and prescription(s) as necessary. Where a hospital acts as an independent laboratory or independent radiology service for persons considered by the hospital as non-hospital 11 Behavioral Health Services Manual
patients, the hospital must have a written request or requisition slip ordering the tests or procedures The need for the service(s) in relationship to the MO HealthNet participant's Treatment Plan The MO HealthNet participant's progress toward the goals stated in the Treatment Plan (Progress Notes) and Long-term care facilities shall be exempt from the seventy-two (72) hour documentation requirements rules applying to paragraphs (2)(A)9 and (2)(A)10. However, applicable documentation should be contained and available in the entirety of the medical report 13 CSR 70-3.030(2)(D) states: Contemporaneous means at the time the service was performed or within seventytwo (72) hours of the time the service was provided.
Electronic signatures are accepted. Stamped signatures are not acceptable. All documentation must be legible and written/submitted in English. As referenced above, documentation must be entered in the patient record within 72 hours of the service delivered. 13.4.A DOCUMENTATION REQUIREMENTS In addition to the requirements outlined in 13 CSR 70-3.030, Section (1)(A), behavioral health services under MO HealthNet have additional specific documentation requirements as noted in the Code of State Regulations, 13 CSR 70-98.015. Documentation required by MO HealthNet does not replace or negate documentation/reports required by the Children's Division for individuals in their care or custody. Providers are expected to comply with policies and procedures established by the Children's Division and MHD. For all medically necessary covered services, a writing of all stipulated documentation elements referenced in this section is an essential and integral part of the service itself. No service is reimbursed if documentation requirements are not met. The patient's progress toward the goals stated in the Treatment Plan/Progress Notes and/or need for the service in relationship to the patient's Treatment Plan must be documented within seventy-two (72) hours of the service.
Reimbursement for each date of service must contain the following documentation in the patients medical record. This documentation must be in narrative form fully describing each session billed. A check-off list or pre-established form is not accepted as sole documentation. 13.4.A(1) Diagnostic Assessment A Diagnostic Assessment from a MO HealthNet enrolled provider shall be documented in the patient's medical record. The Diagnostic Assessment shall assist in ensuring an appropriate level of care, identifying necessary services, developing an individualized Treatment Plan, and documenting the following, in addition to the requirements contained in Section 13.4 and 13.4.A above: A. Statement of needs, goals, and treatment expectations from the individual requesting services. The family's perceptions are also obtained, when appropriate and available; B. Presenting situations/problem and referral source; C. History of previous psychiatric and/or substance abuse treatment including number and type of admissions; documentation of prior/current counseling including date range, purpose, duration and provider D. Current medications and identifications of any medication allergies and adverse reactions; E. Recent alcohol and drug use for at least the past 30 days and, when indicated, a substance abuse history that includes duration, patterns, and consequences of use; F. Current psychiatric symptoms. These current symptoms must address the diagnostic criteria in support of the diagnosis being made. G. Family, social, legal, and vocational/educational status and functioning. The collection and assessment of historical data is also required unless short-term crisis intervention or detoxification is the only services being provided; H. Current use of resources and services from other community agencies; I. Personal and social resources and strengths, including the availability and use of family, social, peer and other natural supports; and J. Multi-axis diagnosis or diagnostic impression in accordance with the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association or the International Classification of Diseases, current edition (ICD). The ICD code is required on the Treatment Plan for billing purposes. The Diagnostic Assessment must be signed and dated by the provider delivering the service. The date should reflect the date the service was 13 Behavioral Health Services Manual
provided. If the Diagnostic Assessment was completed over a span of days each portion of the Diagnostic Assessment should reflect the date that portion of the service was delivered with the date at the end of the form reflecting the date the entire Diagnostic Assessment was completed. The dates billed should reflect the dates each portion was delivered. A Diagnostic Assessment should result in a determination that no further services are required or should be used in developing an individualized Treatment Plan. The Diagnostic Assessment must be current within one year for adults and adolescents (age 13 to 20) or six months for children under 13. An update to the Diagnostic Assessment is required in occurrence of a crisis or significant clinical event. 13.4.A(2) Plan Of Treatment Documentation A plan of treatment is a required document in the overall record of the patient. A Treatment Plan must be developed by the provider based on a Diagnostic Assessment that includes: Examination of the medical, psychological, social, behavioral, and developmental aspects of the patients situation and reflects the need for behavioral health services.
The Treatment Plan shall be individualized to reflect the patient's unique needs and goals. The plan shall include, but is not limited to, the following in addition to the requirements contained in Section 13.4 and 13.4.A above: A. Measurable goals and outcomes; B. Services, support, and actions to accomplish each goal/outcome. This includes services and supports and the staff member responsible, as well as action steps of the patient and other supports (family, social, peer and other natural supports); C. Involvement of family, when indicated; D. Identification of other agencies working with the patient, plans for coordinating with other agencies, or identification of medications, which have been prescribed, where applicable; E. Services needed beyond the scope of the organization or program that are being addressed by referral or services at another community organization, where applicable; F. Projected time frame for the completion of each goal/outcome not to exceed 12 months; and G. Estimated completion/discharge date for the level of care.
The Treatment Plan must be signed and dated by the provider delivering the service. The Treatment Plan must be current within one year for adults and adolescents (age 13 to 20) or six months for children under 13. An update to the Treatment Plan is required in the occurrence of a crisis or significant clinical event. 13.4.A(3) Progress Notes Progress Notes for behavioral health services shall be written and maintained in the patients medical record for each date of service for which a claim is filed. Progress Notes shall specify, in addition to the requirements contained in Section 13.4 and 13.4.A above: First and last name of patient;
When family therapy is furnished: Each member of the family included in the session must be identified. (The family unit is viewed as a social system that affects all its members. A parent must be present 75% of the time to be billed as family therapy. The description of immediate issue addressed in therapy. Identification of underlying roles, conflicts or patterns, Description of therapist intervention must also be identified.
When group therapy is furnished: Each service shall include the number of group members present. (Minimum of three but no more than 10 patients) Description of immediate issue addressed in therapy, identification of underlying roles, conflicts or patterns. Description of therapist intervention and progress towards goals. Documentation of the need for service Describe the type of equipment, devices or other mechanisms used
When interactive therapy is furnished:
The specific service(s) rendered including the Procedure Code; Name of person who provided the service; The date (month/date/year) and the actual begin and end time (e.g., 4:00-4:30 p.m. the face-to-face services; The setting in which the service was rendered; The patient's report of recent symptoms and behaviors related to their diagnosis and Treatment Plan goals; 15
Behavioral Health Services Manual
The therapist interventions for that visit and patient's response; The pertinence of the service to the Treatment Plan; and The patient's progress toward one or more goals stated in the Treatment Plan. The progress note must be signed and dated by the provider delivering the service. The progress note must document the specific service delivered. The service must also be a covered service to be billed to MO HealthNet.
NOTE: The MO HealthNet enrolled provider is the only person who can provide behavioral health services and be reimbursed for these services. Services provided by someone other than the enrolled provider are not covered by MO HealthNet and may not be billed to MO HealthNet by or on behalf of another individual. Services provided by an individual under the direction or supervision of the enrolled provider are not covered. 13.4.A(4) Plan Of Treatment Review The Treatment Plan shall be reviewed on a periodic basis to evaluate progress towards treatment goals and outcomes and to update the plan. Each person shall directly participate in the review of his or her individualized Treatment Plan. The frequency of Treatment Plan reviews shall be based upon the individuals level of care or other applicable program rules. The occurrence of a crisis or significant clinical event may require further review and modification of the Treatment Plan. The individualized Treatment Plan shall be updated and changed as indicated. Each Treatment Plan update shall include the therapist's assessment of current symptoms and behaviors related to diagnosis, progress to treatment goals, justification of changed or new diagnosis, and response to other concurrent treatments such as family or group therapy and medications. The therapist's plan for continuing treatment and/or termination from therapy and aftercare shall be considerations expressed in each Treatment Plan update.
The Treatment Plan update must be signed and dated by the provider delivering the service. The Treatment Plan update must be current within one year for adults and adolescents (age 13 to 20) or six months for children under 13. An update to the Treatment Plan would be necessary in the occurrence of a crisis or significant clinical event.
13.4.A(5) Aftercare Plan When care is completed, the Aftercare Plan shall include, but is not limited to, the following, in addition to the requirements contained in Section 13.4 and 13.4.A above:
Dates begin and end;
Frequency and duration of visits; Target symptoms/behaviors addressed; Interventions; Progress to goals achieved; Final diagnosis; and Final recommendations including further services and providers, if needed, and activities to promote further recovery. The Aftercare Plan must be signed and dated by the provider delivering the service. 13.4.A(6) Pharmacologic Management CPT 90862 All documentation must support that the service was reasonable and medically necessary for the billed diagnosis. The treating provider must document the medical necessity of the chosen treatment and list the diagnosis code that most accurately describes the condition of the patient that necessitated the need for the pharmacologic management on the claim and in the patient's medical record. The medical record should be clear and concise, documenting the reason for the pharmacologic management treatment and the outcomes. A check-off list is not accepted as sole documentation. Documentation of medical necessity for pharmacologic management (procedure code 90862) must address all of the following information in the patient's medical record in legible format, in addition to the requirements contained in Section 13.4 and 13.4.A above: Date and time Diagnosis update at least annually Interim Medication history Current symptoms and problems that include any physical symptoms Problems, reactions, and side effects, if any, to medications and/or ECT Current Mental Status Exam Any medication modifications The reasons for medication adjustments/changes or continuation Desired therapeutic drug levels, if applicable Current laboratory values, if applicable 17 Behavioral Health Services Manual
Anticipated physical and behavioral outcome(s)
13.4.B RETENTION OF RECORDS MO HealthNet providers must retain for six (6) years, from the date of service, fiscal and medical records that coincide with and fully document services billed to the MO HealthNet Program, and must furnish or make the records available for inspection or audit by the Department of Social Services (DSS) or its representative upon request. Failure to furnish, reveal and retain adequate documentation for services billed to the MO HealthNet Program may result in recovery of the payments for those services not adequately documented and may result in sanctions to the providers participation in the MO HealthNet Program. This policy continues to apply in the event of the providers discontinuance as an actively participating MO Healthnet provider through change of ownership or any other circumstance.
13.5 PATIENT COST SHARING AND COPAY

Patients eligible to receive certain MO HealthNet services are required to pay a small portion of the cost of the services. This amount is referred to as copay. The copay amount is paid by the patient at the time services are rendered. Services of the Behavioral Health Services Program described in this manual are subject to a copay amount. The provider must accept in full the amounts paid by the state agency plus any copay amount required of the patient. 13.5.A PROVIDER RESPONSIBILITY TO COLLECT COPAYMENT Providers of service must charge and collect the copay amount. Providers of service may not deny or reduce services to persons otherwise eligible for benefits solely on the basis of the patient's inability to pay the fee when charged. A patient's inability to pay a required amount, as due and charged when a service is delivered, shall in no way extinguish the patient's liability to pay the amount due. As a basis for determining whether an individual is able to pay the charge, the provider is permitted to accept, in the absence of evidence to the contrary, the patient's statement of inability to pay at the time the charge is imposed. The provider of service must keep a record of copay amounts collected and of the copay amount due but uncollected because the patient did not make payment when the service was rendered. The copay amount is not to be shown as an amount received on the claim form submitted for payment. When determining the reimbursement amount, the copay amount is deducted from the MO HealthNet maximum allowable amount, as applicable, before reimbursement is made.
13.5.B PATIENT RESPONSIBILITY TO PAY COPAY It is the responsibility of the patient to pay the required copay amount due. Whether or not the patient has the ability to pay the required copay amount at the time the service is furnished, the amount is a legal debt and is due and payable to the provider of service. The copay only applies to identified services and patients with certain ME codes. 13.5.B(1) Uncollected Copay Amount If it is the routine business practice of a provider to discontinue future services to an individual with uncollected debt, the provider may include uncollected copays under this practice. However, a provider shall give a MO HealthNet participant a reasonable opportunity to pay an uncollected copay. If a provider is not willing to provide services to a MO HealthNet participant with uncollected copay, the provider must give the participant advance notice and a reasonable opportunity to arrange care with a different provider before services are discontinued. 13.5.C SERVICES REQUIRING A COPAY Adults receiving a limited benefit package are required to pay a copay for some behavioral health services. Provider types required to collect a copay and the copay amounts are listed below. COPAY AMOUNT $1.00 $1.00 $1.00 $2.00 $2.00 $0.50 $0.50 $0.50 $2.00
TYPE OF PROVIDER Physician, M.D. Physician, D.O. Nurse Practitioner Psychologist Independent Clinic/FQHC Independent Clinic Teaching Institution Department Teaching Institution Rural Health Clinic
Copay is applied once regardless of how often the procedure code is billed to get the total allowed units. The copay amount is deducted from the MHD Maximum Allowable amount for fee-forservice claims reimbursed by MO HealthNet.
13.5.D EXEMPTIONS TO THE COPAY REQUIREMENTS The following exemptions apply to the MO HealthNet copay requirements: Services provided to participants under nineteen (19) years of age; or participants receiving MO HealthNet under the following categories of assistance: ME Codes 06, 33, 34, 36, 40, 52, 56, 57, 60, 62, 64, 65, 71, 72, 73, 74, 75, 87, and 88; Services provided to participants residing within a skilled nursing home, and intermediate care nursing home, a residential care home, an adult boarding home or a psychiatric hospital; or participants receiving MO HealthNet under the following categories of assistance: ME Codes 23 and 41; Services provided to participants who have both Medicare and MO HealthNet if Medicare covers the service and provides payment for it; or participants receiving MO HealthNet under the following category of assistance: ME Code 55; Emergency services provided in an outpatient clinic or emergency room after the sudden onset of a medical condition manifesting itself by acute symptom of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in: Placing the patient's health in serious jeopardy; Serious impairment to bodily functions; or Serious dysfunction of any bodily organ or part; Certain therapy services (physical therapy, chemotherapy, radiation therapy, and chronic renal dialysis) except when provided as an inpatient hospital service; Services provided to pregnant women who are receiving MO HealthNet under the following categories of assistance only: ME Code 18, 43, 44, 45, 58, 59, and 61; Services provided to foster care participants who are receiving MO HealthNet under the following categories of assistance: ME Codes 07, 08, 28, 29, 30, 37, 38, 49, 50, 51, 63, 66, 67, 68, 69, and 70; Services identified as medically necessary through an Early Periodic Screening, Diagnostic and Treatment (EPSDT) screen; Services provided to persons receiving MO HealthNet under a category of assistance for the blind: ME Codes 02, 03, 12, and 15; Services provided to MC+ Managed Care enrollees; Mental Health services provided by community mental health facilities operated by the Department of Mental Health or designated by the Department of Mental Health as a community mental health facility or as an alcohol and drug abuse facility or as a child-servicing agency within the comprehensive children's mental health service system.
13.5.E PROVIDER PARTICIPATION PRIVILEGES Participant privileges in the MO HealthNet program shall be limited to providers who accept, as payment in full, the amounts paid by the state agency plus any copay amount required of the participant. Provider of services in the program areas affected by the copay requirement must charge copay as specified at the time the service is provided to retain their participation privileges in the MO HealthNet program. Providers must maintain records of copay amounts for six (6) years and must make those records available to the Department of Social Services upon request.
13.6 PATIENT NONLIABILITY

MO HealthNet covered services rendered to an eligible patient are not billable to the patient if MO HealthNet would have paid had the provider followed the proper policies and procedures for obtaining payment through the MO HealthNet Program as set forth in 13 CSR 70-4.030.
13.7 EMERGENCY SERVICES

Emergency services are services required when there is a sudden or unforeseen situation or occurrence or a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in: 1. Placing the patients health in serious jeopardy; or 2. Serious impairment to bodily functions; or 3. Serious dysfunction of any bodily organ or part.
13.8 OUT-OF-STATE, NONEMERGENCY SERVICES

All non-emergency, MO HealthNet covered services that are to be performed or furnished outof-state for eligible MO HealthNet patients and for which MO HealthNet is to be billed, must be prior authorized before the services are provided. Services that are not covered by the MO HealthNet Program are not approved. Out-of-state is defined as not within the physical boundaries of the State of Missouri or within the boundaries of any state that physically borders on the Missouri boundaries. Border-state providers of services (those providers located in Arkansas, Illinois, Iowa, Kansas, Kentucky, Nebraska, Oklahoma and Tennessee) are considered as being on the same MO HealthNet participation basis as providers of services located within the State of Missouri.
A Prior Authorization Request form is not required for out-of-state non-emergency services. To obtain prior authorization for out-of-state, non-emergency services, a written request must be submitted by a physician to: MO HealthNet Division Participant Services Unit P.O. Box 6500 Jefferson City, MO 65102 The request may be faxed to (573) 526-2471. The written request must include: 1. A brief past medical history. 2. Services attempted in Missouri. 3. Where the services are being requested and who will provide them. 4. Why services cant be done in Missouri. NOTE: The out-of-state medical provider must agree to complete an enrollment application and accept MO HealthNet reimbursement. Prior authorization for out-of-state services expires 180 days from the date the specific service was approved by the state. 13.8.A EXCEPTIONS TO OUT-OF-STATE PRIOR AUTHORIZATION (PA) REQUESTS The following are exempt from the out-of-state prior authorization requirement: 1. All Medicare/Medicaid crossover claims. 2. All children in Foster Care living outside the State of Missouri. However, nonemergency services or services that routinely require prior authorization continue to require prior authorization by out-of-state providers even though the service was provided to a child in Foster Care. 3. Emergency ambulance services. 4. Independent laboratory services.
13.9 PRIOR AUTHORIZATION

Under the MO HealthNet Behavioral Health Services Program, certain covered services require prior approval if the provider is to be reimbursed. Prior Authorization (PA) is used to promote the most effective and appropriate use of available services. The PA approves the delivery of the requested service only and does not guarantee payment. The PA must be obtained prior to delivery of services. The patient must meet eligibility requirements on the date the service is provided and the provider must be enrolled and eligible to bill for the services.
PA hours are issued based on the patient's age, diagnosis, and ME Code. Refer to Section 13.10 for hours issued for adults (ages 21 and over) and Section 13.11 for hours issued for children (ages 0 through 20). ALL Family Therapy Without the Patient Present (CPT 90846) requires PA regardless of age, ME code, or placement. Individual Interactive Therapy (CPT 90810 and 90812) must be prior authorized, regardless of age, ME Code, or placement of the child. All services for children aged birth through two years must be prior authorized, regardless of the ME Code or placement of the child. 13.9.A REQUESTING PRIOR AUTHORIZATION Providers may deliver four hours of behavioral health services without a PA to a patient they have not treated within the last rolling year. Providers who have been paid for services in excess of four hours for a patient in the last year do not receive four non-PA hours for that patient. The four non PAd hours apply to the group if services are provided in a clinic setting, not to each individual performing provider of that group. PA requests may be authorized if they are determined medically necessary when using the current addition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). In order to maintain compliance with the Health Insurance Portability and Accountability Act (HIPAA), the appropriate International Classification of Diseases, most current edition, diagnosis code must be used when filing a claim for the service. Please refer to section 18.3 of the Behavioral Health Services Manual. Family Therapy Without the Patient Present, Individual Interactive Therapy, and all Behavioral Health services for patients age birth through 2 years are not included in the four non-PA hours. The claims for the four non-PA hours should be submitted and payment adjudicated prior to submitting claims for any PAd hours/services. If services are required beyond the initial four non-PAd hours, the provider must request PA. To request an initial PA the provider or a staff member may call (866) 771-3350. Although not mandatory, the provider should complete the Psychological Services Request for Prior Authorization form as the information on this form is required to complete the request for services. Telephoned requests receive an approval or denial at the time of the call. (If additional information is needed, the caller is instructed to fax or mail the Psychological Services Request for Prior Authorization form and required documentation. These requests are not approved during the phone call.) To request continuing services beyond the initial authorization, the Psychological Services Request for Prior Authorization form must be completed and submitted along with the current Diagnostic Assessment, current updated Treatment Plan, and copies of the last three Progress Notes reflecting the therapy type being requested. 23 Behavioral Health Services Manual
This documentation may be faxed to: (573) 635-6516 or mailed to: MO HealthNet Division PO Box 4800 Jefferson City, MO 65102 Providers do not receive a disposition letter when services are authorized or denied via a phone call. An authorization number is provided. Services that require submission of the Psychological Services Request for Prior Authorization form and attachments receive a disposition letter after review. When PA requests are denied partially or in full, the patient receives a letter outlining the reason for denial and their appeal rights. Do not give patients the provider Prior Authorization Request telephone number or fax number. Their contact information is listed in their denial letter. If the current PA was approved for less than 10 hours, additional hours may be requested when 40% of the current PA hours have been used. If the current PA was approved for 10 hours or more, 75% of the current PA hours must be used before additional hours may be requested. Hours used must be documented in the medical record. When requesting an authorization for additional hours, the documentation must include information from the most recent contact available for review. All requests for PA for Family Therapy Without the Patient Present and Individual Interactive Therapy require the Psychological Services Request for Prior Authorization form, current Diagnostic Assessment, current Treatment Plan, and the last three Progress Notes be mailed or faxed. All requests for PA for services for children ages birth through two years of age require written clinical justification sufficient to determine need for services when requesting PA. If the patient is changing providers, the provider listed on the current PA must end that PA before the new provider can be issued a PA. If the current provider refuses to close the PA, the new provider must submit a signed release from the patient, or patient's guardian, requesting a change in provider in order to close the current PA. The signed release must include the client DCN, type of therapy to be closed and the name of the therapist whose authorization is to be closed. If a provider needs to change a PA, the provider may call or fax in the information to request a change. The patients name, DCN, type of therapy, what the current PA says, and the requested change must be indicated. When a patient changes providers any available units are transferred from the closed PA to the new providers approved PA if requested. The new provider does not receive an additional 10 or 20 hours for therapy. However, clinical exceptions may be granted based upon documentation of extenuating circumstances. A patient may have an open PA with one provider for individual therapy and/or family therapy and a second PA open with the same or different provider for group therapy.
If the therapist is part of a clinic or group, the PA should be requested using the clinic/group NPI. If the provider is not part of a group or clinic (private practice), the PA should be requested using the individual NPI. PAs for services being delivered by a member of an FQHC must be requested by using the FQHC NPI. PAs for services being rendered by a member of an RHC must request PA using the RHC NPI. PA is required even when third party insurance coverage exists. Medicare is not considered third party insurance; however, if Medicare does not cover the service, a PA is required for payment by MO HealthNet. Prior authorization is required for patients residing in a nursing home but behavioral health services may not be provided at the nursing home. Providers may only bill for services they personally provide. MO HealthNet does not cover services provided by someone other than the enrolled provider. All PA requests must be complete in order to be processed. A PA cannot be processed if the participant or provider identifying information is incomplete or inaccurate (including Provider NPI, DCN, etc.). Every attempt is made by the Behavioral Health Services Help Desk to reconcile any incorrect/inaccurate information with providers; however, it remains the provider's responsibility to provide complete and accurate information when submitting a request for Prior Authorization. 13.9.B CLINICAL EXCEPTIONS MO HealthNet recognizes there are rare instances where behavioral health services may be needed beyond the PA guidelines established for adults and children. For those persons requiring more therapy than what is allowed under those guidelines, Clinical Exceptions may be granted based upon documentation of extenuating circumstances. Providers requesting Clinical Exceptions may contact the Behavioral Health Services Help Desk at (886)771-3350. 13.9.C PRIOR AUTHORIZATION EXEMPTIONS Procedure codes with a medical Evaluation and Management service component, inpatient hospital services, pharmacologic management, narcosythesis, and electroconvulsive therapy are exempt from the PA process. Crisis Intervention is exempt from the PA process. The definition of Crisis Intervention is: "The situation must be of significant severity to pose a threat to the patient's well being or is a danger to self or others." Crisis Intervention services cannot be scheduled nor can they be PAd.
13.9.D RESIDENTIAL CARE EXEMPTIONS Services provided in a residential treatment facility setting are exempt from the PA process. Services provided in residential treatment facilities are identified by the following place of service codes: 14 Group Home 33 Custodial Care Facility 56 Psychiatric Residential Treatment Center The correct place of service code must be reported on the claim submitted to MO HealthNet. Services provided to children with an ME Code of 07, 08, 37, or 88 who are residing in or are under the care of a residential care facility are exempt from the PA process if the services are provided at a site other than the residential care facility. The TJ modifier should be used to indicate that the services were provided to a child residing in or under the care of a residential facility at a site other than the facility (office, outpatient hospital, home, etc.). The TJ modifier should not be used for services provided at the facility. The place of service codes above exempt those services from the PA process. NOTE: Family Therapy Without the Patient Present, Individual Interactive Therapy, and all services for patients age birth through 2 years continue to require PA, regardless of the child's placement. 13.9.E PARTICIPANT APPEAL RIGHTS When a PA request is denied, the participant will receive a letter which outlines the reason for the denial and the procedure for appeal. The State Fair Hearings Process may be requested by the participant, in writing, to the MO HealthNet Division, Participant Services Unit (PSU), P.O. Box 3535, Jefferson City, MO 65102-3535. The Participant Services Unit may also be called toll-free at 1-800-392-2161 or 573-751-6527 at the caller's expense. The participant must contact PSU within 90 days of the date of the denial letter if they wish to request a hearing. After 90 days, requests to appeal are denied.
13.10 SERVICES FOR ADULTS

PSYCHIATRIST, PSYCHOLOGIST, PLP, PCNS, PMHNP, RHC, FQHC Many behavioral health services provided to adults (21 years of age or older) must be PAd when performed by a Psychiatrist, Psychologist, PLP, PCNS, RHC, or FQHC. Services provided to adults by LCSWs and LMSWs are not covered by MO HealthNet, except in an RHC or FQHC setting. Services provided to adults by LPCs and PLPCs are not covered by MO HealthNet in any circumstance. 26 Behavioral Health Services Manual
13.10.A PRIOR AUTHORIZATION GUIDELINES ADULTS Independent LCSWs, LMSWs, LPCs, and PLPCs may not be reimbursed by MHD for services provided to adults and should not request PA. LCSWs and LMSWs who provide services through an FQHC or RHC may provide adult services as part of the clinic. These services require PA but the request must be made using the facility NPI. See Section 13.9 for additional information regarding the Prior Authorization process. Behavioral health services are covered if they are determined medically necessary when using the current addition of the DSM diagnostic criteria. PA approval is based on the current addition of the DSM diagnosis code. However, the diagnosis code on a submitted claim must be the appropriate ICD code. Up to 10 hours of Individual or Family Therapy or a combination of both for adults may be authorized initially for a covered diagnosis of Adjustment Disorder, V-codes, or NOS codes. Up to 20 hours may be authorized initially for Individual and Family Therapy or a combination of both for adults, for all other covered diagnosis codes. The authorized hours may be divided between Individual and Family Therapy based upon provider request, patient need and documentation in the Treatment Plan. Up to 10 hours of Group Therapy may be authorized for a covered diagnosis of Adjustment Disorder, V-codes, or NOS codes. Up to 20 hours of Group Therapy may be authorized for all other covered diagnosis codes. An additional 10 hours of Individual, Family, or Group Therapy or any combination may be requested based upon documentation of patient need. PAs for continued treatment are based upon review of clinical documentation to include: Psychological Services Request for Prior Authorization form; Current Diagnostic Assessment see Section 13.4.A(1); Current/Updated Treatment Plan see Section 13.4.A(2) and Section 13.4.A(4) and Section 13.4.A(5); Three Progress Notes reflective of therapy type requested (i.e. requests for additional Family Therapy should include Progress Notes from the three most recent Family Therapy sessions attended by the patient).
PAs for continued treatment are not issued for diagnosis codes including Adjustment Disorder, V-codes, or NOS codes. All documentation submitted must meet the requirements as stated in 13 CSR 70-98-015. Requests submitted with non-compliant documentation as outlined above result in denial of the request. 27 Behavioral Health Services Manual
MHD recognizes there are rare instances where psychological services may be required beyond the limits outlined above. For those persons requiring more than the 50 hours of Individual, Family or Group Therapy per year, as discussed above, Clinical Exceptions may be granted based upon documentation of extenuating circumstances. Providers requesting clinical exceptions may contact the Behavioral Health Services Help Desk at (866) 771-3350. 13.10.B ADULTS - CODES REQUIRING PRIOR AUTHORIZATION PSYCHIATRIST, PCNS, PMHNP, PSYCHOLOGIST, PLP, RHC, AND FQHC CPT CODE CPT CODE DESCRIPTION 90802 Interactive Psychiatric diagnostic interview examination using play equipment, physical devises, language interpreter, or other mechanisms of communication (30 minute unit) Maximum of 2 units per patient, per provider, per rolling year Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility (approx 20 to 30 minutes face-to-face with the patient) Maximum of 1 unit per day, 5 units per month, per patient, per provider Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility (approx 45 to 50 minutes face-to-face with the patient) Maximum of 1 unit per day, 5 units per month, per patient, per provider Individual Psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility (approx 20 to 30 minutes face-to-face with the patient) Maximum of 1 unit per day, 5 units per month, per patient, per provider Not allowed under the four hours of non-PAd services
90804
90806
90810
90812
Individual Psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility (approx 45 to 50 minutes face-to-face with the patient) Maximum of 1 unit per day, 5 units per month, per patient, per provider Not allowed under the four hours of non-PAd services Family Psychotherapy (without patient present) (30 minute unit) Maximum of 2 units per day, 10 units per month, per patient, per provider Not allowed under the four hours of non-PAd services Family Psychotherapy (conjoint Psychotherapy with patient present) (30 minute unit) Maximum of 2 units allowed per day, 10 units per month, per patient, per provider Group Psychotherapy (other than of a multi-family group) (30 minute unit) Maximum of 3 units per day, 15 units per month, per patient, per provider
90846
90847
90853
Regardless of PA, providers are required to adhere to the maximum daily and monthly unit limitations and all other program restrictions. Units billed over the daily, monthly, yearly limits represent a violation of MHD policy and are not reimbursed. 13.10.C ADULTS - CODES NOT REQUIRING PRIOR AUTHORIZATION PSYCHIATRIST, PCNS, PMHNP, PSYCHOLOGIST, PLP, RHC, AND FQHC CPT CODE 90801 CPT CODE DESCRIPTION Psychiatric diagnostic interview examination (30 minute unit) Maximum of 6 units per patient, per provider, per rolling year 29 Behavioral Health Services Manual
90805
Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, with Evaluation and Management services (approx 20 to 30 minutes face-to-face with the patient) Maximum of 1 unit per day, 5 units per month, per patient, per provider
90807
Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, with Evaluation and Management services (approx 45 to 50 minutes face-to-face with the patient) Maximum of 1 unit per day, 5 units per month, per patient, per provider
90811
Individual Psychotherapy, Interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, with medical evaluation and management services (approx 20 to 30 minutes face-to-face with the patient) Maximum of 1 unit per day, 5 units per month, per patient, per provider
90813
Individual Psychotherapy, Interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, with medical evaluation and management services (approx 45 to 50 minutes face-to-face with the patient) Maximum of 1 unit per day, 5 units per month, per patient, per provider
90816
Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital, or residential care setting (approx 20 to 30 minutes face-to-face with the patient)
90817
Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital, or residential care setting, with medical Evaluation and Management services (approx 20 to 30 minutes face-to-face with the patient)
90818
Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital, or residential care setting 30
(approx 45 to 50 minutes face-to-face with the patient) 90819 Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital, or residential care setting, with medical Evaluation and Management services (approx 45 to 50 minutes face-to-face with the patient) 90823 Individual Psychotherapy, Interactive, using play equipment, physical devices, language interpreter or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital, or residential setting (approx 20 to 30 minutes face-to-face with the patient) 90824 Individual Psychotherapy, Interactive, using play equipment, physical devices, language interpreter or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital, or residential setting, with medical Evaluation and Management services (approx 20 to 30 minutes face-to-face with the patient) 90826 Individual Psychotherapy, Interactive, using play equipment, physical devices, language interpreter or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital, or residential setting (approx 45 to 50 minutes face-to-face with the patient) 90827 Individual Psychotherapy, Interactive, using play equipment, physical devices, language interpreter or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital, or residential setting, with medical Evaluation and Management services (approx 45 to 50 minutes face-to-face with the patient) 90862 Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical Psychotherapy (approx 15 minutes face-to-face with the patient) 90865 Narcosynthesis for Psychiatric diagnostic and therapeutic purposes (e.g. sodium amobarbital (Amytal) interview) (30 minute unit) 90870 Electroconvulsive therapy (includes necessary monitoring) 31 Behavioral Health Services Manual
(30 minute unit) 90885 Psychiatric evaluation of hospital records, other Psychiatric reports, Psychometric and/or projective tests, and other accumulated date for medical diagnostic purposes (60 minute unit) 96101 Psychological testing (includes psycho-diagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g. MMPI, Rorschach, WAIS), per hour of the psychologist's or physician's time, both face-to-face with the patient and time interpreting test results and preparing the report (60 minute unit) Maximum of 4 units of testing (96101, 96103, 96105, 96111, and/or 96116 per rolling year, per patient, per provider) 96103 Psychological testing (includes psycho-diagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g. MMPI) administered by a computer, with qualified health care professional interpretation and report (60 minute unit) Maximum of 4 units of testing (96101, 96103, 96105, 96111, and/or 96116 per rolling year, per patient, per provider) 96105 Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g. by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour (60 minute unit) Maximum of 4 units of testing (96101, 96103, 96105, 96111, and/or 96116 per rolling year, per patient, per provider) 96111 Developmental testing; extended (includes assessment of motor language, social, adaptive and/or cognitive functioning by standardized developmental instruments) with interpretation and report (60 minute unit)
Maximum of 4 units of testing (96101, 96103, 96105, 96111, and/or 96116 per rolling year, per patient, per provider) 96116 Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, e.g. acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report (60 minute unit) Maximum of 4 units of testing (96101, 96103, 96105, 96111, and/or 96116 per rolling year, per patient, per provider) S9484 Crisis Intervention 0 mental health services, per hour (60 minute unit) Maximum of 6 units per patient, per provider, per calendar year
13.11 SERVICES FOR CHILDREN AND YOUTH

The PA process has been implemented for children and youth, ages birth through 20 years, who are not in state custody and for children and youth in Foster Care (ME Codes 07, 08, 37, and 38), not residing in a residential treatment facility. The requirement for PA includes services provided by a Psychiatrist, PCNS, PMHNP, Psychologist, PLP, LCSW, LMSW, LPC, PLPC, RHC, or FQHC. Please refer to Section 13.9 for additional information regarding PA. 13.11.A PRIOR AUTHORIZATION GUIDELINES - CHILDREN AND YOUTH The PA process includes services provided by a Psychiatrist, PCNS, PMHNP, Psychologist, PLP, LCSW, LMSW, LPC, PLPC, RHC, and FQHC. Assessment and Testing for a child birth through 2 years must be PAd. Providers must submit clinical justification for providing these services. PA does not allow the provider to exceed the unit limitations for these services. Family Therapy Without the Patient Present, Individual Interactive Therapy, and all services for children ages birth through 2 years require PA and are not included in the four (4) non-PAd hours.
Approval is based on the current addition of the DSM diagnosis code. Up to 10 hours of Individual, Family, and/or Group Therapy are allowed for a diagnosis of Adjustment Disorder, V-codes, or NOS codes. Up to 20 hours are allowed for all other covered diagnosis codes. The authorized number of hours is based on the primary AXIS I diagnosis as documented by the provider. Multiple therapies are the treatment of the individual with more than one therapy, such as Individual and Family, within the same authorization period. The Treatment Plan must document the need for more than one therapy. If a childs age changes during the PA period, the PA continues as authorized. However, if the child turns 21 during the authorization period, the policy for services provided to adults applies. Only one PA per household is approved at any given time for Family Therapy. If there is more than one eligible child and no child is exclusively identified as the primary patient, the oldest child's DCN must be used for PA and billing purposes. When a specific child is identified as the primary patient, that child's DCN must be used for PA and billing purposes. Providers should not request more than one Family Therapy PA per household. If a child needs to transition to a new provider, a PA of five (5) hours for transition to the new provider will be allowed without submission of documentation. The PA request can be made by phone or fax. These five (5) hours are in addition to the four (4) non PAd hours. In order for a new provider to obtain PA, the existing PA must be closed. (Refer to Section 13.9.A regarding closure of an existing PA.) If additional hours are needed, the provider may request more hours by submitting the Psychological Services Request for Prior Authorization form, current Diagnostic Assessment, current Treatment Plan, and last 3 Progress Notes. 13.11.A(1) Prior Authorization For Children And Youth By Age Group Children Not In State Custody Or Not Residing In Residential Care Facility Behavioral health services for children birth through 2 years, Family Therapy Without the Patient Present and Individual Interactive Therapy are not allowed under the 4 hours of non-prior authorized service. As delineated below, the preferred method of treatment is indicated first. If no documentation is required a telephone call may be made to request PA. Services other than the preferred method and multiple therapies require the Psychological Services Request for Prior Authorization form and documentation be submitted via fax or mail. Children Birth Through 2
Up to three hours of Diagnostic Assessment and/or up to four hours of Psychological Testing may be authorized with submission of documentation. Assessment and testing for a child birth through 2 years must be prior authorized and providers must submit clinical justification for providing these services. Children ages birth through 2 years are not allowed the four (4) hours of nonPAd services. Family Therapy may be authorized initially up to 20 hours based upon the submission of required clinical documentation Individual and/or Individual Interactive Therapy is not authorized Group Therapy is not authorized
Children Age 3 Family Therapy may be authorized initially up to 5 hours without submitting documentation Family Therapy may be reauthorized up to 15 hours based upon the submission of required documentation Individual Therapy is not authorized with the exception of Individual Interactive Therapy, which may be authorized up to 10 hours based upon the submission of required clinical documentation. The provider's documentation must support the reason why Individual Interactive Therapy is being provided Group Therapy will not be authorized
Children Age 4 Family Therapy may be authorized initially up to 5 hours without submitting documentation Family Therapy may be reauthorized up to 15 hours based upon the submission of required documentation Individual Therapy may be authorized up to 5 hours without submitting documentation Individual Therapy may be reauthorized up to 10 hours based upon the submission of required documentation Individual Interactive Therapy may be authorized for up to 10 hours based upon the submission of required justification Group Therapy is not authorized
Children and Youth 5 Through 12
Family Therapy may be authorized initially up to 20 hours without submitting documentation Family Therapy may be reauthorized up to 20 hours based upon the submission of required documentation Individual Therapy may be authorized initially up to 5 hours without submitting documentation Individual Therapy may be reauthorized up to 10 hours based upon the submission of required documentation Group Therapy may be authorized initially up to 5 hours without submitting documentation Group Therapy may be reauthorized up to 10 hours based upon the submission of required documentation
Youth 13 Through 17 Individual or Family Therapy or a combination of both may be authorized initially up to 25 hours without submitting documentation Individual or Family Therapy or a combination of both may be reauthorized up to 30 hours based upon the submission of required documentation Group Therapy may be authorized initially up to 5 hours without submitting documentation Group Therapy may be reauthorized up to 10 hours based upon the submission of required documentation
Youth 18 Through 20
Individual Therapy may be authorized initially up to 20 hours without submitting documentation Individual Therapy may be reauthorized up to 20 hours based upon the submission of required documentation Family Therapy may be authorized initially up to 5 hours without submitting documentation Family Therapy may be reauthorized up to 10 hours based upon the submission of required documentation Group Therapy may be authorized initially up to 5 hours without submitting documentation Group Therapy may be reauthorized up to 10 hours based upon the submission of required documentation
13.11.A(2) Prior Authorization For Children and Youth By Age Group Foster Care (ME Code 07, 08, 37, and 38) Not Residing In Residential Care Facility Behavioral health services for children birth through 2 years, Family Therapy Without the Patient Present, and Individual Interactive Therapy are not allowed under the 4 hours of non-PAd services. As delineated below, the preferred method of treatment is indicated first. If no documentation is required a telephone call may be made to request PA. Children Birth through 2 years Up to three hours of Diagnostic Assessment and/or up to four hours of Psychological Testing may be authorized with submission of documentation. Assessment and testing for a child birth through 2 years must be PAd and providers must submit clinical justification for providing these services. Children ages birth through 2 years are not allowed the four (4) hours of nonPAd services. Family Therapy may be authorized initially up to 10 hours based upon the submission of required clinical documentation Family Therapy may be reauthorized up to 10 hours based upon the submission of required clinical documentation Family Therapy may be reauthorized up to an additional 20 hours based upon the submission of required clinical documentation Individual and/or Individual Interactive Therapy will not be authorized Group Therapy will not be authorized
Children Age 3 Family Therapy may be authorized initially up to 10 hours without submitting documentation Family Therapy may be reauthorized up to 15 hours based upon the submission of required documentation Family Therapy may be reauthorized up to an additional 15 hours based upon the submission of required documentation Individual Therapy OR Individual Interactive Therapy may be authorized up to 5 hours based upon the submission of required documentation. The provider's documentation must support the reason why Individual Interactive Therapy is being provided. Group Therapy will not be authorized
Children Age 4 Family Therapy may be authorized initially up to 10 hours without submitting documentation Family Therapy may be reauthorized up to 15 hours based upon the submission of required documentation Family Therapy may be reauthorized up to an additional 15 hours based upon the submission of required documentation Individual Interactive Therapy must be authorized initially up to 5 hours based upon the submission of required documentation. The provider's documentation must support the reason why Individual Interactive Therapy is being provided. Individual Interactive Therapy may be reauthorized up to 15 hours based upon the submission of required documentation Individual Interactive Therapy may be reauthorized up to an additional 15 hours based upon the submission of required documentation OR Individual Therapy may be authorized up to 5 hours without submitting documentation Individual Therapy may be reauthorized up to 15 hours based upon the submission of required documentation Individual Therapy may be reauthorized up to an additional 15 hours based upon the submission of required documentation Group Therapy will not be authorized
Children and Youth 5 through 20 Family Therapy may be authorized initially up to 10 hours without submitting documentation Family Therapy may be reauthorized up to 15 hours based upon the submission of required documentation Family Therapy may be reauthorized up to an additional 15 hours based upon the submission of required documentation Individual Therapy may be authorized initially up to 10 hours without submitting documentation Individual Therapy may be reauthorized up to 15 hours based upon the submission of required documentation Individual Therapy may be reauthorized up to an additional 15 hours based upon the submission of required documentation 38 Behavioral Health Services Manual
Group Therapy may be authorized initially up to 10 hours without submitting documentation Group Therapy may be reauthorized up to 15 hours based upon the submission of required documentation
MHD recognizes there are instances within the Foster Care setting where a child may require additional Family Therapy services. If a child in Foster Care requires Family Therapy sessions with the foster parent and separate Family Therapy session with the biological parent/parents, the provider should obtain one Family Therapy PA for the child. The provider must develop an integrated Treatment Plan for the Family Therapy with objectives and outcomes for therapy with the foster family and biological family. The hours may be split between the two families, i.e. Family Therapy sessions with foster parents and separate Family Therapy sessions with the biological parent(s). Hours will be issued in accordance with the guidelines above. Hours required beyond these guidelines may be requested through the Clinical Exception process, as outlined in Section 13.9.B. Requests for additional hours of Family Therapy for separate sessions with the biological and foster families must be recommended by the Family Support Team. Providers are required to adhere to the maximum daily and monthly unit limitations and all other program restrictions. Units billed over the daily, monthly, yearly limits represent a violation of MHD policy and are not reimbursed. Foster families that consist of several unrelated children should request one Family Therapy PA per family. Rare circumstances may arise when each unrelated child in a foster family requires a separate Family Therapy session with the foster parent. Requests for multiple Family Therapy PAs per foster family will only be considered through the Clinical Exceptions process as stated in Section 13.9.B. Requests for multiple authorizations within the same household must be recommended by the Family Support Team. 13.11.B CHILDREN AND YOUTH CODES REQUIRING PRIOR AUTHORIZATION CPT CODE 90802
CPT CODE DESCRIPTION Interactive Psychiatric diagnostic interview examination using play equipment, physical devises, language interpreter, or other mechanisms of communication (30 minute unit) Maximum of 2 units per patient, per provider, per rolling year 39
90804
Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility (approx 20 to 30 minutes face-to-face with the patient) Maximum of 1 unit per day, 5 units per month, per patient, per provider Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility (approx 45 to 50 minutes face-to-face with the patient) Maximum of 1 unit per day, 5 units per month, per patient, per provider Individual Psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility (approx 20 to 30 minutes face-to-face with the patient) Maximum of 1 unit per day, 5 units per month, per patient, per provider Not allowed under the four hours of non-PAd services Individual Psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility (approx 45 to 50 minutes face-to-face with the patient) Maximum of 1 unit per day, 5 units per month, per patient, per provider Not allowed under the four hours of non-PAd services Family Psychotherapy (without patient present) (30 minute unit) Maximum of 2 units per day, 10 units per month, per patient, per provider Not allowed under the four hours of non-PAd services Family Psychotherapy (conjoint Psychotherapy with patient present) (30 minute unit) Maximum of 2 units allowed per day, 10 units per month, per patient, per provider 40
90806
90810
90812
90846
90847
90853
Group Psychotherapy (other than of a multi-family group) (30 minute unit) Maximum of 3 units per day, 15 units per month, per patient, per provider
Regardless of PA, providers are required to adhere to the maximum daily and monthly limitations and all other program restrictions. Units billed over the daily, monthly, yearly limits represent a violation of MHD policy and are not reimbursed. The AH modifier must be included when billing claims for Psychologists and PLPs. The AJ modifier must be included when billing claims for LCSWs or LMSWs. The UD modifier must be included when billing claims for LPCs or PLPCs. 13.11.C CHILDREN AND YOUTH CODES NOT REQUIRING PRIOR AUTHORIZATION CPT CODE 90801
CPT CODE DESCRIPTION Psychiatric diagnostic interview examination (30 minute unit) Maximum of 6 units per patient, per provider, per rolling year Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, with Evaluation and Management services (approx 20 to 30 minutes face-to-face with the patient) Maximum of 1 unit per day, 5 units per month, per patient, per provider Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, with Evaluation and Management services (approx 45 to 50 minutes face-to-face with the patient) Maximum of 1 unit per day, 5 units per month, per patient, per provider
90805
90807
90811
Individual Psychotherapy, Interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, with medical evaluation and management services 41
(approx 20 to 30 minutes face-to-face with the patient) Maximum of 1 unit per day, 5 units per month, per patient, per provider Individual Psychotherapy, Interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, with medical evaluation and management services (approx 45 to 50 minutes face-to-face with the patient) Maximum of 1 unit per day, 5 units per month, per patient, per provider Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital, or residential care setting (approx 20 to 30 minutes face-to-face with the patient) Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital, or residential care setting, with medical Evaluation and Management services (approx 20 to 30 minutes face-to-face with the patient) Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital, or residential care setting (approx 45 to 50 minutes face-to-face with the patient) Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital, or residential care setting, with medical Evaluation and Management services (approx 45 to 50 minutes face-to-face with the patient) Individual Psychotherapy, Interactive, using play equipment, physical devices, language interpreter or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital, or residential setting (approx 20 to 30 minutes face-to-face with the patient) Individual Psychotherapy, Interactive, using play equipment, physical devices, language interpreter or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital, or residential setting, with medical Evaluation and Management services (approx 20 to 30 minutes face-to-face with the patient) Individual Psychotherapy, Interactive, using play equipment, physical devices, language interpreter or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital, or residential setting
90813
90816
90817
90818
90819
90823
90824
90826
90827
(approx 45 to 50 minutes face-to-face with the patient) Individual Psychotherapy, Interactive, using play equipment, physical devices, language interpreter or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital, or residential setting, with medical Evaluation and Management services (approx 45 to 50 minutes face-to-face with the patient) Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical Psychotherapy (approx 15 minutes face-to-face with the patient) Narcosynthesis for Psychiatric diagnostic and therapeutic purposes (e.g. sodium amobarbital (Amytal) interview) (30 minute unit) Electroconvulsive therapy (includes necessary monitoring) (30 minute unit) Psychiatric evaluation of hospital records, other Psychiatric reports, Psychometric and/or projective tests, and other accumulated date for medical diagnostic purposes (60 minute unit) Psychological testing (includes psycho-diagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g. MMPI, Rorschach, WAIS), per hour of the psychologist's or physician's time, both face-to-face with the patient and time interpreting test results and preparing the report (60 minute unit) Maximum of 4 units of testing (96101, 96103, 96105, 96111, and/or 96116 per rolling year, per patient, per provider) Psychological testing (includes psycho-diagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g. MMPI) administered by a computer, with qualified health care professional interpretation and report (60 minute unit) Maximum of 4 units of testing (96101, 96103, 96105, 96111, and/or 96116 per rolling year, per patient, per provider)
90862
90865
90870
90885
96101
96103
96105
Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g. by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour (60 minute unit) Maximum of 4 units of testing (96101, 96103, 96105, 96111, and/or 96116 per rolling year, per patient, per provider) Developmental testing; extended (includes assessment of motor language, social, adaptive and/or cognitive functioning by standardized developmental instruments) with interpretation and report (60 minute unit) Maximum of 4 units of testing (96101, 96103, 96105, 96111, and/or 96116 per rolling year, per patient, per provider) Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, e.g. acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report (60 minute unit) Maximum of 4 units of testing (96101, 96103, 96105, 96111, and/or 96116 per rolling year, per patient, per provider) Crisis Intervention 0 mental health services, per hour (60 minute unit) Maximum of 6 units per patient, per provider, per calendar year
96111
96116
S9484
13.12 SCHOOL-BASED SERVICES

MO HealthNet Behavioral Health services are included in the school based services program for public schools. The program allows for the school district to receive the federal match portion of the funds allocated for certain medical services. Only the services identified in the Individualized Education Plan (IEP) and up to the amount and duration identified in the IEP will be considered reimbursable. All Behavioral Health services guidelines and limitations, including daily and monthly limitations, apply to school based services. School based Behavioral Health services are medically necessary mental health services that consist of Diagnostic Assessment, Psychological Testing, Individual Therapy, and Individual Interactive Therapy, provided by a Psychiatrist, PCNS, PMHNP, Psychologist, PLP, LCSW, LMSW, LPC, or PLPC. To participate in the MO HealthNet school based Behavioral Health Services Program, the billing provider of the services must be a recognized public school district in the State of Missouri. These services are billed by and reimbursement is made only to the school district. The school district will be considered the billing provider and all services included in the school based Behavioral Health Services Program must be billed by the school district. School districts must contract with a Behavioral Health Services provider enrolled with MO HealthNet to provide behavioral health services. The arrangements made by the school district with the behavioral health service providers are between the school district and the provider. The Behavioral Health Services provider delivering the school based behavioral health service is considered the performing provider and can only be shown as the performing provider on the school districts claim submitted to MO HealthNet for reimbursement of school based services. An individually enrolled MO HealthNet Behavioral Health Services program provider cannot bill directly for MO HealthNet school based behavioral health services. Services provided in the school setting are subject to existing Behavioral Health Services Program Prior Authorization (PA) guidelines and limitations. Refer to Section 13.10 above. All documentation requirements for the Behavioral Health Services Program apply to services provided in the school setting. Refer to Section 13.4 above. The child receiving school based Behavioral Health services must be eligible for MO HealthNet coverage for each date a service is rendered for reimbursement to be made. The child must be under the age of 21 years. All services rendered to a child must be billed under the childs individual MO HealthNet identification number. Services provided as documented in an IEP are reimbursed at the Federal Financial Participation Rate (FFP). The remainder of the allowed amount is the responsibility of the school district originating the IEP. The MO HealthNet maximum allowable fee for each code can be found on the Internet at http://www.dss.mo.gov/mhd/providers/pages/cptagree.htm. The school district must bill the actual cost of providing the service. The school district and the Behavioral Health Services provider must maintain a copy of the official public school generated IEP and the treatment plan in the childs record to document the service as an IEP service. 45 Behavioral Health Services Manual
Children enrolled in a MO HealthNet managed care health plan receive school based Behavioral Health services that are identified in an IEP on a fee-for-service basis outside of the MO HealthNet managed care benefit package. 13.12.A PROVIDER ENROLLMENT Each school district interested in billing MO HealthNet for school based services must enroll as a MO HealthNet provider. Each individual Behavioral Health Services provider that provides Behavioral Health services for a school district MUST also enroll with MO HealthNet. For all enrollment information, go to http://peu.momed.com/momed/presentation/commongui/PeHome.jsp. School districts currently enrolled for therapy services who wish to expand to include other school based services must contact Provider Enrollment to request each service be added to the provider file. This request can be e-mailed to MMAC.providerenrollment@dss.mo.gov or mailed to Missouri Medicaid Audit and Compliance, Attn: Provider Enrollment, PO Box 6500, Jefferson City, MO 65102, or faxed to 573-526-2054. If the school district is not actively enrolled with MO HealthNet to provide school based therapy services, a provider application must be completed on-line at the MHD website, www.dss.mo.gov/mhd, for any or all of the expanded services. Enrollment applications are not available on paper. Information provided on the enrollment application must agree with the information on file with the Department of Elementary and Secondary Education. 13.12.B TREATMENT PLAN Services are considered school based when they are included in an IEP as defined by the Individuals with Disabilities Education Act, Part B (34 CFR 300 and 301). A providersigned treatment plan must be maintained at the facility where services are performed and must be made available for audit purposes at anytime. The MO HealthNet Division does not dictate a standardized treatment plan. Services must be provided as indicated in the IEP and treatment plan. A childs treatment plan must be evaluated at regular intervals. The treatment plan must specify: the diagnosis; the desired outcome; the nature of the treatment; the frequency of treatment (number of minutes per day/per week/per month); and The duration (weeks or months) of services.
The child or his/her family may not be charged for development of the treatment plan. MO HealthNet does not reimburse the school district or the Behavioral Health Services provider to participate in IEP meetings or when developing a treatment plan for a child. The childs treatment record must also include all components, including adequate documentation as required in 13 CSR 70-98. 13.12.C PROCEDURE CODES The following procedure code/modifier combinations are the allowable codes for the school based services program and must be utilized within the providers scope of practice and the licensure limits. Psychiatrist, PCNS, PMHNP 90801 TM 90802 TM 90804 TM Psychologist, PLP 90801 AH TM 90802 AH TM 90804 AH TM LCSW, LMSW 90801 AJ TM 90802 AJ TM 90804 AJ TM LPC, PLPC 90801 UD TM 90802 UD TM 90804 UD TM
Service
Diagnostic Assessment Diagnostic Assessment, Interactive Individual Therapy, outpatient, 20-30 min Individual Therapy, outpatient, 20-30 min w/ E& M Individual Therapy, outpatient, 45-50 min Individual Therapy, outpatient, 45-50 min w/ E&M Individual Interactive Therapy, outpatient, 2030 min Individual Interactive Therapy, outpatient, 2030 min w/ E&M Individual Interactive Therapy, outpatient, 4550 min Individual Interactive Therapy, outpatient, 4550 min w/ E&M Psych Testing Administered by Psychologist Behavioral Health Services Manual
90805 TM 90806 TM
N/A 90806 AH TM
N/A 90806 AJ TM
N/A 90806 UD TM
90807 TM
N/A
N/A
N/A 90810 UD TM
90810 TM
90810 AH TM
90810 AJ TM
90810 TM
N/A
N/A
N/A 90812 UD TM
90812 TM
90812 AH TM
90812 AJ TM
90813 TM
N/A
N/A
N/A
96101 TM
96101 AH TM
N/A
N/A 47
Psych Testing Administered by Computer Assessment of Aphasia Developmental Testing Neurobehavior Status Exam
96103 TM 96105 TM 96111 TM 96116 TM
96103 AH TM 96105 AH TM 96111 AH TM 96116 AH TM
N/A N/A N/A N/A
N/A N/A N/A N/A
13.13 PROCEDURE CODE LIMITATIONS

Any code listed below that is not assigned a time value in the Current Procedural Technology (CPT) book is considered a 30 minute code. Pharmacologic management (90862) is assigned a fifteen (15) minute minimum time requirement by MHD. All Testing codes (96101, 96103, 96105, 96111, and 96116) are assigned a 60 minute time requirement by MHD. The current reimbursement amount may be accessed at the MO HealthNet Fee Schedule at http://dss.mo.gov/mhd/pages/cptagree.htm. 13.13.A PROCEDURE CODES FOR LCSW, LMSW, LPC AND PLPC The procedure codes listed below are the only behavioral health services codes billable by an LCSW, LMSW, LPC or PLPC. The appropriate AJ (LCSW or LMSW) or UD (LPC or PLPC) must be used for all codes. The U8 modifier should be used for services billed with a Place of Service 12 (home) or 99 (other). Proc Code 90801 90801 90802 U8 Maximum Quantity 6 6 2
Modifier
90802 90804 90804 90806
U8
2 1
U8
1 1
Brief Description Psychiatric diagnostic interview examination (Diagnostic Assessment) Psychiatric diagnostic interview examination (Diagnostic Assessment) - home Interactive psychiatric diagnostic interview examination (Interactive Diagnostic Assessment) Interactive psychiatric diagnostic interview examination (Interactive Diagnostic Assessment) home Individual Psychotherapy, insight oriented, 20-30 min. Individual Psychotherapy, insight oriented, 20-30 min. - home Individual Psychotherapy, insight oriented, 45-50 48
90806 90810 90810 90812 90812 90816 90818 90823 90826 90846 90846 90847 90847 90853 S9484 S9484 99406 99407
U8
1 1 1 1 1 1 1 1 1 2 2 2 2 3 6 6 1 1
U8
U8
U8 U8
U8
min. Individual Psychotherapy, insight oriented, 45-50 min. - home Individual psychotherapy, interactive, 20-30 min. Individual psychotherapy, interactive, 20-30 min. home Individual psychotherapy, interactive, 45-50 min. Individual psychotherapy, interactive, 45-50 min. home Individual psychotherapy, insight oriented, inpatient hospital, 20-30 min. Individual psychotherapy, insight oriented, inpatient hospital, 45-50 min. Individual psychotherapy, interactive, inpatient hospital, 20-30 min. Individual psychotherapy, interactive, inpatient hospital, 45-50 min. Family psychotherapy without patient Family psychotherapy without patient - home Family psychotherapy with patient Family psychotherapy with patient - home Group psychotherapy (other than a multiple-family group) Crisis Intervention, 60 min. Crisis Intervention, 60 min. - home Behavior change, smoking, 3-10 min. Behavior change, smoking, greater than 10 min.
13.13.B PROCEDURE CODES FOR PSYCHOLOGISTS OR PROVISIONALLY LICENSED PSYCHOLOGISTS The procedure codes listed below are the only behavioral health services codes billable by a psychologist or PLP. The AH modifier must be used on all codes. The U8 modifier should be used for services billed with Place of Service 12 (home) or 99 (other). Proc Code 90801 90801 90802 U8 Maximum Quantity 6 6 2
Modifier
90802 90804 90804 90806 90806 90810 90810 90812 90812 90816 90818 90823 90826 90846 90846 90847 90847
U8
2 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2
U8
U8
U8
U8
U8 U8
Brief Description Psychiatric diagnostic interview examination (Diagnostic Assessment) Psychiatric diagnostic interview examination (Diagnostic Assessment) - home Interactive psychiatric diagnostic interview examination (Interactive Diagnostic Assessment) Interactive psychiatric diagnostic interview examination (Interactive Diagnostic Assessment) home Individual Psychotherapy, insight oriented, 20-30 min. Individual Psychotherapy, insight oriented, 20-30 min. - home Individual Psychotherapy, insight oriented, 45-50 min. Individual Psychotherapy, insight oriented, 45-50 min. - home Individual psychotherapy, interactive, 20-30 min. Individual psychotherapy, interactive, 20-30 min. home Individual psychotherapy, interactive, 45-50 min. Individual psychotherapy, interactive, 45-50 min. home Individual psychotherapy, insight oriented, inpatient hospital, 20-30 min. Individual psychotherapy, insight oriented, inpatient hospital, 45-50 min. Individual psychotherapy, interactive, inpatient hospital, 20-30 min. Individual psychotherapy, interactive, inpatient hospital, 45-50 min. Family psychotherapy without patient Family psychotherapy without patient - home Family psychotherapy with patient Family psychotherapy with patient - home 50
90853 90885 96101 96101 96103 96103 96105 96111 96116 96116 S9484 S9484 99406 99407 U8 U8 U8 U8
3 1 4 4 4 4 1 1 1 1 6 6 1 1
Group psychotherapy (other than a multiple-family group) Psychiatric evaluation of records Psychological Testing - admin. by Psychologist, Prof interpretation and report Psychological Testing - admin. by Psychologist, Prof interpretation and report - home Psychological Testing - admin. by computer, Prof interpretation and report Psychological Testing - admin. by computer, Prof interpretation and report - home Assessment of aphasia, Prof interpretation and report Developmental Testing, Prof interpretation and report Neurobehavior status exam, Prof interpretation and report Neurobehavior status exam, Prof interpretation and report - home Crisis Intervention, 60 min. Crisis Intervention, 60 min. - home Behavior change, smoking, 3-10 min. Behavior change, smoking, greater than 10 min.
13.13.C PSYCHIATRISTS, PCNS, PMHNP, FQHC, AND RHC The U8 Modifier should be used for services billed with place of service 12 (home) or 99 (other). Proc Code 90801 90801 90802 90802 90804 90804 90805 Behavioral Health Services Manual
Modifier
Maximum Quantity 6
U8
6 2
U8
2 1
Brief Description Psychiatric diagnostic interview examination (Diagnostic Assessment) Psychiatric diagnostic interview examination (Diagnostic Assessment) - home Interactive psychiatric diagnostic interview examination (Interactive Diagnostic Assessment) Interactive psychiatric diagnostic interview examination (Interactive Diagnostic Assessment) Individual Psychotherapy, insight oriented, 20-30 min. Individual Psychotherapy, insight oriented, 20-30 min. - home Individual Psychotherapy, insight oriented, w/medical evaluation and management, 20-30 min. 51
U8
1 1
90805 90806 90806 90807 90807 90810 90810 90811 90811 90812 90812 90813 90813 90816
U8
1 1
Individual Psychotherapy, insight oriented, w/medical evaluation and management, 20-30 min. - home Individual Psychotherapy, insight oriented, 45-50 min. Individual Psychotherapy, insight oriented, 45-50 min. - home Individual Psychotherapy, insight oriented, w/medical evaluation and management, 45-50 min. Individual Psychotherapy, insight oriented, w/medical evaluation and management, 45-50 min. - home Individual psychotherapy, interactive, 20-30 min. Individual psychotherapy, interactive, 20-30 min. home Individual psychotherapy, interactive, w/medical evaluation and management, 20-30 min. Individual psychotherapy, interactive, w/medical evaluation and management, 45-50 min. - home Individual psychotherapy, interactive, 45-50 min. Individual psychotherapy, interactive, 45-50 min. home Individual psychotherapy, interactive, w/medical evaluation and management, 45-50 min. Individual psychotherapy, interactive, w/medical evaluation and management, 45-50 min. - home Individual psychotherapy, insight oriented, inpatient hospital, 20-30 min. Individual psychotherapy, insight oriented, inpatient hospital, w/medical evaluation and management, 2030 min. Individual psychotherapy, insight oriented, inpatient hospital, 45-50 min. Individual psychotherapy, insight oriented, inpatient hospital, w/medical evaluation and management, 4550 min. Individual psychotherapy, interactive, inpatient hospital, 20-30 min. Individual psychotherapy, interactive, inpatient hospital, w/medical evaluation and management, 2030 min. Individual psychotherapy, interactive, inpatient hospital, 45-50 min. 52
U8
1 1
U8
1 1 1 1
U8
U8
1 1 1 1
U8
U8
1 1
90817 90818
1 1
90819 90823
1 1
90824 90826
1 1
90827 90846 90846 90847 90847 90853 90862 90870 90885 96101 96101 96103 96103 96105 96111 96116 96116 S9484 S9484 99406 99407
U8 U8
1 2 2 2 2 3 1 1 1 4
U8
4 4
U8
4 1 1 1
U8 U8
1 6 6 1 1
Individual psychotherapy, interactive, inpatient hospital, w/medical evaluation and management, 4550 min. Family psychotherapy without patient Family psychotherapy without patient - home Family psychotherapy with patient Family psychotherapy with patient - home Group psychotherapy (other than a multiple-family group) Pharmacologic management Electroconvulsive therapy (includes monitoring) Psychiatric evaluation of records Psychological Testing - admin. by Physician, Prof interpretation and report Psychological Testing - admin. by Physician, Prof interpretation and report - home Psychological Testing - admin. by computer, Prof interpretation and report Psychological Testing - admin. by computer, Prof interpretation and report - home Assessment of aphasia, Prof interpretation and report Developmental Testing, Prof interpretation and report Neurobehavior status exam, Prof interpretation and report Neurobehavior status exam, Prof interpretation and report - home Crisis Intervention, 60 min. Crisis Intervention, 60 min. - home Behavior change, smoking, 3-10 min. Behavior change, smoking, greater than 10 min.
13.14 TIME-BASED SERVICE LIMITATIONS

An Individual Therapy or Individual Interactive Therapy procedure code representing a measure of time as defined in the CPT is covered for one unit per day. The provider must choose the code that most accurately defines the service being provided. A unit of service, which represents 20-30 minutes, must include at least 20 minutes face-to-face with the patient. A unit of service, which represents 45-50 minutes, must include at least 45 minutes face-to-face with the patient. 53 Behavioral Health Services Manual
The CPT definition of Diagnostic Assessment (90801, 90802), Family Therapy With or Without the Patient Present (90846, 90847), and Group Therapy (90853) is not time limited. MHD defines a unit of service as 30 minutes for these procedure codes. In order to be reimbursed by MHD, the services must be provided in full 30-minute units. The CPT definition of Pharmacologic Management (90862) is not time limited. MHD defines a unit of service as fifteen (15) minutes for this procedure code. Testing (96101, 96103, 96105, 96111, 96116) and Crisis Intervention (S9484) are defined in the CPT as one hour services. In order to be reimbursed by MHD, the services must be provided in full 60 minute units.
13.15 MUTUALLY EXCLUSIVE CODES

MHD requires providers to follow Medicare's Physician NCCI guidelines. Providers can find the current Physician NCCI edits and the current Mutually Exclusive Code (MEC) edits on the CMS website at: http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/list.asp
13.16 POSTPAYMENT REVIEW

All services reimbursed through the MHD Behavioral Health Services Program are subject to post payment reviews to monitor compliance with established policies and procedures pursuant to Title 42 CFR 456.1 through 456.23. Non-compliance may result in recoupment according to State Regulation 13 CSR 70-3.030(5) and the provider may be subjected to prepayment review on all MHD claims. Continued non-compliance may result in termination of the provider enrollment agreement.
13.17 PREPAYMENT REVIEW PROCESS

Services that are on prepayment review must be billed on a paper claim form (CMS-1500 or the approved claim form at the time of submission). The required documentation must be attached. For Behavioral Health Services procedure codes, the current Diagnostic Assessment, Treatment Plan, and Progress Note must be attached to the claim form for review to determine if the services were medically necessary. For Pharmacologic Management, the note for the visit must be attached to the claim form for review. For the required elements of a Diagnostic Assessment, Treatment Plan, Progress Note and Pharmacologic Management note, please refer to Section 13.4.
13.18 DIAGNOSTIC ASSESSMENT

Diagnostic Assessment: A Diagnostic Assessment from an MHD enrolled provider shall be documented in the patient's case record, which shall assist in ensuring an appropriate level of care, identifying necessary services, developing an Individualized Treatment Plan and 54 Behavioral Health Services Manual
documenting the following, in addition to the requirements outlined in 13 CSR 70-3.030, Section (1)(A): Statement of needs, goals, and treatment expectations from the individual requesting services. The family's perceptions are also obtained, when appropriate and available; Presenting situations/problem and referral source; History of previous psychiatric and/or substance abuse treatment including number and type of admissions; documentation of prior counseling received by previous and current provider including date range, purpose, duration and provider; Current medications and identifications of any medication allergies and adverse reactions; Recent alcohol and drug use for at least the past 30 days and, when indicated, a substance abuse history that includes duration, patterns, and consequences of use; Current psychiatric symptoms; Family, social, legal, and vocational/educational status and functioning. The collection and assessment of historical data is also required unless short-term crisis intervention or detoxification is the only services being provided; Current use of resources and services from other community agencies; Personal and social resources and strengths, including the availability and use of family, social, peer and other natural supports; and Multi-axis diagnosis or diagnostic impression in accordance with the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association or the International Classification of Diseases, current edition (ICD). The ICD code is required on the Treatment Plan for billing purposes.
13.18.A PSYCHIATRIC DIAGNOSTIC INTERVIEW EXAMINATION (90801) A Psychiatric Diagnostic Interview Examination must include direct patient contact and may include the following types of activities with patient present at least 75% of time billed:
Interview with child (includes topics of family, peers, school relationships, behavior, emotions, observation of social skills, developmental level of planning skills and informal assessment of overall development)
Parent report: Teacher report: This procedure is limited to six half-hour units per patient, per provider, per rolling year.
13.18.B INTERACTIVE PSYCHIATRIC DIAGNOSTIC INTERVIEW (90802) An Interactive Psychiatric Diagnostic Interview may be used to overcome barriers of communication for those patients who have not yet developed or have lost expressive language skills. This procedure consists of interactive psychiatric diagnostic interview examination using play equipment, physical devices, language interpreter or other mechanisms of communication. The Progress Note must adequately document the medical need for this service and type of equipment, device or other mechanisms of communication used. The patient must be present at least 75% of the time billed.
This procedure is limited to two half-hour units per patient, per provider, per rolling year.
13.19 TESTING
Psychological Testing services may be provided in addition to a Diagnostic Assessment when warranted for proper evaluation. This procedure is limited to a maximum of four hours per patient per provider per rolling year. Testing services are only reimbursed when provided by a Psychiatrist, PCNS, PMNHP, Psychologist, or PLP. MHD reimburses for the following Testing services: Procedure code 96101 - Psychological Testing (includes psycho diagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g. MMPI, Rorschach, WAIS), per hour of Psychologists or Physicians time , both faceto-face time with the patient and time interpreting test results and preparing the report. Procedure code 96103 Psychological Testing (includes psycho-diagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g. MMPI), administered by a computer, with interpretation and report. Procedure code 96105 Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g. by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour. Procedure code 96116 Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, e.g. acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the Psychologist's or Physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report.
The patient record must include the clinical justification for conducting the test as well as the intended purpose of the results. Testing services are reimbursed by full 60 minute units and are limited to a maximum of four hours per patient, per provider, per rolling year. 56 Behavioral Health Services Manual
13.20 INDIVIDUAL THERAPY

Individual Therapy procedure codes are divided into two categories, Interactive Psychotherapy (90810, 90811, 90812, 90813, 90823, 90824, 90826, and 90827) and Insight Oriented, Behavior Modifying and/or Supportive Psychotherapy (90804, 90805, 90806, 90807, 90816, 90817, 90818, and 90819). 13.20.A INSIGHT ORIENTED, BEHAVIOR MODIFIYING AND/OR SUPPORTIVE PSYCHOTHERAPY 90804 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient. 90806 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with patient. 90805 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient, with medical evaluation and management services. 90807 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient, with medical evaluation and management services.
Individual Psychotherapy is limited to 1 unit per day/5 units per month. 13.20.B INTERACTIVE PSYCHOTHERAPY 90810 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient. 90812 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient. 90811 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient, with medical evaluation and management services. 57 Behavioral Health Services Manual
90813 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient, with medical evaluation and management services.
Interactive psychotherapy is typically furnished to children. It involves the use of physical aids and non-verbal communication to overcome barriers to therapeutic interaction between the clinician and a patient who has not yet developed, or has lost, either the expressive language communication skills to explain his/her symptoms and response to treatment, or the receptive communication skills to understand the clinician if he/she were to use ordinary adult language for communication. Observing children playing on playground equipment, playing at daycare, and children playing at home in their normal routine or taking them to a playroom in a public place is not included in this procedure and is not reimbursable by MHD. Individual Interactive Therapy is NOT play therapy. Play Therapy includes a variety of treatment techniques and theoretical approaches. Play Therapy is generally employed with young children and provides a way for them to express their experiences and feelings through a natural, self-guided, self-healing process. As children's experiences and knowledge are often communicated through play, it becomes an important vehicle for them to know and accept themselves and others. The appropriate CPT code used to capture Play Therapy would depend on the specific therapeutic approach used and could be Individual Therapy, Individual Interactive Therapy, or Family Therapy. The Treatment Plan should include the billable service in the "services, supports and actions to accomplish each goal" section. Ideally, the Treatment Plan would go further and describe specific planned interventions, strategies and actions. If specific Play Therapy techniques are planned they may be included, but "Play Therapy" alone is not sufficient to describe the service that will be provided. The same considerations apply to Progress Notes. Progress Notes must include the specific MO HealthNet billable service rendered. 13 CSR 70-98.15 requirements include that "documentation must be in narrative form, fully describing each session billed" and Progress Notes must include "therapist's interventions for that visit and patient's response". Because of the breadth of techniques that could be described as Play Therapy, description of the specific Play Therapy interventions utilized is needed. The Progress Note narrative describing Play Therapy must include techniques that are consistent with the service billed. Individual Psychotherapy, Interactive, is limed to 1 unit per day/5 units per month and requires PA regardless of the age or placement of the child.
13.20.C INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE PSYCHOTHERAPY INPATIENT SETTING 90816 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient. 90818 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient. 90817 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient, with medical evaluation and management services. 90819 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient, with medical evaluation and management services.
Individual Psychotherapy in the inpatient setting is limited to one unit per day. Monthly limits do not apply when in an Inpatient Hospital setting; however, the services are counted in the maximum of one hundred fifty (150) hours in a single month. 13.20.D INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE INPATIENT SETTING 90823 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient. 90826 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient. 90824 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient, with medical evaluation and management services. 90827 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care 59 Behavioral Health Services Manual
setting, approximately 45 to 50 minutes face-to-face with the patient, with medical evaluation and management services. Individual Psychotherapy, Interactive, is limited to one unit per day. Monthly limits do not apply when in an Inpatient Hospital setting; however, the services are counted in the maximum of one hundred fifty (150) hours in a single month.
13.21 FAMILY THERAPY

Family Therapy is defined as the treatment of family members as a family unit, rather than individual patients. When Family Therapy Without the Patient Present (90846) or Family Therapy With the Patient Present (90847) is provided, the session is billed as one service (one family unit), regardless of the number of individuals present at the session. Providers may not bill Family Therapy for each family member. Family Therapy furnished by an LCSW, LMSW, LPC, or PLPC must be directed exclusively to the treatment of the child. Parental issues may not be billed and Family Therapy is only billable when defined in the Treatment Plan as necessary on behalf of the identified patient. Only one PA per household is approved and open at a time for Family Therapy. If there is more than one eligible child and no child is exclusively identified as the primary patient, then the oldest childs DCN must be used for PA and billing purposes. When a specific child is identified as the primary patient, that childs DCN must be used for PA and billing purposes. Providers should not request more than one Family Therapy PA per household. A family may be defined as biological, foster, adoptive or other family configuration. A family is not a group and providers may not submit a claim for each eligible person attending the same Family Therapy session. At least 75% of the session must have both child/children and parent(s) present.
13.22 GROUP THERAPY

Group therapy must consist of at least 3 but no more than 10 individuals who are not members of the same family. This applies to inpatient group therapy sessions also. Group therapy may not be billed on the same date of service as family therapy (90846 or 90847) unless the patient is inpatient, in a residential treatment facility, or custodial care facility. Services must be provided at the facility location. Group therapy in a group home is billed with Place of Service Code 14. Group therapy in a residential/custodial facility is billed with Place of Service Code 33. Group Therapy in a homeless shelter is billed with Place of Service Code 04.
13.23 CRISIS INTERVENTION

Crisis Intervention is used to offer immediate, short-term help to patients who experience an event that produces emotional, mental, physical, and behavioral distress or problems. A crisis 60 Behavioral Health Services Manual
can refer to any situation in which the patient perceives a sudden loss of the ability to use effective problem-solving and coping skills. Crisis Intervention aims to reduce the intensity of the patient's emotional, mental, physical and behavioral reactions to a crisis and help the patient return to their level of functioning before the crisis. Crisis Intervention is appropriate for children, adolescents, and younger and older adults. Elements of Crisis Intervention include helping the individual understand the crisis and their response to it as well as becoming aware of and expressing feelings, such as anger and guilt. A major focus of Crisis Intervention is exploring coping strategies. Crisis Intervention (S9484) must be a face-to-face contact to diffuse a situation of immediate crisis. The situation must be severe enough to pose a threat to the patient's well being or danger to him/herself or others. Crisis Intervention services cannot be scheduled. Crisis Intervention services are limited to six (6) units per patient, per provider, per calendar year.
13.24 SMOKING CESSATION

MHD reimburses for both behavioral and pharmacologic interventions for smoking cessation for MHD eligible participants. MHD requires the behavioral intervention to be initiated within 30 days of the pharmacologic intervention. The pharmacologic intervention is reimbursed through the MHD Pharmacy Program. MO HealthNet will cover two (2) quit attempts of up to 12 weeks of intervention per lifetime, including behavioral and pharmacologic interventions. The smoking cessation behavioral intervention reimbursable by MHD is based upon well established evidence as defined by the U.S. Surgeon General. The face-to-face intervention utilizes the "5-A's" (Ask, Advise, Assess, Assist, Arrange), education materials, self-help materials, problem solving guidance, and social support. U.S. Preventive Services Task Force (USPSTF) also recommends the use of motivational interviewing, assessing readiness to change, and telephone quit lines. Frequency and duration of the behavioral intervention should be determined on an individual basis and related to the patient's history of smoking and willingness to quit. Quit lines are currently available to all Missourians attempting to quit smoking via the MO Department of Health and Senior Services at http://www.dhss.mo.gov/SmokingAndTobacco/. Additional links, including resources for clinicians and smokers, may be accessed via the MHD Web site at http://www.dss.mo.gov/mhd/cs/psych/pages/smoking.htm. 13.24.A PROCEDURE CODES The following procedure codes should be used to bill for the behavioral intervention:
13.24.A(1) Physicians, Nurse Practitioners, Nurse Midwives, PCNS, PMHNP, Psychologists, and PLP (Psychologists and PLPs must use the AH modifier) Reimbursement Rate
Procedure Code
Description Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes and up to 10 minutes 99406 face-to-face with the patient. Intensive, greater than 10 minutes face99407 to-face with the patient
$8.00 $12.00
13.24.A(2) LCSWs, LMSWs, LPCs, and PLPCs (LCSWs and LMSWs must use the AJ modifier. LPCs and PLPCs must use the UD modifier) Reimbursement Rate
Procedure Code
Description Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes and up to 10 minutes 99406 face-to-face with the patient. Intensive, greater than 10 minutes face99407 to-face with the patient
$6.00 $9.00
LCSWs and LMSWs may be reimbursed for services provided to adults in the Rural Health Clinic or Federally Qualified Health Center setting only. 13.24.B DIAGNOSIS CODES In order to be reimbursed by MHD, the claim for the behavioral intervention must contain one of the following diagnosis codes: 305.1, V22.0 V22.2, V23.0 V23.9, 649.0 649.04. MHD will cover up to 12 sessions in a 12 week period. A maximum of 24 sessions per lifetime is allowed. Reimbursement is limited to one session per day. The behavioral intervention must be face-to-face with the patient. The behavioral intervention is included in the global fee for prenatal/delivery/post partum care billed by physicians and nurse midwives and should not be billed separately. Participants enrolled in a MO HealthNet Managed Care Health Plan receive the smoking cessation pharmacologic and behavioral interventions on a fee-for-service basis outside of the Managed Care benefit package.
13.25 EPSDT/HCY SERVICES

Mental health services are covered when the need for treatment is a result of a complete, partial, or interperiodic Healthy Children and Youth (HCY) screening and the service is medically necessary. See Section 9 of this provider manual for additional information on Healthy Children and Youth (HCY) Screening services. 13.25.A PARTIAL EPSDT/HCY SCREENS Partial EPSDT/HCY screens for Developmental Mental Health Assessment may be performed by a Psychiatrist, PCNS, PMHNP, Psychologist, PLP, LCSW, LMSW, LPC, or PLPC. Other providers who may perform Developmental Mental Health Assessments are listed in Section 9. A Developmental Mental Health Assessment includes: Assessment of personal, social and language development. Assessment of fine and gross motor skill development. Assessment of emotional and psychological status. Age appropriate guides can be found in the HCY Screening Guide included in Section 9. The diagnosis code of V202 must appear as the primary diagnosis in Field #23A on the CMS-1500 claim form when billing for HCY developmental screening service. Developmental partial screens (99429 59 and 99429 59 UC) are covered for children under the age of 21 in the HCY Behavioral Health Services program. It is the providers responsibility to encourage the child/youth to have an HCY examination to facilitate total health care that establishes the need for the treatment services. 13.25.A(1) EPSDT/HCY Partial Screen For Developmental Assessment PROC CODE 99429 59 99429 59 UC MAXIMUM ALLOWABLE AMOUNT $15.00 $15.00
DESCRIPTION Developmental/mental health partial screen Developmental/mental health partial screen with referral
13.25.A(2) Partial Screeners The provider of a partial medical screen should have a patient referral source for the remaining required components of the screen. Examples of partial screeners may include but are not limited to: Public Health Departments 63 Behavioral Health Services Manual
Early Childhood Programs School Districts
13.26 NONCOVERED SERVICES

Services that are performed to treat individuals over 21 associated with an EPSDT/HCY child are not covered. If it is determined that the parent/guardian or other individual is in need of service, the appropriate referral should be made to a Psychiatrist, PCNS, PMHNP, Psychologist, or PLP. The following services are not covered under the Behavioral Health Services Program such as but not limited to: Biofeedback therapy Auditory Therapy Services that require prior authorization (PA), but were performed without a PA; or
Non-covered services may be billed to the patient. 13.26.A NON-ALLOWED SERVICES The following services are non-allowed under the Behavioral Health Services Program and may not be billed to a Medicaid patient: Courtesy calls such as patient drop in visits to give a progress report that was not scheduled, and no therapy services were rendered Missed appointments or failure to show Additional payment is not made for services that are performed after regularly scheduled office hours, on holidays, or on weekends Services performed by non-licensed, non-enrolled personnel Participation in Individual Education Plan (IEP) or Individualized Family Service Plan (IFSP) meeting Telephone calls Court appearances Mental health services that are performed to treat the parent of an MHD eligible child who is not in MC+ are not covered on a fee-for-service basis. If it is determined that the parent/guardian is in need of mental health services, the appropriate referral must be made. Testing when performed by an LCSW, LMSW, LPC, or PLPC. Telephone consultations
13.26.B PSYCHOLOGICAL SERVICES IN A NURSING HOME MHD does not cover Behavioral Health services provided by a Psychiatrist, PCNS, PMHNP, Psychologist, LCSW, LMSW, LPC, or PLPC, with the exception of 90862 and 90801 (see Section 13.14), to nursing facility residents when those services are provided in the nursing home setting. This is the policy regardless of any arrangement a provider may have with a nursing facility concerning the leasing of office space within the nursing home. If Behavioral Health services are provided in the long term facility itself, there is no MHD coverage afforded a patient. Any costs incurred by a facility for the provision of these services are not allowable costs on the nursing facility's MHD cost report. In addition to Pharmacologic Management (procedure code 90862) MHD will allow a Psychiatric Diagnostic Interview Examination (procedure code 90801) for participants in a Skilled Nursing Facility (nursing home) when performed by a Psychiatrist, PCNS, or PMHNP. The Psychiatric Diagnostic Interview Examination includes a history, mental status, and a disposition, and may include communication with family or other sources, ordering and medical interpretation of laboratory or other medical diagnostic studies. Please see Section 13.4 for documentation requirements and content of a Psychiatric Diagnostic Interview Examination and Pharmacologic Management.
13.27 TELEHEALTH SERVICES

Effective August 30, 2008, MHD began reimbursing for Telehealth Services through the Behavioral Health Services Program. The Missouri Code of State Regulations 13 CSR 70-3.190 Telehealth Services establishes coverage for Telehealth Services through the MO HealthNet program. Telehealth Services are medical services provided through advanced telecommunications technology from one location to another. Medical information is exchanged in real-time communication from an Originating Site, where the participant is located, to a Distant Site, where the provider is located, allowing them to interact as if they are having a face-to-face, "hands-on" session. Telehealth offers participants, particularly those in rural areas of the state, access to health care services without having to travel extensive miles for an appointment. 13.27.A TELEHEALTH COVERED SERVICES A Telehealth service requires the use of a two (2)-way interactive video technology. Asynchronous telecommunication systems or store-and-forward systems are not covered technologies. Telehealth is not a telephone conversation, email, faxed transmission between a healthcare provider and a patient, or a consultation between two healthcare providers. The participant must be able to see and interact with the off-site provider at the time services are provided via Telehealth. Services provided via videophone or webcam are not covered. 65 Behavioral Health Services Manual
Telehealth services are only covered if medically necessary. rendered through Telehealth at the distant site is limited to: 1. Consultations made to confirm a diagnosis; or 2. Evaluation and management services; or 3. A diagnosis, therapeutic, or interpretative service; or
Coverage of services
4. Individual psychiatric or substance abuse assessment diagnostic interview examinations; or 5. Individual psychotherapy; or 6. Pharmacologic management. 13.27.B ELIGIBLE PROVIDERS Health care providers utilizing Telehealth at either an originating site or a distant site must be enrolled as a MO HealthNet provider prior to rendering services. Providers eligible to receive payment for Telehealth services include: Physicians Advanced Registered Nurse Practitioners, including Nurse Practitioners with a Mental Health specialty Psychologists
13.27.C TELEHEALTH SERVICE REQUIREMENTS Medically necessary Telehealth services may be arranged for participants by a referring provider. The referring provider evaluates the participant, determines the need for a consultation, and arranges the services of a consulting provider at the distant site for the purpose of diagnosis or treatment. The originating site is where the MO HealthNet participant receiving the Telehealth service is physically located for the encounter. The originating site must be one of the following locations: Office of a physician or health care provider Hospital Critical Access Hospital Rural Health Clinic (RHC) Federally Qualified Health Center (FQHC) Missouri State Habilitation Center or Regional Center Community Mental Health Center Missouri State Mental Health Facility Missouri State Facility 66 Behavioral Health Services Manual
A referring provider may introduce a participant to the consulting provider at the distant site for examination, observation, or consideration of medical information. The referring provider may assist with the Telehealth service if requested by the consulting provider. The consulting provider at the distant site may request a Telepresenter to be present with the participant at the originating site to assist with the service. A Telepresenter will aid in the examination by following the orders of the consulting provider, including the manipulation of cameras and appropriate placement of other peripheral devices used to conduct the patient examination. The services of the Telepresenter are included in the reimbursement of the facility fee billed by the originating site and are not separately reimbursable. It is not appropriate for the same provider to bill for both the originating and distant site charges on the same date of service. All claims are subject to post payment review and improper billing will result in recoupments and possible sanctions against the provider. It is not required for a referring provider or a Telepresenter to be present with the participant during the service; however, the originating site must ensure the immediate availability of clinical staff during the Telehealth encounter in the event a participant requires assistance. 13.27.D REIMBURSEMENT Reimbursement to the health care provider delivering the medical service at the distant site is equal to the current fee schedule amount for the service provided. Use the appropriate CPT code for the service along with the "GT" modifier (via interactive audio and video telecommunications system) indicating interactive communication was used. The following Behavioral Health services are billable by the distant site provider using the "GT" modifier: Proc Code
Mod
Mod GT
Description Psychiatric diagnostic interview examination Psychiatric diagnostic interview examination Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face 67
90801 AH 90801 GT
90804 AH
GT
90804 GT
with the patient
90805 GT
Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; with evaluation and management services. Pharmacological Management
90806 AH
GT
90806 GT
90807 GT 90862 GT
The originating site is only eligible to receive a facility fee for the Telehealth service. Claims should be submitted with HCPCS code Q3014 (Telehealth originating site facility fee). Reimbursement will be made at the lesser of the actual charge or $14.60. Procedure code Q3014 is used by the originating site to receive reimbursement for the use of the facility while telehealth services are being rendered. The telepresenter at the originating site is not considered a performing provider as he/she is only assisting the consulting provider at the distant site. As a result, the originating site does not have a performing provider to report on its claim. Providers billing procedure code Q3014 must leave the Performing Provider ID field blank on the claims (field 24J on the paper CMS1500 claim form or the corresponding field on an electronic claim). Claims for procedure code Q3014 containing performing provider information will be considered improperly billed. 68 Behavioral Health Services Manual
13.27.E PRIOR AUTHORIZATION AND UTILIZATION REVIEW All services are subject to utilization review for medical necessity and program compliance. Reviews can be performed before services are furnished, before payment is made, or after payment is made. Certain procedures or services can require PA from the MO HealthNet Division or its authorized agents. Services for which PA was obtained remain subject to utilization review at any point in the payment process. A service provided through Telehealth is subject to the same PA and utilization review requirements which exist for the service when not provided through Telehealth. 13.27.F DOCUMENTATION FOR THE ENCOUNTER Participant records at the originating and distant sites must document the Telehealth encounter. A request for a Telehealth service from a referring provider and the medical necessity for the Telehealth service must be documented in the participant's medical record. A health care provider is required to keep a complete medical record of a Telehealth service provided to a participant and follow applicable state and federal statutes and regulations for medical record keeping and confidentiality in accordance with 13 CSR 70-3.020 and 13 CSR 70-98.015. Documentation of a Telehealth service by the health care provider must be included in the participant's medical record maintained at the participant's location and must include: 1. The diagnosis and Treatment Plan resulting from the Telehealth service and Progress Note by the health care provider; 2. The location of the distant site and originating site; 3. A copy of the signed informed consent form; and 4. Documentation supporting the medical necessity of the Telehealth service. Documentation for a Telehealth service must meet all requirements for the Behavioral Health Services Program as stated in Section 13.4. 13.27.G CONFIDENTIALITY AND DATA INTEGRITY/APPROVED MISSOURI TELEHEALTH NETWORK (MTN) All Telehealth activities must comply with the requirements of the Health Insurance Portability and Accountability Act of 1996 and all other applicable state and federal laws and regulations. A Telehealth service is to be performed on a private, dedicated telecommunications line approved through the Missouri Telehealth Network (MTN). The telecommunications line must be secure and utilize a method of encryption adequate to protect the confidentiality and integrity of the Telehealth service information. The Missouri 69 Behavioral Health Services Manual
Telehealth Network must also approve the equipment that will be used in Telehealth service. Both a distant site and an originating site must use authentication to ensure the confidentiality of a Telehealth service. Providers of Telehealth services must implement confidentiality protocols that include identifying personnel who have access to a Telehealth transmission and preventing unauthorized access to a Telehealth transmission. A provider's protocols and guidelines must be available for inspection by MHD upon request. 13.27.H INFORMED CONSENT Before providing the initial Telehealth service to a patient, each health care provider must document written informed consent from the participant and ensure that the following written information is provided to the participant in a format and manner that the participant is able to understand: 1. The participant shall have the option to refuse the Telehealth service at any time without affecting the right to future care and treatment and without risking the loss or withdrawal of a MO HealthNet benefit to which the participant is entitled; 2. The participant shall be informed of alternatives to the Telehealth service that are available to the participant; 3. The participant shall have access to medical information resulting from the Telehealth service as provided by law; 4. The dissemination, storage, or retention of an identifiable participant image or other information from the Telehealth service must not occur without the written informed consent of the participant or the participant's legally authorized representative; 5. The participant shall have the right to be informed of the parties who will be present at the originating site and the distant site during the Telehealth service and shall have the right to exclude anyone from either site; and 6. The participant shall have the right to object to the videotaping or other recording of a Telehealth service. A copy of the signed informed consent must be retained in the participant's medical record and provided to the participant or the participant's legally authorized representative upon request. The requirement to obtain informed consent before providing a service will not apply to an emergency situation if the participant is unable to provide informed consent and the participant's legally authorized representative is unavailable. 13.27.I MISSOURI TELEHEALTH NETWORK Providers interested in obtaining information on an approved Missouri Telehealth Network (MTN) and services in your area may contact: 70 Behavioral Health Services Manual
Missouri Telehealth Network 2401 Lemone Industrial Boulevard DC345.00 Columbia, MO 65212 Phone: 573.884.7958 Email: mtn@health.missouri.edu Or may go to their website: http://www.telehealth.muhealth.org
13.28 MODIFIERS
Claims must be submitted using the appropriate modifier(s). The specialty modifier is always required. AH Psychologist AJ Licensed Clinical Social Worker UD Licensed Professional Counselor
The following modifiers are required when appropriate: U8 in home (12) or private school (99). The U8 modifier is not appropriate when billing 90853, regardless of POS) CR Catastrophe/Disaster Related. The CR modifier is used to track services provided to patients identified as a catastrophe/disaster victims in any part of the country. This modifier is used in addition to any other required modifiers. There is no additional reimbursement associated with the use of this modifier. TM used when billing School Based Behavioral Health services (see Section 13.12) The appropriate NCCI modifier should be used when appropriate. (see Section 13.15)
13.29 FREQUENTLY USED PLACE OF SERVICE CODES

03 Public School 04 Homeless Shelter 11 Office 12 Home 14 Group Home 21 Inpatient Hospital 22 Outpatient Hospital 33 Custodial Care Facility 71 Behavioral Health Services Manual
50 FQHC 51 Inpatient Psychiatric Facility 55 Residential Substance Abuse Treatment Facility 56 Psychiatric Residential Treatment Facility 61 Comprehensive Inpatient Rehabilitation Facility 72 Rural Health Clinic 99 Private School 13.29.A PLACE OF SERVICE CODE The only valid setting for using place of service code 99 is a private/parochial school. (Head Start is not considered a private school.) Services provided in a public school setting must be billed with place of service 03. Place of service 99 cannot be used for therapy provided in a public setting. A public setting includes but is not limited to: a parked or moving vehicle, library, park, shopping center, restaurants, etc. Providers must use the appropriate place of service code for the setting in which services are rendered. If there is no place of service code that matches the setting, services may not be billed to MHD. Although there is a place of service 15 for mobile unit, MHD does not cover services provided in this setting. Place of service 11 (office) may be used for settings such as a Head Start. Centers for Medicare and Medicaid Services (CMS) have defined an office as a location where the health professional routinely provides services. Place of service 04 (homeless shelter) should be used when services are provided in a setting such as a crisis center or Salvation Army housing. The CMS definition of a homeless shelter is a facility or location that provides temporary housing. Services provided to children who reside in a Residential Treatment Center and who are under the care and custody of the Childrens Division must use place of service code 33 when the services are provided at the Residential Treatment Center. Group therapy services are not covered in place of service "12", home. When providing therapy to a group of children in a group home, group therapy (90853) is billed with a place of service group home (POS 14) (Documentation must show the reason for providing services in the home.).
13.30 REFERRAL SERVICES

Services for parent(s)/guardian(s) and/or the family unit that are medically necessary but beyond the scope of the HCY Behavioral Health Services Program may be obtained through the adult Behavioral Health Services Program or by a referral to other programs. Medically necessary Behavioral Health services are also available through the Department of Mental Healths 72 Behavioral Health Services Manual
Comprehensive Substance Treatment and Rehabilitation (CSTAR) Program, Community Psychiatric Rehabilitation (CPR) Program, or in an FQHC/RHC setting; however, these services are available under specific guidelines. MHD provides for Psychiatric/psychological services to patients without regard to age when medically necessary. These services are covered only when performed by a Psychiatrist, PCNS, PMHNP, Psychologist, or PLP.
13.31 THIRD PARTY LIABILITY (TPL)

When a MHD patient has a third party resource (TPR) that may be liable for the payment of all or a portion of the service, it must be submitted to the insurance company before MHD considers the claim for payment. See Section 5 of this provider manual for further instructions on how to submit claims affected by a TPR. Federal regulation 42 CFR 447.20 states the following: A provider may not refuse to furnish services covered under the plan to an individual who is eligible for medical assistance under the plan on account of a third partys potential liability for the service(s). 13.31.A TPL BYPASS Certain services are eligible to bypass Third Party Liability (TPL) editing in the MHD payment system. Those claims involve preventative pediatric services (including EPSDT services), prenatal care, and those that the third party resource is derived from a noncustodial parent whose medical support obligation is being enforced by the Family Support Division. Federal regulation, 42 CFR 433.139 (B)(3)(i)(ii) requires the state Medicaid agency to pay and chase these claims when the provider elects not to pursue the third party resource for payment. If the claim falls into one of the above categories and the provider elects not to bill the third party resource, the Third Party Liability Unit pursues reimbursement of the MHD payment for this service directly from the TPR. The provider must indicate on the claim form whether or not the TPR has been billed. When this option is exercised, the providers payment is limited to the MHD payment amount. If a TPR payment is received after MHD has been billed for the service, the payment must be forwarded to the MHD agency to be distributed as specified by federal regulation. 13.31.B TPL LIABILITY INSURANCE REPORTING FORM Many providers have requested the capability to report changes in insurance coverage directly to MHD when they learn of them from the patient or the insurance company. In the past, changes were to be reported to the patients caseworker. A form has been developed for the provider to report changes or additions to a patients insurance records. Please refer to Section 5 of this manual for additional information regarding submission of this form. 73 Behavioral Health Services Manual
13.32 MANAGED CARE BEHAVIORAL HEALTH SERVICES

Managed care health plans provide behavioral health services for children except for those children in state care and custody (Group 4). Children in Group 4 receive behavioral health services on a fee-for-service basis outside of the health plan. Refer to Section 1 and Section 11 for further information.
13.33 REPORTING CHILD ABUSE CASES

State Statute at 210.115 RSMo (Cum. Supp. 1992) requires hospitals and other specified personnel to report possible child abuse cases to the Family Support Division Child Abuse Hotline. Children's Division Child Abuse and Neglect Hotline Unit (CA/NHU) accepts confidential reports of suspected child abuse, neglect, or exploitation. Reports are received through a toll-free telephone line which is answered 7 days a week, 24 hours a day. Members of certain occupational groups, such as teachers, social workers, and physicians, are mandated by law to make reports to the hotline. Any person may report, and anonymous reports are accepted from individuals who are not mandated by occupation to report. Effective August 28, 2004, Missouri law requires Mandated Reporters to identify themselves when making a report. The toll-free number is (800) 392-3738. Persons calling from outside Missouri should dial (573) 751- 3448. Text telephone number: (800) 669-8689.
Section 14 Special Documentation Requirements
SECTION 14 -SPECIAL DOCUMENTATION REQUIREMENTS

14.1 HEALTHY CHILDREN AND YOUTH SCREENING (HCY/EPSDT) ......................... 2 14.2 DIAGNOSTIC ASSESSMENT ........................................................................................... 2 14.3 INDIVIDUAL TREATMENT PLAN ................................................................................. 3 14.4 PROGRESS NOTES ............................................................................................................ 3 14.5 PRIOR AUTHORIZATION REQUEST............................................................................ 3 14.6 AFTERCARE PLAN ............................................................................................................ 3

SECTION 14SPECIAL DOCUMENTATION REQUIREMENTS

Program limits may require medical necessity or prior authorization. This program does not require submission of a Certificate of Medical Necessity form as outlined in Section 7. Reference Section 14.5 for unique requirements for prior authorization. Reference Section 8, Prior Authorization, for general instructions. The MO HealthNet Program has requirements for other documentation when processing claims under certain circumstances. Refer to Section 13.17 for submitting claims for prepayment review. Refer to Sections 15, Billing Instructions, and 16, Medicare/Medicaid Crossover Claims, for further information. Refer to Sections 1-11 and 20 for general program documentation requirements.
14.1 HEALTHY CHILDREN AND YOUTH SCREENING (HCY/EPSDT)

The medical record for each child for whom a screening examination under the Healthy Children and Youth/Early Periodic Screening, Diagnosis and Treatment Program is performed must document that all components of the screening were performed. A copy of the Healthy Children and Youth Screening document should serve as an age-specific guide to recommended services appropriate to each age group. This document must be filed in the childs medical record. For more information on this form, including instructions for completion and a copy of the form, reference Section 9.
14.2 DIAGNOSTIC ASSESSMENT

A Diagnostic Assessment from a MO HealthNet enrolled provider shall be documented in the patients' medical record. An assessment service is for the purpose of identifying the treatment needs of the individual or family. A Diagnostic Assessment should result in a determination that no further services are required or should be used in developing an individualized Treatment Plan. The Diagnostic Assessment must be current - within one year for adults and adolescents (age 13 to 20) or six months for children under 13. An update to the Diagnostic Assessment is required in occurrence of a crisis or significant clinical event. The Diagnostic Assessment shall assist in ensuring an appropriate level of care, identifying necessary services, developing an Individualized Treatment Plan and documenting the details listed in Section 13.4.A(1).
14.3 INDIVIDUAL TREATMENT PLAN

A treatment plan must be developed for each patient who receives Individual Therapy, Family Therapy (with or without the patient present), or Group Therapy. Refer to Section 13.4.A(2) and Section 13.4.A(4) for Treatment Plan Specifics. A treatment plan is a plan of action developed by the provider based on a diagnostic evaluation that includes examination of the medical, psychological, social behavioral and developmental aspects of the patient's situation and reflects the need for behavioral health services.
14.4 PROGRESS NOTES

Progress Notes for behavioral health services shall be written and maintained in the patient's medical record for each date of service for which a claim is filed. Progress Note specifications can be found in Section 13.4.A(3) .
14.5 PRIOR AUTHORIZATION REQUEST

Detailed Prior Authorization information may be obtained in Section 13.9. Information specific to Adult Prior Authorization guidelines can be found in Section 13.10. Information specific to Children and Youth Prior Authorization guidelines can be found in Section 13.11. All providers should submit their completed prior authorization request to: Wipro Infocrossing P. O. Box 4800 Jefferson City, MO 65102 Phone (toll free) 866-771-3350 Fax 573-635-6516
14.6 AFTERCARE PLAN

When care is completed, the Aftercare Plan shall be filed. Refer to Section 13.4.A(5).
END OF SECTION TOPOFPAGE
Section 15 Billing Instructions
SECTION 15 - BILLING INSTRUCTIONS
15.1 ELECTRONIC DATA INTERCHANGE .......................................................................... 2 15.2 INTERNET ELECTRONIC CLAIM SUBMISSION ....................................................... 2 15.3 CMS-1500 CLAIM FORM .................................................................................................. 3 15.4 PROVIDER COMMUNICATION UNIT .......................................................................... 3 15.5 RESUBMISSION OF CLAIMS .......................................................................................... 3 15.6 BILLING PROCEDURES FOR MEDICARE/MO HEALTHNET CLAIMS ............... 3 15.7 CMS-1500 CLAIM FILING INSTRUCTIONS ................................................................. 4 15.8 PLACE OF SERVICE CODES AND DEFINITIONS .................................................... 10 15.9 INSURANCE COVERAGE CODES ................................................................................ 14
SECTION 15BILLING INSTRUCTIONS 15.1 ELECTRONIC DATA INTERCHANGE

Billing providers who want to exchange electronic transactions with MO HealthNet should access the ASC X12N Implementation Guides, adopted under HIPAA, at www.wpc-edi.com. For Missouri specific information, including connection methods, the billers responsibilities, forms to be completed prior to submitting electronic information, as well as supplemental information, reference the X12 Version v5010 and NCPDP Telecommunication D.0 & Batch Transaction Standard V.1.1 Companion Guides found through this web site. To access the Companion Guides, select: MO HealthNet Electronic Billing Layout Manuals System Manuals Electronic Claims Layout Manuals X12 Version v5010 or NCPDP Telecommunication D.0 & Batch Transaction Standard V.1.1 Companion Guide.
15.2 INTERNET ELECTRONIC CLAIM SUBMISSION

Providers may submit claims via the Internet. The web site address is www.emomed.com. Providers are required to complete the on-line Application for MO HealthNet Internet Access Account. Please reference http://www.dss.mo.gov/mhd/providers/index.htmand click on the Apply for Internet Access link. Providers are unable to access www.emomed.com without proper authorization. An authorization is required for each individual user. For full functionality of the Internet application, either the Internet Explorer 5.0 or higher web browser or the Netscape 4.7 or higher web browser is recommended. The features of the Internet application include claim submissions, claim credits and eligibility verification. The following claim types can be used in Internet applications: Medical (NSF), Inpatient and Outpatient (UB-04), Dental (ADA 1999, Version 2000), Nursing Home and Pharmacy. For convenience, some of the input fields are set as indicators or accepted values in drop-down boxes. Providers have the option to input and submit claims individually or in a batch submission. A confirmation file is returned for each transmission.
15.3 CMS-1500 CLAIM FORM

The CMS-1500 claim form is always used to bill MO HealthNet for all behavioral health services, unless a provider bills those services electronically. Instructions on how to complete the CMS-1500 claim form are on the following pages.
15.4 PROVIDER COMMUNICATION UNIT

It is the responsibility of the Provider Communication Unit to assist providers in filing claims. For questions, providers may call (573) 751-2896. Section 3 of this manual has a detailed explanation of this unit. If assistance is needed regarding establishing required electronic claim formats for claims submissions, accessibility to electronic claim submission via the Internet, network communications, or ongoing operations, the provider should contact the Wipro Infocrossing Help Desk at (573) 635-3559.
15.5 RESUBMISSION OF CLAIMS

Any line item on a claim that resulted in a zero payment can be resubmitted if it denied due to a correctable error. The error that caused the claim to deny must be corrected before resubmitting the claim. The provider may resubmit electronically or on a CMS-1500 claim form. An example of a correctable error is the use of an invalid procedure code. If a line item on a claim paid but the payment was incorrect do not resubmit that line item. For instance, if the claim shows an incorrect number of units for a procedure and the claim pays, that claim cannot be resubmitted. It will deny as a duplicate. In order to correct that payment, the provider must submit an Individual Adjustment Request. Section 6 of this manual explains the adjustment request process.
15.6 BILLING PROCEDURES FOR MEDICARE/MO HEALTHNET CLAIMS

When a patient has both Medicare Part B and MO HealthNet coverage, a claim must be filed with Medicare first as primary payor. If the patient has Medicare Part B but the service is not covered or the limits of coverage have been reached previously, an electronic claim must be submitted to MO HealthNet along with the Medicare Remittance Advice attached indicating the denial. Reference Section 16.5 of this manual for instructions for submission of claims to MO HealthNet. If a claim was submitted to Medicare indicating that the patient also had MO HealthNet and disposition of the claim is not received from MO HealthNet within 60 days of the Medicare remittance advice date (a reasonable period for transmission for Medicare and MO HealthNet 3 Behavioral Health Services Manual
processing), an electronic crossover claim must be submitted to MO HealthNet. Reference Section 16 for billing instructions.
15.7 CMS-1500 CLAIM FILING INSTRUCTIONS

The CMS-1500 claim form should be typed or legibly printed. It may be duplicated if the copy is legible. MO HealthNet claims should be mailed to: Wipro Infocrossing P.O. Box 5600 Jefferson City, MO 65102 NOTE: An asterisk (*) beside the field number indicates required fields. These fields must be completed or the claim is denied. All other fields should be completed as applicable. Two asterisks (**) beside the field number indicate the field is required in specific situations. FIELD NUMBER & NAME 1. Type of Health Insurance Coverage INSTRUCTIONS FOR COMPLETION Show the type of health insurance coverage applicable to this claim by checking the appropriate box, e.g., if a Medicare claim is being filed, check the Medicare box, if a MO HealthNet claim is being filed, check the Medicaid box and if the participant has both Medicare and MO HealthNet, check both boxes. Enter the patients 8-digit MO HealthNet or MO HealthNet Managed Care ID number (DCN) as shown on the participants ID card. Enter last name, first name, middle initial in that order as it appears on the ID card.
*1a. Insureds I.D.
*2. Patients Name
3. Patients Birth Date
Enter month, day and year of birth.
Sex **4. Insureds Name
Mark appropriate box. If there is individual or group insurance besides MO HealthNet, enter the name of primary policyholder. If this field is completed, also complete Fields 6, 7, 11 and 13. 4
5. Patients Address **6. Patients Relationship to Insured **7. Insureds Address
Enter address and telephone number if available. Mark appropriate box if there is other insurance. If no private insurance is involved, leave blank. Enter the primary policy holders address; enter policy holders telephone number, if available. If no private insurance is involved, leave blank.
8. Patient Status **9. Other Insureds Name
Not required. If there is other insurance coverage in addition to the primary policy, enter the secondary policyholders name. If no private insurance is involved, leave blank. (See Note)(1)
**9a. Other Insureds Group Number
Enter the secondary policyholders insurance policy number or group number if the insurance is through a group such as an employer, union, etc. If no private insurance is involved, leave blank. (See Note)(1)
**9b. Other Insureds Date of Birth
Enter the secondary policyholders date of birth and mark the appropriate box for sex. If no private insurance is involved, leave blank. (See Note)(1)
**9c. Employers Name
Enter the secondary policyholders employer name. If no private insurance is involved, leave blank. (See Note)(1)
**9d. Insurance Plan Name or Program Name
Enter the secondary policyholders insurance plan name. If the insurance plan denied payment for the service provided, attach a valid denial from the insurance plan. If no private insurance is involved, leave blank. (See Note)(1)
**10a-10c. Is Patients Condition Related to:
If services on the claim are related to participants employment, auto accident or other accident, mark the appropriate box. If the services are not related to an accident, leave blank. 5
(See Note)(1) 10d. Reserved for local use. **11. Insureds Policy or FECA Number May be used for comments/descriptions. (See Note)(1) Enter the primary policyholders insurance policy number or group number, if the insurance is through a group such as, an employer, union, etc. If no private insurance is involved, leave blank. (See Note)(1) **11a. Insureds Date of Birth Enter primary policyholders date of birth and mark the appropriate box reflecting the sex of the primary policy holder. If no private insurance is involved, leave blank. (See Note)(1) **11b. Employers Name Enter the primary policyholders employer name. If no private insurance is involved, leave blank. (See Note)(1) **11c. Insurance Plan Name Enter the primary policyholders insurance plan name. If no private insurance is involved, leave blank. If the insurance plan denied payment for the service provided, attach a valid denial from the insurance plan. (See Note)(1) **11d. Other Health Plan Indicate whether the participant has another health insurance plan; if so, complete Fields #9-#9d with the secondary insurance information. If no private insurance is involved, leave blank. (See Note)(1) 12. Patients Signature 13. Insureds Signature Leave blank. This field should only be completed when the participant has another health insurance policy. Obtain the policyholders or authorized persons signature for assignment of benefits. The signature is necessary to ensure the insurance plan pays any benefits directly to the provider or MO HealthNet. Otherwise payment may be issued to the policyholder requiring the provider to collect insurance benefits from the policyholder. 6 Behavioral Health Services Manual
14. Date of Current Illness, Injury or Pregnancy 15. Date Same/Similar Illness 16. Dates Patient Unable to Work *17. Name of Referring Physician or Other Source *17a. Other ID
Leave blank. Leave blank. Leave blank. Enter the name of the referring MO HealthNet enrolled primary care provider.
Enter the Provider Taxonomy qualifier ZZ in the first shaded area if the provider reported in 17b is required to report a Provider Taxonomy Code to MO HealthNet. Enter the corresponding 10-digit Provider Taxonomy Code in the second shaded area for the provider reported in 17b. Enter the NPI number of the referring or ordering provider. Leave Blank. Providers may use remarks/descriptions. Leave blank. Enter the complete ICD, current edition, diagnosis code(s). Enter the primary diagnosis under No. 1, the secondary diagnosis under No. 2, etc. For timely filing purposes; if this is a resubmitted claim, enter the Internal Control Number (ICN) of the previous related claim or attach a copy of the original Remittance Advice indicating the claim was initially submitted timely. Leave blank. Enter the date of service under from in month/day/year format, using six-digit format in the unshaded area of the 7 this field for additional
*17b. NPI **18. Hospitalization Dates 19. Reserved for Local Use 20. Lab Work Performed Outside Office *21. Diagnosis
22. Medicaid Resubmission
23. Prior Authorization Number *24a. Date of Service
field. All line items must have a from date. Multiple dates of service cannot be billed on a single line of the claim form. Each date of service must be shown on a separate line of the claim form with no more than six (6) lines per claim form. *24b. Place of Service Enter the appropriate place of service code in the unshaded area of the claim. See Section 15.8 for the list of appropriate place of service codes. Reference Section 13.30 for Program Specific Place of Service Codes. Leave blank. Enter the appropriate procedure code and applicable modifiers, if any, corresponding to the service rendered in the unshaded area of this field. Enter 1, 2, 3, 4 or the actual diagnosis code(s) from Field #21 in the unshaded area of this field. Enter the providers usual and customary charge for each line item in the unshaded area of this field. This should be the total charge when there are multiple units entered for a line item. Enter the number of units of service provided for each detail line in the unshaded area of this field. The system automatically plugs a 1, if the field is left blank. If this service is an EPSDT/HCY screening or referral, enter an E in the unshaded area of this field. Enter the Provider Taxonomy qualifier ZZ in the shaded are if the rendering/performing provider is required to report a Provider Taxonomy Code to MO HealthNet. If the provider Taxonomy qualifier was reported in 24i, enter the 10-digit Provider Taxonomy Code in the shaded area. Enter the 10-digit NPI number of the individual rendering/performing the service in the unshaded area. This field is only required if the billing provider is a clinic, FQHC, teaching institution, or a group practice. 25. SS#/Fed. Tax ID 26. Patient Account Number Leave blank. For the providers own information, a maximum of 12 8 Behavioral Health Services Manual
24c. EMG - Emergency *24d. Procedure Code
*24e. Diagnosis Code or Pointer *24f. Charges
*24g. Days or Units
24h. EPSDT/HCY/Family Planning **24i. ID Qualifier
**24j. Rendering Provider ID #
alpha and/or numeric characters may be listed here. 27. Assignment *28. Total Charge 29. Amount Paid Not required on MO HealthNet only claims. Enter the sum of the line item charges. Enter the total amount received by all other insurance resources. Previous MO HealthNet payments, Medicare payments, cost sharing and copay amounts are not to be entered in this field. Enter the difference between the total charge (Field #28) and the amount paid (Field #29). Not required. If services were rendered in a facility other than the home or office, enter the name and location of the facility. This field is required if other than home or office. Enter the 10-digit NPI number of the service facility location in field 32. Enter the Provider Taxonomy qualifier ZZ and the corresponding 10-digit Provider Taxonomy Code for the NPI number reported in 32a if the provider is required to report a Provider Taxonomy Code to MO HealthNet. Do not enter a space, hyphen or other separator between the qualifier and the number. A Provider Taxonomy Code must be reported if the provider has a one to many provider NPI. *33. Billing Provider Info & Phone # *33a NPI Number **33b Other ID# Enter the providers name, address, and phone number. Enter the NPI number of the Billing Provider listed in field 33. Enter the Provider Taxonomy qualifier ZZ and the corresponding 10-digit Provider Taxonomy Code for the NPI number reported in 33a if the provider is required to report a Provider Taxonomy Code to MO HealthNet. Do not enter a space, hyphen or other separator between the qualifier and the number. A provider taxonomy code must be reported if the 9 Behavioral Health Services Manual
30. Balance Due 31. Provider Signature **32. Name and Address of Service Facility
**32a NPI Number **32b Other ID Number
provider has a one to many provider NPI.
* ** (1)
These fields are mandatory on all CMS-1500 claim forms. These fields are mandatory only in specific situations, as described. NOTE: This field is for private insurance information only. If no private insurance is involved LEAVE BLANK. If Medicare, MO HealthNet, employers name or other information appears in this field, the claim will deny. See Section 5 for further TPL information.
15.8 PLACE OF SERVICE CODES AND DEFINITIONS
CODE 03 School 04 Homeless Shelter
DEFINITION A facility whose primary purpose is education (e.g., public school). A facility or location whose primary purpose is to provide temporary housing to homeless individuals (e.g., emergency shelters, individual or family shelters). A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to American Indians and Alaska Natives who do not require hospitalization. A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services rendered by, or under the supervision of, physicians to American Indians or Alaska Natives admitted as inpatients or outpatients.
05 Indian Health Service Freestanding Facility
06 Indian Health Service Provider-based Facility
07 Tribal 638 Free-standing Facility
A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to tribal members who do not require hospitalization. A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and non-surgical), and 10
08 Tribal 638 Provider-based Facility
rehabilitation services to tribal members admitted as inpatients or outpatients. 11 Office Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis. Services performed in a Head Start facility may use this place of service. Location, other than a hospital or other facility, where the patient receives care in a private residence. Congregate residential facility with self-contained living units providing assessment of each resident's needs and on-site support 24 hours a day, 7 days a week, with the capacity to deliver or arrange for services including some health care and other services. Congregate residential facility care setting for children and adolescents in state custody that provides some social, health care, and educational support services and that promotes rehabilitation and reintegration of residents into the community. A facility/unit that moves from place-to-place equipped to provide preventive, screening, diagnostic, and/or treatment services. Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention. A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions. A portion of a hospital which provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
12 Home 13 Assisted living Facility
14 Group Home
15 Mobile Unit
20 Urgent Care Facility
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room-Hospital 24 Ambulatory Surgical Center
A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided. A free-standing facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis. A facility, other than a hospital's maternity facilities or a physician's office, which provides a setting for labor, delivery, and immediate post-partum care as well as immediate care of newborn infants. A medical facility operated by one or more of the Uniformed Services. Military Treatment Facility (MTF) also refers to certain former U.S. Public Health Service (USPHS) facilities now designated as Uniformed Service Treatment Facilities (USTF). A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital. A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals. A facility which provides room, board and other personal assistance services, generally on a long-term basis, and which does not include a medical component. A facility, other than a patient's home, in which palliative and supportive care for terminally ill patients and their families are provided. A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only. A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary medical care under the general direction of a physician.
25 Birthing Center
26 Military Treatment Facility
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
46 Independent Clinic
50 Federally Qualified Health Center
51 Inpatient Psychiatric Facility
A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by and under the supervision of a physician. A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full time hospitalization, but who need broader programs than are possible from outpatient visits to a hospital0 based or hospital-affiliated facility. A facility that provides the following services: outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC's mental health services area who have been discharged from inpatient treatment at a mental health facility; 24 hour a day emergency care services; day treatment, other partial hospitalization services, or psychosocial rehabilitation services; screening for patients being considered for admission to State mental health facilities to determine the appropriateness of such admission; and consultation and education services. A facility which primarily provides health-related care and services above the level of custodial care to mentally retarded individuals but does not provide the level of care or treatment available in a hospital or SNF. A facility which provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing, and room and board. A facility or distinct part of a facility for psychiatric care which provides a total 24-hour therapeutically planned and professionally staffed group living and learning environment. A location which provides treatment for substance (alcohol and drug) abuse on an ambulatory basis. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing. A location where providers administer pneumococcal pneumonia and influenza virus vaccinations and submit these services as electronic media claims, paper claims, or using the 13
52 Psychiatric Facility Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/Mentally Retarded
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Center 57 Non-residential Substance Abuse Treatment Facility
60 Mass Immunization Center
roster billing method. This generally takes place in a mass immunization setting, such as, a public health center, pharmacy, or mall but may include a physician office setting. 61 Comprehensive Inpatient Rehabilitation Facility A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include physical therapy, occupational therapy, speech pathology, social or psychological services, and orthotics and prosthetics services. A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities. Services include physical therapy, occupational therapy, and speech pathology services. A facility other than a hospital, which provides dialysis treatment, maintenance, and/or training to patients or caregivers on an ambulatory or home-care basis. A facility maintained by either a State or local health department that provides ambulatory primary medical care under the general direction of a physician. A certified facility which is located in a rural medically underserved area that provides ambulatory primary medical care under the general direction of a physician. A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician's office. Other place of service not identified above (e.g., private school).
62 Comprehensive Outpatient Rehabilitation Facility
65 End Stage Renal Disease Treatment Facility 71 Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory 99 Other Place of Service
15.9 INSURANCE COVERAGE CODES

Type of insurance coverage codes identified on the interactive voice response (IVR) system or eligibility files accessed via the Internet are listed in Section 5, Third Party Liability. While providers are verifying the patients eligibility, they can obtain the TPL information contained on the MO HealthNet Divisions' participant file. Eligibility may be verified by calling the Interactive Voice Response (IVR) system at (573) 751-2896, which allows the provider to inquire on third party resources. The provider may also use the Internet at www.emomed.com to verify eligibility and inquire on third party resources. Reference Sections 1 and 3 for more information. 14 Behavioral Health Services Manual
Participants must always be asked if they have third party insurance regardless of the TPL information given by the IVR or Internet. IT IS THE PROVIDERS RESPONSIBILITY TO OBTAIN FROM THE PATIENT THE NAME AND ADDRESS OF THE INSURANCE COMPANY, THE POLICY NUMBER, AND THE TYPE OF COVERAGE. Reference Section 5 of this manual, Third Party Liability.
Section 16 - Medicare/Medicaid Crossover Claims
SECTION 16 - MEDICARE/MEDICAID CROSSOVER CLAIMS

16.1 GENERAL INFORMATION ........................................................................................................2 16.2 BILLING PROCEDURES FOR MEDICARE/MO HEALTHNET CLAIMS (CROSSOVERS) .............................................................................................................................2 16.3 BILLING OF SERVICES NOT COVERED BY MEDICARE .................................................4 16.4 MEDICARE PART C CROSSOVER CLAIMS FOR QMB PARTICIPANTS .......................5 16.4.A MEDICARE PART C COORDINATION OF BENEFITS FOR NON-QMB PARTICIPANTS ...................................................................................................................6 16.5 TIMELY FILING............................................................................................................................6 16.6 REIMBURSEMENT .......................................................................................................................6 16.6.A REIMBURSEMENT OF MEDICARE PART A AND MEDICARE ADVANTAGE/ PART C INPATIENT HOSPITAL CROSSOVER CLAIMS ................................................6 16.6.B REIMBURSEMENT OF OUTPATIENT HOSPITAL MEDICARE CROSSOVER CLAIMS ................................................................................................................................7
SECTION 16MEDICARE/MEDICAID CROSSOVER CLAIMS 16.1 GENERAL INFORMATION

This section includes general information about the Medicare and MO HealthNet Programs, comparisons between them, and how they relate to one another in cases in which an individual has concurrent entitlement to medical care benefits under both programs. Both Medicare and MO HealthNet are part of the Social Security Act. Medicare is an insurance program designed and administered by the federal government. Medicare is also called Title XVIII (18) of the Social Security Act. Medicare services and rules for payment are the same for all states in the United States. Applications for this program can be made at local Social Security Offices, which can also provide some details regarding services. Medicare claims are processed by federally contracted private insurance organizations called carriers and intermediaries located throughout the U.S. MO HealthNet is an assistance program that is a federal-state partnership. Some services, as established by the federal government, are required to be provided. Additional services may be provided at the option of individual states. MO HealthNet is also called Title XIX (19) of the Social Security Act. Each state designs and operates its own program within federal guidelines; therefore, programs vary among states. In Missouri, an individual may apply for Mo HealthNet benefits by completing an application form at a Family Support Division (FSD) office. In Missouri, MO HealthNet claims are processed by a state-contracted fiscal agent that operates according to the policies and guidelines of the MO HealthNet Division within the Department of Social Services, which is the single state agency for the administration of the MO HealthNet Program. For participants having both Medicare and MO HealthNet eligibility, the MO HealthNet Program pays the cost-sharing amounts indicated by Medicare due on the Medicare allowed amount. These payments are referred to as Crossovers." Cost-sharing amounts include the participants co-insurance, deductible, and any co-pays that are due for any Medicare-covered service.
16.2 BILLING PROCEDURES FOR MEDICARE/MO HEALTHNET CLAIMS (CROSSOVERS)

When a participant has both Medicare and MO HealthNet coverage, a claim must be filed with Medicare first. After making payment, the Medicare contractor forwards the claim information to MO HealthNet
2
Section 16 - Medicare/Medicaid Crossover Claims for payment of cost-sharing amounts. (Reference Section 16.3 for instructions to bill MO HealthNet when Medicare denies a service.) The MO HealthNet payment of the cost-sharing appears on the providers MO HealthNet Remittance Advice (RA). Some crossover claims cannot be processed in the usual manner for one of the following reasons: The Medicare contractor does not send crossovers to MO HealthNet The provider did not indicate on his claim to Medicare that the beneficiary was eligible for MO HealthNet. The MO HealthNet participant information on the crossover claim does not match the fiscal agents participant file. The providers National Provider Identifier (NPI) number is not on file in the MO HealthNet Divisions provider files. MO HealthNet no longer accepts paper crossover claims. Medicare/MO HealthNet (crossover) claims that do not cross automatically from Medicare to MO HealthNet must be filed through the MO HealthNet billing web portal at www.emomed.com or through the 837 electronic claims transaction. Before filing an electronic crossover claim, providers should wait 30 days from the date of Medicare payment to avoid duplication. The following tips are provided to make filing a claim at the MO HealthNet billing web portal successful: 1) Through the MO HealthNet billing web portal at www.emomed.com, choose the claim form that corresponds with the claim form used to bill Medicare. Enter all appropriate information from that form. HELP screens are accessible to provide instructions in completing the crossover claim forms, the Other Payer header and Other Payer detail screens. The HELP screens are identified by a ? and is located in the upper right-hand corner. There must be an Other Payer header form completed for every crossover claim type. This provides information that pertains to the whole claim. Part A crossover claims need only the Other Payer header form completed and not the Other Payer detail form. Part B and B of A crossover claims need the Other Payer header form completed. An Other Payer detail form is required for each claim line detail with the group code, reason code and adjustment amount information. Choose the appropriate codes that can be entered in the Group Code field on the Other Payer header and detail forms from the dropdown box. For example, the PR code
3
2)
3)
4)
5)
6)
Section 16 - Medicare/Medicaid Crossover Claims (Patient Responsibility) is understood to be the code assigned for the cost-sharing amounts shown on the Medicare EOMB. 7) The codes to enter in the Reason Code field on the Other Payer header and detail forms are also found on the Medicare EOMB. If not listed there, choose the most appropriate code from the list of Claim Adjustment Reason Codes. These HIPAA mandated codes can be found at www.wpc-edi.com/codes. For example, on the Claim Adjustment Reason Codes list the code for deductible amount is 1 and for coinsurance amount it is 2. Therefore, choose a Reason Code of 1 for deductible amounts due and a Reason Code of 2 for coinsurance amounts due. The Adjust Amount should reflect any amount not paid by Medicare including any cost-sharing amounts and any non-allowed amounts. If there is a commercial insurance payment or denial to report on the crossover claim, complete an additional Other Payer header form. Complete an additional Other Payer detail form(s) as appropriate.
8)
9)
Note: For further assistance on how to bill crossover claims, please contact Provider Education at (573) 751-6683.
16.3
BILLING OF SERVICES NOT COVERED BY MEDICARE
Not all services covered under the MO HealthNet Program are covered by Medicare. (Examples are: eyeglasses, most dental services, hearing aids, adult day health care, personal care or most eye exams performed by an optometrist.) In addition, some benefits that are provided under Medicare coverage may be subject to certain limitations. The provider will receive a Medicare Remittance Advice that indicates if a service has been denied by Medicare. The provider may submit a Medicare denied claim to MO HealthNet electronically using the proper claim form for consideration of reimbursement through the 837 electronic claims transaction or through the MO HealthNet web portal at www.emomed.com. If the 837 electronic claims transaction is used, providers should refer to the implementation guide for assistance. The following are tips to assist in successfully filing Medicare denied claims through the MO HealthNet web portal at www.emomed.com: 1) To bill through the MO HealthNet web portal, providers should select the appropriate claim type (CMS 1500, UB-04, Nursing Home, etc.) Do not select the Medicare crossover claim form. Complete all pertinent data for the MO HealthNet claim. 2) Some fields are required for Medicare and not for Third Party Liability (TPL). The code entered in the Filing Indicator field will determine if the attachment is linked to TPL or Medicare coverage.
16.4 MEDICARE PART C CROSSOVER CLAIMS FOR QMB PARTICIPANTS

Medicare Advantage/Part C plans do not forward electronic crossover claims to MHD. Therefore, providers must submit Medicare Advantage/Part C crossover claims through the MHD Web portal at www.emomed.com. The following are tips to assist in successfully filing Medicare Advantage/Part C crossover claim through the MO HealthNet web portal at www.emomed.com: 1) Access the MHD web portal at www.emomed.com. Choose the appropriate Part C crossover claim format. Enter all appropriate information from the Medicare Advantage/Part C plan claim. Do not use the Medicare Part A or Part B crossover claim format. HELP screens are accessible to provide instructions in completing the crossover claim forms, the Other Payer header and Other Payer detail screens. The HELP screens are identified by a ? and is located in the upper right-hand corner. The filing indicator for Medicare Advantage/Part C crossover claims is 16 followed by the appropriate claim type. There must be an Other Payer header detail screen completed for every crossover claim format. This provides information that pertains to the whole claim. Medicare Advantage/Part C institutional claims need only the Other Payer header detail screen completed and not the Other Payer line detail screen. Medicare Advantage/Part C outpatient and professional crossover claims need the Other Payer header detail screen completed. An Other Payer line detail screen is required to be completed for each claim detail line with group code, reason code and adjustment amount information. The appropriate code from the codes available in the Group Code drop down box on the Other Payer header and detail screens must be selected. For example, the PR code (patient responsibility) is understood to be the code assigned for the cost-sharing amounts shown on the Medicare Advantage/Part C explanation of benefits. The codes to enter in the Reason Code field on the Other Payer header and detail screens are found on the Medicare Advantage/Part C Plan explanation of benefits. If no codes are listed, choose the most appropriate code from the list of Claim Adjustment Reason Codes that can be accessed at http://www.wpc-edi.com/codes/Codes.asp. For example, enter Reason Code of 1 for deductible amounts, 2 for coinsurance amounts and 3 for co-payment amounts.
2)
3)
4)
5)
6)
7)
8)
Section 16 - Medicare/Medicaid Crossover Claims 16.4.A MEDICARE PART C COORDINATION OF BENEFITS FOR NON-QMB PARTICIPANTS
For non-QMB MO HealthNet participants enrolled with a Medicare Advantage/Part C Plan, MO HealthNet will process claims in accordance with the established MHD coordination of benefits policy. The policy can be viewed in Section 5.1.A of the MO HealthNet provider manual at http://manuals/momed.com. In accordance with this policy, the amount paid by MO HealthNet is the difference between the MO HealthNet allowable amount and the amount paid by the third party resource (TPR). Claims should be filed using the appropriate claim format (i.e., CMS1500, UB-04). Do not use a crossover claim.
16.5 TIMELY FILING

Claims that have been initially filed with Medicare within the Medicare timely filing requirements, and which are submitted as a crossover through an 837 electronic claim transaction or through the MO HealthNet Web portal at www.emomed.com meet the timely filing requirement by being submitted by the provider and received by the MO HealthNet Division within six months of the date of the allowed Medicare RA/EOMB or one (1) year from the date of service. Refer to Section 4 for further instructions on timely filing.
16.6 REIMBURSEMENT
The MO HealthNet Division reimburses the cost-sharing amount as determined by the Medicare contractor and reflected on the Medicare RA/EOMB. MHD prorates the reimbursement amount allowing a prorated amount for each date the individual was MO HealthNet eligible. Days on which the participant was not MO HealthNet eligible are not reimbursed. 16.6.A REIMBURSEMENT OF MEDICARE PART A AND MEDICARE ADVANTAGE/PART C INPATIENT HOSPITAL CROSSOVER CLAIMS
MO HealthNet is responsible for deductible and coinsurance amounts for Medicare Part A and deductible, coinsurance and copayment amounts for Medicare Advantage/Part C crossover claims only when the MO HealthNet applicable payment schedule exceeds the amount paid by Medicare plus calculated pass-through costs. In those situations where MO HealthNet has an obligation to pay a crossover claim, the amount of MO HealthNets payment is limited to the lower of the actual crossover amount or the amount the MO HealthNet fee exceeds the Medicare payment plus pass-through costs. Medicare/Advantage/Part C primary claims must have been provided to QMB or QMB Plus participant to be considered a Medicare/Medicaid crossover claim. For further information, please see 12.5.A of the Hospital Program Manual.
Section 16 - Medicare/Medicaid Crossover Claims 16.6.B REIMBURSEMENT OF OUTPATIENT HOSPITAL MEDICARE CROSSOVER CLAIMS
MO HealthNet reimbursement of Medicare/Medicaid crossover claims for Medicare Part B and Medicare Advantage/Part C outpatient hospital services is seventy-five percent (75%) of the allowable cost sharing amount. The cost sharing amount includes the coinsurance, deductible and/or copayment amounts reflected on the Medicare RA/EOMB from the Medicare carrier or fiscal intermediary. The crossover claims for Medicare Advantage/Part C outpatient hospital services must have been provided to QMB or QMB Plus participant to be reimbursed at seventyfive percent (75%) of the allowable cost sharing amount. This methodology results in payment which is comparable to the fee-for-service (FFS) amount that would be paid by MHD for those same services.
Section 17 - Claims Disposition
SECTION 17 - CLAIMS DISPOSITION

17.1 ACCESS TO REMITTANCE ADVICES .....................................................................................2 17.2 INTERNET AUTHORIZATION ..................................................................................................3 17.3 ON-LINE HELP ..............................................................................................................................3 17.4 REMITTANCE ADVICE ...............................................................................................................3 17.5 CLAIM STATUS MESSAGE CODES .........................................................................................7 17.5.A FREQUENTLY REPORTED REDUCTIONS OR CUTBACKS .........................................7
17.6 SPLIT CLAIM .................................................................................................................................8 17.7 ADJUSTED CLAIMS .....................................................................................................................8 17.8 SUSPENDED CLAIMS (CLAIMS STILL BEING PROCESSED) ...........................................9 17.9 CLAIM ATTACHMENT STATUS...............................................................................................9 17.10 PRIOR AUTHORIZATION STATUS ........................................................................................10
SECTION 17-CLAIMS DISPOSITION

This section of the manual provides information used to inform the provider of the status of each processed claim. MO HealthNet claims submitted to the fiscal agent are processed through an automated claims payment system. The automated system checks many details on each claim, and each checkpoint is called an edit. If a claim cannot pass through an edit, it is said to have failed the edit. A claim may fail a number of edits and it then drops out of the automated system; the fiscal agent tries to resolve as many edit failures as possible. During this process, the claim is said to be suspended or still in process. Once the fiscal agent has completed resolution of the exceptions, a claim is adjudicated to pay or deny. A statement of paid or denied claims, called a Remittance Advice (RA), is produced for the provider twice monthly. Providers receive the RA via the Internet. New and active providers wishing to download and receive their RAs via the Internet are required to sign up for Internet access. Providers may apply for Internet access at http://manuals.momed.com/Application.html. Providers are unable to access the web site without proper authorization. An authorization is required for each individual user.
17.1 ACCESS TO REMITTANCE ADVICES

Providers receive an electronic RA via the eMOMED Internet website at www.emomed.com or through an ASC X12N 835. Accessing the RA via the Internet gives providers the ability to: Retrieve the RA following the weekend Financial Cycle; Have access to RAs for 62 days (the equivalent of the last four cycles); View and print the RA from an office desktop; and Download the RA into the office operating system. The Internet RA is viewable and printable in a ready to use format. Just point and click to print the RA or save it to the office PC and print at any convenient time. Access to this information is restricted to users with the proper authorization. The Internet site is available 24 hours a day, 7 days a week with the exception of scheduled maintenance.
17.2 INTERNET AUTHORIZATION

If a provider uses a billing service to submit and reconcile MO HealthNet claims, proper authorization must be given to the billing service to allow access to the appropriate provider files. If a provider has several billing staff who submit and reconcile MO HealthNet claims, each Internet access user must obtain a user ID and password. Internet access user IDs and passwords cannot be shared by co-workers within an office.
17.3 ON-LINE HELP

All Internet screens at www.emomed.com offer on-line help (both field and form level) relative to the current screen being viewed. The option to contact the Wipro Infocrossing Help Desk via e-mail is offered as well. As a reminder, the help desk is only responsible for the Application for MO HealthNet Internet Access Account and technical issues. The user should contact the Provider Relations Communication Unit at (573) 751-2896 for assistance on MO HealthNet Program related issues.
17.4 REMITTANCE ADVICE

The Remittance Advice (RA) shows payment or denial of MO HealthNet claims. If the claim has been denied or some other action has been taken affecting payment, the RA lists message codes explaining the denial or other action. A new or corrected claim form must be submitted as corrections cannot be made by submitting changes on the RA pages. Claims processed for a provider are grouped by paid and denied claims and are in the following order within those groups: Crossovers Inpatient Outpatient (Includes Rural Health Clinic and Hospice) Medical Nursing Home Home Health Dental Drug Capitation Credits Claims in each category are listed alphabetically by participants last name. Each category starts on a separate RA page. If providers do not have claims in a category, they do not receive that page. General Manual Production - 04/30/2012 3
If a provider has both paid and denied claims, they are grouped separately and start on a separate page. The following lists the fields found on the RA. Not all fields may pertain to a specific provider type. FIELD NAME PAGE CLAIM TYPE RUN DATE PROVIDER IDENTIFIER RA # PROVIDER NAME PROVIDER ADDR PARTICIPANT NAME FIELD DESCRIPTION The remittance advice page number. The type of claim(s) processed. The financial cycle date. The providers NPI number. The remittance advice number. The name of the provider. The providers address. The participants last name and first name. NOTE: If the participants name and identification number are not on file, only the first two letters of the last name and the first letter of the first name appear. MO HEALTHNET ID ICN The participants current 8-digit MO HealthNet identification number. The 13-digit number assigned to the claim for identification purposes. The first two digits of an ICN indicate the type of claim: 11 Paper Drug 13 Inpatient 14 Dental 15 Paper Medical 16 Outpatient 17 Part A Crossover 18 Paper Medicare/MO HealthNet Part B Crossover Claim 21 Nursing Home 40 Magnetic Tape Billing (MTB)includes crossover claims sent by Medicare intermediaries. 41 Direct Electronic MO HealthNet Information (DEMI) 43 MTB/DEMI 44 Direct Electronic File Transfer (DEFT) 45 Accelerated Submission and Processing (ASAP) 46 Adjudicated Point of Service (POS) 47 Captured Point of Service (POS) 49 Internet 50 Individual Adjustment Request 4 Production - 04/30/2012
General Manual
55 Mass Adjustment The third and fourth digits indicate the year the claim was received. The fifth, sixth and seventh digits indicate the Julian date. In a Julian system, the days of a year are numbered consecutively from 001 (January 1) to 365 (December 31) (366 in a leap year). The last digits of an ICN are for internal processing. For a drug claim, the last digit of the ICN indicates the line number from the Pharmacy Claim form. SERVICE DATES FROM SERVICE DATES TO PAT ACCT CLAIM: ST The initial date of service in MMDDYY format for the claim. The final date of service in MMDDYY format for the claim. The providers own patient account name or number. On drug claims this field is populated with the prescription number. This field reflects the status of the claim. Valid values are: 1 Processed as Primary 3 Processed as Tertiary 4 Denied 22 Reversal of Previous Payment TOT BILLED TOT PAID TOT OTHER LN SERVICE DATES REV/PROC/NDC The total claim amount submitted. The total amount MO HealthNet paid on the claim. The combined totals for patient liability (surplus), participant copay and spenddown total withheld. The line number of the billed service. The date of service(s) for the specific detail line in MMDDYY. The submitted procedure code, NDC, or revenue code for the specific detail line. NOTE: The revenue code only appears in this field if a procedure code is not present. MOD REV CODE The submitted modifier(s) for the specific detail line. The submitted revenue code for the specific detail line. NOTE: The revenue code only appears in this field if a procedure code has also been submitted. QTY General Manual Production - 04/30/2012 The units of service submitted. 5
BILLED AMOUNT ALLOWED AMOUNT PAID AMOUNT PERF PROV SUBMITTER LN ITM CNTL GROUP CODE
The submitted billed amount for the specific detail line. The MO HealthNet maximum allowed amount for the procedure/service. The amount MO HealthNet paid on the claim. The NPI number for the performing provider submitted at the detail. The submitted line item control number. The Claim Adjustment Group Code, which is a code identifying the general category of payment adjustment. Valid values are: COContractual Obligation CRCorrection and Reversals OAOther Adjustment PIPayer Initiated Reductions PRPatient Responsibility
RSN
The Claim Adjustment Reason Code, which is the code identifying the detailed reason the adjustment was made. Valid values can be found at http://www.wpcedi.com/codes/claimadjustment. The dollar amount adjusted for the corresponding reason code. The adjustment to the submitted units of service. This field is not printed if the value is zero. The Code List Qualifier Code and the Health Care Remark Code (Remittance Advice Remark Codes). The Code List Qualifier Code is a code identifying a specific industry code list. Valid values are: HEClaim Payment Remark Codes RXNational Council for Prescription Drug Programs Reject/Payment Codes The Health Care Remark Codes (Remittance Advice Remark Codes) are codes used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Valid values can be found at http://www.wpcedi.com/codes/remittanceadvice.
AMT QTY REMARK CODES
CATEGORY TOTALS
Each category (i.e., paid crossover, paid medical, denied crossover, denied medical, drug, etc.) has separate totals for number of claims, billed amount, allowed amount, and paid amount. The total check amount for the provider. 6 Production - 04/30/2012
CHECK AMOUNT General Manual
EARNINGS REPORT PROVIDER IDENTIFIER RA # EARNINGS DATA NO. OF CLAIMS PROCESSED DOLLAR AMOUNT PROCESSED CHECK AMOUNT The total number of claims processed for the provider. The total dollar amount processed for the provider. The total check amount for the provider. The providers NPI number. The remittance advice number.
17.5 CLAIM STATUS MESSAGE CODES

Missouri no longer reports MO HealthNet-specific Explanation of Benefits (EOB) and Exception message codes on any type of remittance advice. As required by the Health Insurance Portability & Accountability Act of 1996 (HIPAA) national standards, administrative code sets Claim Adjustment Reason Codes, Remittance Advice Remark Codes and NCPDP Reject Codes for Telecommunication Standard are used. Listings of the Claim Adjustment Reason Codes and Remittance Advice Remark Codes can be found at http://www.wpc-edi.com/content/view/180/223/. A listing of the NCPDP Reject Codes for Telecommunication Standard can be found in the NCPDP Reject Codes For Telecommunication Standard appendix. 17.5.A FREQUENTLY REPORTED REDUCTIONS OR CUTBACKS
To aid providers in identifying the most common payment reductions or cutbacks by MO HealthNet, distinctive Claim Group Codes and Claim Adjustment Reason Codes were selected and are being reported to providers on all RA formats when the following claim payment reduction or cutback occurs: Claim Claim Claim Payment Group Adjustment Reduction/Cutback Code Description Reason Description Code Payment reimbursed at CO the maximum allowed Contractual Obligation 45 Charges exceed our fee schedule, maximum allowable or contracted or legislated fee arrangement. Payment adjusted because charges have been paid by another payer 7
Payment reduced by other insurance amount General Manual
OA
Other Adjustment
23
Medicare Part A Repricing
OA
Other Adjustment
45
Payment cut back to federal percentage (IEP therapy services) Payment reduced by co-payment amount Payment reduced by patient spenddown amount Payment reduced by patient liability amount
OA
Other Adjustment Patient Responsibility Patient Responsibility Patient Responsibility
A2
Charges exceed our fee schedule, maximum allowable or contracted or legislated fee arrangement. Contractual adjustment
PR PR
3 178
Co-Payment amount Payment adjusted because patient has not met the required spenddown Claim adjusted by monthly MO HealthNet patient liability amount
PR
142
17.6 SPLIT CLAIM

An ASC X12N 837 electronic claim submitted to MO HealthNet may, due to the adjudication system requirements, have service lines separated from the original claim. This is commonly referred to as a split claim. Each portion of a claim that has been split is assigned a separate claim internal control number and the sum of the service line(s) charge submitted on each split claim becomes the split claim total charge. Currently, within MO HealthNet's MMIS, a maximum of 28 service lines per claim are processed. The 837 Implementation Guides allow providers to bill a greater number of service detail lines per claim. All detail lines that exceed the size allowed in the internal MMIS detail record are split into subsequent detail lines. Any claim that then exceeds the number of detail lines allowed on the internal MMIS claim record is used to create an additional claim.
17.7 ADJUSTED CLAIMS

Adjustments are processed when the original claim was paid incorrectly and an adjustment request is submitted. The RA will show a credit (negative payment) ICN for the incorrect amount and a payment ICN for the correct amount. If a payment should not have been made at all, there will not be a corrected payment ICN.
17.8 SUSPENDED CLAIMS (CLAIMS STILL BEING PROCESSED)

Suspended claims are not listed on the Remittance Advice (RA). To inquire on the status of a submitted claim not appearing on the RA, providers may either submit a 276 Health Care Claim Status Request or may submit a View Claim Status query using the Real Time Queries function online at www.emomed.com. The suspended claims are shown as either paid or denied on future RAs without any further action by the provider.
17.9 CLAIM ATTACHMENT STATUS

Claim attachment status is not listed on the Remittance Advice (RA). Providers may check the status of six different claim attachments using the Real Time Queries function on-line at www.emomed.com. Claim attachment status queries are restricted to the provider who submitted the attachment. Providers may view the status for the following claim attachments on-line: Acknowledgement of Receipt of Hysterectomy Information Certificate of Medical Necessity (for Durable Medical Equipment only) Medical Referral Form of Restricted Participant (PI-118) Oxygen and Respiratory Equipment Medical Justification Form (OREMJ) Second Surgical Opinion Form (Sterilization) Consent Form Providers may use one or more of the following selection criteria to search for the status of a claim attachment on-line: Attachment Type Participant ID Date of Service/Certification Date Procedure Code/Modifiers Attachment Status Detailed Help Screens have been developed to assist providers searching for claim attachment status on-line. If technical assistance is required, providers are instructed to call the Wipro Infocrossing Help Desk at (573) 635-3559.
17.10 PRIOR AUTHORIZATION STATUS

Providers may check the status of Prior Authorization (PA) Requests using the Real Time Queries function on-line at www.emomed.com. PA status queries are restricted to the provider who submitted the Prior Authorization Request.
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Section 18 Diagnosis Codes
SECTION 18 - DIAGNOSIS CODES

18.1 GENERAL INFORMATION .............................................................................................. 2 18.2 EPSDT/HCY SCREENING SERVICES ............................................................................ 3 18.3 BEHAVIORAL HEALTH SERVICES CODES ............................................................... 3

SECTION 18 - DIAGNOSIS CODES 18.1 GENERAL INFORMATION

The diagnosis code(s) is a required field, and the accuracy of the code that describes the recipients condition is important. NOTE: The MO HealthNet claims processing system uses ICD, current edition, codes only. DSM codes must not be used and are not recognized by the claims processing system. The diagnosis code must be entered on the claim form exactly as it appears in the ICD, current edition. Note that the appropriate code(s) may be three, four or five digits, depending upon the patients diagnosis. The fourth and fifth digits give greater detail or specificity and must be used as applicable to the patients diagnosis(es) when available. For more information on ordering the ICD, current edition, call or write: St. Anthonys Publishing, Inc. P.O. Box 96561 Washington, DC 20090 (800) 632-0123 or Medicode Publications P.O. Box 27116 Salt Lake City, UT 84127-0116 (800) 999-4600
18.2 EPSDT/HCY SCREENING SERVICES

When billing for EPSDT/HCY Screening services, reference Sections 9 and 13. The diagnosis code of V202 must appear as the primary diagnosis code on the CMS-1500 claim form or the UB-04 claim form for RHCs.
18.3 BEHAVIORAL HEALTH SERVICES CODES

The diagnosis code must be a valid ICD, current edition, diagnosis code and must be mental health related. This does not include developmental disabilities. The only valid code ranges for the Behavioral Health Services Program are 295-316, V11-V118, V154-V1542, V17-V170, V40-V401, V61-V619, V624, V628-V6289, V673, V710-V7102 and V79-V791. An appropriate 4th or 5th digit may be required for the diagnosis code to be valid.
Section 19 Procedure Codes
SECTION 19 -PROCEDURE CODES

19.1 CPT CODES .......................................................................................................................... 2 19.2 BEHAVIORAL HEALTH SERVICES FOR CHILDREN AND YOUTH ..................... 2 19.3 BEHAVIORAL HEALTH SERVICES FOR ADULTS ................................................... 2 19.4 PATIENTS WHO ARE REQUIRED TO PAY A COPAY (text del. 5/07)...................... 2 19.5 SERVICES REQUIRING COPAY (text del. 5/07) ............................................................ 2

Section 19 Procedure Codes
SECTION 19PROCEDURE CODES

Procedure codes used by MO HealthNet are identified as HCPCS codes (Health Care Financing Administrations [HCFA] Common Procedure Coding System). HCPCS codes consist of Level I codes (those found in the Physicians Current Procedural TerminologyCPT), and Level II and Level III codes not found in CPT, but assigned by HCFA according to need.
19.1 CPT CODES

A copy of the Physicians Current Procedural Terminology (CPT) may be purchased by writing to the following address: Order Department American Medical Association P.O. Box 7046 Dover, DE 19903-7046 Telephone Number: (800) 621-8335 Fax Orders: (312) 464-5600 Refer to Section 13.13 for a listing of valid procedure codes for the Behavioral Health Services Program. Section 13.10 and Section 13.11 contain age specific procedure codes and identifies special limitations.
19.2 BEHAVIORAL HEALTH SERVICES FOR CHILDREN AND YOUTH

Refer to Section 13.11 for listings of valid procedure codes for Children and Youth in the Behavioral Health Services Program. The listings identify special limitations.
19.3 BEHAVIORAL HEALTH SERVICES FOR ADULTS

Refer to Section 13.10 for listings of valid procedure codes for Adults in the Behavioral Health Services Program. The listings identify special limitations.
19.4 PATIENTS WHO ARE REQUIRED TO PAY A COPAY (text del. 5/07) 19.5 SERVICES REQUIRING COPAY (text del. 5/07)
END OF SECTION
TOP OF PAGE
Section 20 - Exception Process
SECTION 20 - EXCEPTION PROCESS

The Exception Process is a formal process under which the MO HealthNet Division may grant an exception and authorize an essential medical service or item of equipment that otherwise exceeds the benefits and limitations set in policy. Section 20, Exception Process, is not applicable to the following manuals, because services cannot be approved in accordance with the exception process regulation. Adult Day Health Care Aged and Disabled Waiver AIDS Waiver Ambulance Community Psychiatric Rehabilitation Comprehensive Day Rehabilitation CSTAR Environmental Lead Assessment Hearing Aid Hospice MRDD Waiver Nurse Midwife Optical Personal Care Private Duty Nursing Psychology/Counseling Therapy
Section 21 - Advance Health Care Directives
SECTION 21- ADVANCE HEALTH CARE DIRECTIVES

This section describes the responsibility of certain providers to inform adult participants of their rights under state law to make medical care decisions and the right to make an advanced health care directive. Section 21, Advance Health Care Directives, is not applicable to the following manuals: Adult Day Health Care Aged and Disabled Waiver Ambulance Ambulatory Surgical Centers Community Psychiatric Rehabilitation Comprehensive Day Rehabilitation CSTAR Dental Durable Medical Equipment Environmental Lead Assessment Hearing Aid MRDD Waiver Nurse Midwife Optical Pharmacy Private Duty Nursing Psychology/Counseling Rehabilitation Centers Therapy
Section 22 - Non-Emergency Medical Transportation (NEMT)
SECTION 22 - NON-EMERGENCY MEDICAL TRANSPORTATION (NEMT)

22.1 INTRODUCTION...........................................................................................................................3 22.2 DEFINITIONS ................................................................................................................................3 22.3 COVERED SERVICES..................................................................................................................7 22.4 PARTICIPANT ELIGIBILITY ....................................................................................................8 22.5 NON-COVERED PARTICIPANTS .............................................................................................8 22.6 TRAVEL STANDARDS ................................................................................................................9 22.7 COPAYMENTS ............................................................................................................................12 22.8 MODES OF TRANSPORTATION.............................................................................................13 22.9 ARRANGING TRANSPORTATION.........................................................................................14 22.10 22.11 22.12 22.13 22.14 22.15 22.16 22.17 NON-COVERED SERVICES ..................................................................................................14 PUBLIC ENTITY REQUIREMENTS....................................................................................15 PROVIDER REQUIREMENTS ..............................................................................................16 PROVIDER INQUIRY, COMPLAINT, GRIEVANCE AND APPEAL PROCESS .........17 PARTICIPANT RIGHTS ........................................................................................................17 DENIALS ...................................................................................................................................18 PARTICIPANT GRIEVANCE PROCESS ............................................................................18 MTM SERVICES AVAILABLE FOR FACILITY SUPPORT ...........................................18
22.17.A. CARE MANAGEMENT (CM) ............................................................................................19 22.17.B. QUALITY MANAGEMENT DEPARTMENT (QM) .........................................................19 22.17.C. CUSTOMER SERVICE CENTER (CSC) ............................................................................20 22.17.D. WHAT IS CARE MANAGEMENT (CM)?..........................................................................20 22.17.E. CARE MANAGEMENT OUTREACH................................................................................21 22.17.F. WHAT IS QUALITY MANAGEMENT (QM)? ..................................................................22 22.17.G. WHAT IS THE CUSTOMER SERVICE CENTER (CSC)? ................................................22 22.17.H. ARRANGING TRANSPORTATION FOR FACILITIES ...................................................23 22.17.I. HOW DOES A FACILITY REQUEST TRANSPORTATION? ..........................................24 22.17.J. FORMS COMPLETED BY FACILITIES ............................................................................24 22.17.K. SCHEDULING URGENT TRIPS ........................................................................................25 General Manual Production - 04/30/2012
22.17.L. SCHEDULING A HOSPITAL DISCHARGE .....................................................................25 22.17.M. TRANSPORTATION RESTRICTIONS ..............................................................................25 22.17.N. AMERICAN WITH DISABILITIES ACT (ADA) CERTIFICATION ................................26 22.17.O. PARTICIPANT ASSISTANCE DURING TRANSPORT ...................................................26 22.17.P. WHAT MTM WILL DO IF A CAREGIVER IS NOT AVAILABLE ..................................26 22.17.Q. FILING A GRIEVANCE ......................................................................................................27
SECTION 22-NON-EMERGENCY MEDICAL TRANSPORTATION (NEMT)
22.1 INTRODUCTION
This section contains information pertaining to the Non-Emergency Medical Transportations (NEMT) direct service program. The NEMT Program provides for the arrangement of transportation and ancillary services by a transportation broker. The broker may provide NEMT services either through direct service by the broker and/or through subcontracts between the broker and subcontractor(s). The purpose of the NEMT Program is to assure transportation to MO HealthNet participants who do not have access to free appropriate transportation to and from scheduled MO HealthNet covered services. The Missouri NEMT Program is structured to utilize and build on the existing transportation network in the state. The federally-approved method used by Missouri to structure the NEMT Program allows the state to have one statewide transportation broker to coordinate the transportation providers. The broker determines which transportation provider will be assigned to provide each transport. Effective October 1, 2010, the NEMT broker for Missouri is: Medical Transportation Management, Inc. 16 Hawk Ridge Drive Lake St. Louis, MO 63367 (866) 269-5927
22.2 DEFINITIONS
The following definitions apply for this program: Action Ancillary Services The denial, termination, suspension, or reduction of an NEMT service. Meals and lodging are part of the transportation package for participants, when the participant requires a particular medical service which is only available in another city, county, or state and the distance and travel time warrants staying in that place overnight. For children under the age of 21, ancillary services may include an attendant and/or one parent/guardian to accompany the child.
Appeal
The mechanism which allows the right to appeal actions of the broker to a transportation provider who as (1) has a claim for reimbursement or request for authorization of service delivery denied or not acted upon with reasonable promptness; or (2) is aggrieved by an rule or policy or procedure or decision by the broker. An individual who goes with a participant under the age of 21 to the MO HealthNet covered service to assist the participant because the participant cannot travel alone or cannot travel a long distance without assistance. An attendant is an employee of, or hired by, the broker or an NEMT transportation provider. Contracted entity responsible for enrolling and paying transportation providers, determining the least expensive and most appropriate type of transportation, authorizing transportation and ancillary services, and arranging and scheduling transportation for eligible participants to MO HealthNet covered services. A claim that can be processed without obtaining additional information from the transportation provider of the NEMT service or from a third party. A verbal or written expression by a transportation provider which indicates dissatisfaction or dispute with a participant, broker policies and procedures, claims, or any aspect of broker functions. Departmental Client Number. A unique eight-digit number assigned to each individual who applies for MO HealthNet benefits. The DCN is also known as the MO HealthNet Identification Number. A medical or mental health condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention could reasonably be expected to result in placing the participants physical or mental health (or, with respect to a pregnant woman, the health of the woman or
Attendant
Broker
Clean Claim
Complaint
DCN
Emergency
her unborn child) in serious jeopardy, serious impairment to bodily functions, serious dysfunction of any bodily organ or part, serious harm to self or others due to an alcohol or drug abuse emergency, injury to self or bodily harm to others, or with respect to a pregnant woman having contractions: (1) that there is inadequate time to effect a safe transfer to another hospital before delivery, or (2) that transfer may pose a threat to the health or safety of the woman or the unborn child. Fraud Any type of intentional deception or misrepresentation made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the entity, himself/herself, or some other person. Any appropriate mode of transportation that can be secured by the participant without cost or charge, either through volunteers, organizations/associations, relatives, friends, or neighbors. A verbal or written expression of dissatisfaction from the participant about any matter, other than an action. Possible subjects for grievances include, but are not limited to, the quality of care or services received, condition of mode of transportation, aspects of interpersonal relationships such as rudeness of a transportation provider or brokers personnel, or failure to respect the participants rights. A written request for further review of a transportation providers complaint that remains unresolved after completion of the complaint process. A request from a transportation provider regarding information that would clarify brokers policies and procedures, or any aspect of broker function that may be in question. The mode of transportation that accommodates the participants physical, mental, or medical condition. Covered services under the MO HealthNet program. Service(s) furnished or proposed to be furnished that is (are) reasonable and medically necessary for the prevention, diagnosis, or treatment of a physical or mental illness or injury;
Free Transportation
Grievance (Participant)
Grievance (Transportation Provider) Inquiry
Most Appropriate MO HealthNet Covered Services Medically Necessary
to achieve age appropriate growth and development; to minimize the progression of a disability; or to attain, maintain, or regain functional capacity; in accordance with accepted standards of practice in the medical community of the area in which the physical or mental health services are rendered; and service(s) could not have been omitted without adversely affecting the participants condition or the quality of medical care rendered; and service(s) is (are) furnished in the most appropriate setting. Services must be sufficient in amount, duration, and scope to reasonably achieve their purpose and may only be limited by medical necessity. Medical Service Provider An individual firm, corporation, hospital, nursing facility, or association that is enrolled in MO HealthNet as a participating provider of service, or MO HealthNet services provided free of charge by the Veterans Administration or Shriners Hospital. Non-Emergency Medical Transportation (NEMT) services are a ride, or reimbursement for a ride, and ancillary services provided so that a MO HealthNet participant with no other transportation resources can receive MO HealthNet covered services from a medical service provider. By definition, NEMT does not include transportation provided on an emergency basis, such as trips to the emergency room in life-threatening situations, unloaded miles, or transportation provider wait times. State, county, city, regional, non-profit agencies, and any other entity, who receive state general revenue or other local monies for transportation and enter into an interagency agreement with the MO HealthNet Division to provide transportation to a specific group of eligibles. A person determined by the Department of Social Services, Family Support Division (FSD) to be eligible for a MO HealthNet category of assistance. From pick up point to destination. Any individual, including volunteer drivers, or entity who, through arrangement or subcontract with the broker, provides non-emergency medical transportation services. Transportation
NEMT Services
Public Entity
Participant
Transportation Leg Transportation Provider
providers are not enrolled as MO HealthNet providers. Urgent A serious, but not life threatening illness/injury. Examples include, but are not limited to, high temperature, persistent vomiting or diarrhea, symptoms which are of sudden or severe onset but which do not require emergency room services, and persistent rash. Urgent care is determined by the participants medical care provider. An appointment shall be considered urgent if the medical service provider grants an appointment within five (5) days of the participants request.
22.3 COVERED SERVICES

The broker shall ensure the provision of Non-Emergency Medical Transportation (NEMT) services for participants to MO HealthNet covered services for the Department of Social Services, MO HealthNet Division. The broker must ensure that NEMT services are available 24 hours per day, 7 days per week, when medically necessary. To provide adequate time for NEMT services to be arranged, a participant should call at least five (5) calendar days in advance. NEMT services may be scheduled with less than five (5) calendar days notice if they are of an urgent nature. Urgent calls are defined as a serious, but not life threatening illness/injury. Urgent care is determined by the participant's medical care provider. An appointment shall be considered urgent if the medical service provider grants an appointment within five (5) calendar days of the participant's request. The number for scheduling transportation is (866) 269-5927. This number is accessible 24 hours a day, 7 days a week. The broker shall provide NEMT services to MO HealthNet covered services that do not include transportation. In addition, the broker must arrange NEMT services for one parent/guardian to accompany children under the age of 21, if requested. The broker must also arrange NEMT services for an attendant, if appropriate, to accompany children under the age of 21. In addition to authorizing the transportation services, the broker shall authorize and arrange the least expensive and most appropriate ancillary services. Ancillary services shall only be authorized if: 1. 2. The medical appointment requires an overnight stay, AND Volunteer, community, or other ancillary services are not available at no charge to the participant.
The broker shall also authorize and arrange ancillary services for one parent/guardian when a MO HealthNet eligible child is inpatient in a hospital setting and meets the following criteria: 1. Hospital does not provide ancillary services without cost to the participants General Manual Production - 04/30/2012
parent/guardian, AND 2. Hospital is more than 120 miles from the participants residence, OR 3. Hospitalization is related to a MO HealthNet covered transplant service. The broker shall obtain prior authorization from the state agency for out-of-state transportation to non-bordering states. If the participant meets the criteria specified above, the broker shall also authorize and arrange ancillary services to eligible participants who have access to transportation at no charge to the participant or receive transportation from a Public Entity and such ancillary services were not included as part of the transportation service. The broker shall direct or transfer participants with requests that are of an emergent nature to 911 or an appropriate emergency (ambulance) service.
22.4 PARTICIPANT ELIGIBILITY

The participant must be eligible for MO HealthNet to receive transportation services. The broker shall verify whether the individual seeking NEMT services is eligible for NEMT services on the date of transport by accessing eligibility information. Information regarding participant eligibility may be found in Section 1.
22.5 NON-COVERED PARTICIPANTS

The following participants are not eligible for NEMT services provided by the broker: 1. 2. 3. 4. 5. Participants with the following MO HealthNet Eligibility (ME) codes: 02, 08, 52, 55, 57, 59, 64, 65, 73, 74, 75, 80, 82 and 89. Participants who have access to transportation at no cost to the participant. However, such participants may be eligible for ancillary services. Participants who have access to transportation through a Public Entity. However, such participants may be eligible for ancillary services. Participants who have access to NEMT through the Medicare program. Participants enrolled in the Hospice Program. However, the broker shall arrange NEMT services for such participants accessing MO HealthNet covered services that are not related to the participant's terminal illness. Participants in a MO HealthNet managed care health plan.
6.
a. NEMT services for participants enrolled in MO HealthNet Managed Care and PACE programs are arranged by those programs for services included in the benefit package. The broker shall not be responsible for arranging NEMT services for those programs.
22.6 TRAVEL STANDARDS

The participant must request NEMT services to a MO HealthNet qualified, enrolled medical service provider located within the travel standards, willing to accept the participant. The travel standards are based on the participants county of residence. Counties are classified as urban, basic, and rural. The counties are categorized as follows: 1. 2. 3. Urban- Clay, Greene, Jackson, Jefferson, St. Charles, St. Louis, and St. Louis City; Basic- Boone, Buchanan, Cape Girardeau, Cass, Christian, Cole, Franklin, Jasper, Johnson, Lincoln, Newton, Platte, St. Francois; Rural-all other counties.
The mileage that a participant can travel is based on the county classification and the type of provider being seen. The following table contains the mileage allowed under the travel standards. TRAVEL STANDARDS: MAXIMUM MILEAGE Provider/Service Type Urban Access County Physicians PCPs Obstetrics/Gynecology Neurology Dermatology Physical Medicine/Rehab Podiatry Vision Care/Primary Eye Care Allergy General Manual Production 04/30/2012 10 15 25 25 25 25 15 25 20 30 50 50 50 50 30 50 30 60 100 100 100 100 60 100 Basic Access County Rural Access County
Cardiology Endocrinology Gastroenterology Hematology/Oncology Infectious Disease Nephrology Ophthalmology Orthopedics Otolaryngology Pediatric Pulmonary Disease Rheumatology Urology General surgery Psychiatrist-Adult/General Psychiatrist-Child/Adolescent Psychologists/Other Therapists Chiropractor Hospitals Basic Hospital Secondary Hospital
25 25 25 25 25 25 25 25 25 25 25 25 25 15 15 22 10 15
50 50 50 50 50 50 50 50 50 50 50 50 50 30 40 45 20 30
100 100 100 100 100 100 100 100 100 100 100 100 100 60 80 90 40 60
30 50
30 50
30 50
Level I or Level II trauma unit Neonatal intensive care unit
Tertiary Services 100 100
100 100
100 100
Perinatology services Comprehensive cancer services Comprehensive cardiac services Pediatric subspecialty care
100 100 100 100 Mental Health Facilities
100 100 100 100
100 100 100 100
Inpatient mental health treatment facility Ambulatory mental health treatment providers Residential mental health treatment providers
25 15 20
40 25 30
75 45 50
Physical Therapy Occupational Therapy Speech Therapy Audiology
Ancillary Services 30 30 50 50
30 30 50 50
30 30 50 50
The broker must transport the participant when the participant has chosen a qualified, enrolled medical service provider who is not within the travel standards if the participant is eligible for one of the exceptions listed below and can provide proof of the exception: 1. 2. 3. The participant has a previous history of other than routine medical care with the qualified, enrolled medical service provider for a special condition or illness. The participant has been referred by a Primary Care Provider (PCP) to a qualified, enrolled medical service provider for a special condition or illness. There is not a routine or specialty care appointment available within thirty (30) calendar days to a qualified, enrolled medical service provider within the travel standards.
The broker shall transport the participant to the following MO HealthNet services without regard to the travel standards. 1. The participant is scheduled for an appointment arranged by the family Support Division (FSD) eligibility specialist for a Medical Review Determination (MRD) to determine continued MO HealthNet eligibility.
2. The participant has been locked into a medical service provider by the state agency. The broker shall receive prior authorization from the state agency for lock-in trips that exceed the travel standards. 3. The broker must transport the participant when the participant has chosen to receive MO HealthNet covered services free of charge from the Veterans Administration or Shriners Hospitals. Transportation to the Veterans Administration or Shriners Hospital must be to the closest, most appropriate Veterans Administration or Shriners Hospital. The broker must document and maintain verification of service for each transport provided to free care. The broker must verify each request of such transport meets all NEMT criteria including, but not limited to: Participant eligibility; and MO HealthNet covered service.
22.7 COPAYMENTS
The participant is required to pay a $2.00 copayment for transportation services. The $2.00 is charged regardless if the trip is a single destination trip, a round trip, or a multiple destination trip. The broker cannot deny transportation services because a participant is unable to pay the copay. The copay does not apply for public transportation or bus tokens, or for participants receiving gas reimbursement. The following individuals are exempt from the copayment requirements: 1. 2. Children under the age of 19; Persons receiving MO HealthNet under a category of assistance for pregnant women or the blind;
03, Aid to the blind; 12, MO HealthNet-Aid to the blind; and 15, Supplemental Nursing Care-Aid to the blind; 18, MO HealthNet for pregnant women; 43, Pregnant women-60 day assistance; 44, Pregnant women-60 day assistance-poverty; 45, Pregnant women-poverty; and 61, MO HealthNet for pregnant women-Health Initiative Fund.
3. 4. Residents of a skilled nursing facility, intermediate care nursing home, residential care home, adult boarding home, or psychiatric hospital; and Foster Care participants.
A participant's inability to pay a required copayment amount, as due and charged when a service is delivered, in no way shall extinguish the participants liability to pay the due amount or prevent a provider from attempting to collect a copayment. If it is the routine business practice of a transportation provider to discontinue future services to an individual with uncollected debt, the transportation provider may include uncollected co-payments under this practice. However, a transportation provider shall give a MO HealthNet participant a reasonable opportunity to pay an uncollected co-payment. If a transportation provider is not willing to provide services to a MO HealthNet participant with uncollected co-payment, the transportation provider must give the participant advance notice and a reasonable opportunity to arrange care with a different transportation provider before services can be discontinued.
22.8 MODES OF TRANSPORTATION

The broker must arrange the least expensive and most appropriate mode of transportation based on the participants medical needs. The modes of transportation that may be utilized by the broker include, but are not limited to: 1. 2. 3. 4. 5. 6. 7. 8. Public transit/bus tokens; Gas reimbursement Para-lift van; Taxi; Ambulance (for non-emergent transportation only); Stretcher van; Multi-passenger van; and Volunteer driver program if approved by the State agency.
The broker must not utilize public transit/bus token/pass for the following situations: 1. 2. 3. 4. 5. 6. High-risk pregnancy, Pregnancy after the eighth month, High risk cardiac conditions, Severe breathing problems, More than three block walk to the bus stop, Any other circumstance in which utilization of public transit/bus token/pass may not be medically appropriate.
Prior to reimbursing a participant for gas, the broker shall verify that the participant actually saw a medical service provider on the date of request for gas reimbursement and verify the mileage from the participants trip origin street address to the trip destination street address. If the street address is not available, the broker shall use the zip code for mileage verification. Gas reimbursement shall be made at the IRS standard mileage rate for medical reason in effect on the date of service. The broker shall limit the participant to no more than three (3) transportation legs (2 stops) per day unless the broker received prior authorization from the state agency. The broker shall ensure that the transportation provided to the participant is comparable to transportation resources available to the general public (e.g. buses, taxis, etc.).
22.9 ARRANGING TRANSPORTATION

When calling to arrange for transport, the caller must provide the following information:
The
patient/participants name, date of birth, address, phone number, and the MO HealthNet ID number;
The name, address, and phone number of the medical provider that will be seen by the
participant;
y The date and time of the medical appointment; y Any special transportation needs of the patient/participant, such as the patient/participant
uses a wheelchair;
y Whether the patient/participant is under 21 years of age and needs someone to go along to
the appointment.
y For facilities arranging transportation for your dialysis participants, please refer to the
Section 22.17.
22.10 NON-COVERED SERVICES

The following services are not eligible for NEMT: 1. 2. The broker shall not provide NEMT services to a pharmacy. Transportation to services included in the Mentally Retarded Developmental Disabilities (MRDD) Waiver Program, Comprehensive Substance Treatment Abuse and Rehabilitation (CSTAR) Program, Community Psychiatric Rehabilitation Program, and Adult Day Health Care Program are arranged by those programs. Community psychiatric rehabilitation services only provide transportation to attend the psychosocial rehabilitation program and to receive medication services. The broker shall not be responsible for arranging NEMT
services for these programs. However, the broker shall arrange NEMT services for the participants to other qualified, enrolled medical service providers such as physician, outpatient hospital, lab, etc. 3. 4. School districts must supply a ride to services covered in a childs Individual Education Plan (IEP). The broker shall not arrange NEMT services to a Durable Medical Equipment (DME) provider that provides free delivery or mail order services. The broker shall not provide delivery of DME products in lieu of transporting the participant. The broker shall not provide NEMT services for MO HealthNet covered services provided in the home such as personal care, home health, etc. The broker shall not provide NEMT services for discharges from a nursing home.
5. 6.
22.11 PUBLIC ENTITY REQUIREMENTS

The state agency has existing interagency agreements with public entities to provide access (subject to availability) to transportation services for a specific group(s) of participants. The broker shall refer participants to public entities when the participant qualifies for transportation services under such agreements. The following is a list of the public entities and the specific individuals for which transportation is covered: 1. Childrens Division (CD) CD provides reimbursement for transportation services to MO HealthNet covered services for some children. Eligible individuals are identified by the CD. School-based NEMT Services Some school districts provide transportation for children to obtain medically necessary services provided as a result of a childs Individual Education Plan (IEP). Eligible children are identified by the school district. Kansas City Area Transit Authority/Share-A-Fare Program (KCATA) Share-A-Fare provides door-to-door accessible transportation to persons with disabilities and the elderly. Services are available to residents of Kansas City, Missouri. Individuals must complete an application and be approved to participate in the program. Missouri Kidney Program (MOKP) MOKP provides reimbursement for transportation expenses for dialysis patients who do not have access to transportation for dialysis treatment. Dialysis patients who need assistance with transportation to dialysis services should contact the dialysis center. Bi-State Development Call-A-Ride Call-A-Ride provides curb-to-curb accessible transportation to persons with disabilities and the elderly who reside in St. Louis City and County.
2.
3.
4.
5.
6.
City Utilities of Springfield City Utilities operates a para-transit service to serve disabled who are unable to ride a fixed route bus. This service is operated on a demand-responsive curb to curb basis. A one-day notice is required for reservations. Jefferson City Transit System, Handi-Wheels Handi-Wheels is a curb-to-curb, origin to destination transportation service with wheelchair, lift-equipped buses. Handi-Wheels is provided to all eligible individuals with disability without priority given for trip purpose. Handi-Wheels is intended to be used by individuals who, because of disability, cannot travel to or from a regular fixed route bus stop or cannot get on, ride, or get off a regular fixed route bus not wheelchair lift-equipped. This service operates to and from any location within Jefferson City. Nevada Regional Medical Center (NRMC) NRMC transports individuals who live within a 20 mile radius of Nevada. City of Columbia, Columbia Transit Columbia Transit transports individuals with disabilities within the Columbia City Limits. This service provides buses on peak hours including para-transit curb to curb services.
7.
8. 9.
22.12 PROVIDER REQUIREMENTS

The broker shall maintain a network of appropriate transportation providers that is sufficient to provide adequate access to all MO HealthNet covered services. In establishing and maintaining the network, the broker must consider the following: 1. 2. 3. 4. 5. The anticipated MO HealthNet enrollment; The expected utilization of services taking into consideration the characteristics and health care needs of MO HealthNet populations; The numbers and types (in terms of training, experience, and specialization) of transportation providers required to furnish services; The capacity of transportation providers to provide services; and If the broker is unable to provide necessary NEMT services to a particular participant utilizing the services of an in-network transportation provider, the broker must adequately and timely provide the NEMT services for the participant utilizing the services of a transportation provider outside the brokers network, for as long as the broker is unable to provide such NEMT services utilizing an in-network transportation provider. Out-ofnetwork transportation providers must coordinate with the broker with respect to payment. The broker must ensure that cost to the participant is no greater than it would be if the NEMT services were furnished utilizing the services of an in-network transportation provider.
The broker and all transportation providers shall comply with applicable city, county, state, and federal requirements regarding licensing and certification of all personnel and vehicles. The broker shall ensure the safety of the participants while being transported. The broker shall ensure that the vehicles operated by the transportation providers are in compliance with federal motor vehicle safety standards (49 Code of Federal Regulations Part 571). This provision does not apply when the broker provides direct reimbursement for gas. The broker shall maintain evidence of providers non-compliance or deficiencies, as identified either through individual reports or as a result of monitoring activities, the corrective action taken, and improvements made by the provider. The broker shall not utilize any person as a driver or attendant whose name, when checked against the Family Care Safety Registry, registers a hit on any list maintained and checked by the registry.
22.13 PROVIDER INQUIRY, COMPLAINT, GRIEVANCE AND APPEAL PROCESS

All transportation provider inquiries, complaints, grievances and appeals as defined under Definition, must be filed with the NEMT broker. The broker must resolve all complaints, grievances and appeals in a timely manner. The transportation provider will be notified in writing of the outcome of each complaint, grievance and appeal. In order to inquire about a broker policy or procedure or to file a complaint, grievance or appeal, contract the broker at the following address or telephone number: Medical Transportation Management, Inc 16 Hawk Ridge Drive Lake St. Louis, MO 63367 Attn: Grievance and Appeals Committee (866) 436-0457
22.14 PARTICIPANT RIGHTS

Participants must be given the rights listed below: 1. General Rule. The broker must comply with any applicable Federal and State laws that pertain to participant rights and ensure that the brokers personnel and transportation providers take those rights into account when furnishing services to participants. Dignity and privacy. Each participant is guaranteed the right to be treated with respect and with due consideration for his or her dignity and privacy.
2.
3. 4.
Copy of transportation records. Each participant is guaranteed the right to request and receive a copy of his or her transportation records. Free exercise of rights. Each participant is free to exercise his or her rights, and that the exercise of those rights does not adversely affect the way the broker and the brokers transportation providers or the state agency treat the participant.
22.15 DENIALS
The broker shall make a decision to arrange for NEMT services within 24 hours of the request. If the broker denies the request for services, the broker shall provide written notification to the participant. The notice must indicate that the broker has denied the services, the reasons for the denial, the participants right to request a State fair hearing, and how to request a State fair hearing. The broker shall review all denials for appropriateness and provide prior verbal notification of the denial in addition to written notification. The state agency shall maintain an independent State fair hearing process as required by federal law and regulation, as amended. The State fair hearing process shall provide participants an opportunity for a State fair hearing before an impartial hearing officer. The parties to the State fair hearing include the broker as well as the participant and his or her representative or the representative of a deceased participants estate.
22.16 PARTICIPANT GRIEVANCE PROCESS

If a participant is unhappy with the services that NEMT provides, a grievance can be filed. The broker thoroughly investigates each grievance and shall acknowledge receipt of each grievance in writing within ten business days after receiving the grievance. The number to call is (866) 436-0457. Written grievances can be sent to: Medical Transportation Management, Inc 16 Hawk Ridge Drive Lake St. Louis, MO 63367 Attn: Grievance and Appeals
22.17 MTM SERVICES AVAILABLE FOR FACILITY SUPPORT

MTM carries out its processes in the following customer service departments: 1. Care Management (CM) 2. Quality Management (QM) 3. Customer Service Center (CSC) General Manual Production - 04/30/2012
22.17.A. CARE MANAGEMENT (CM) MTM Care Management Coordinators (CMCs) are the single point of contact for facility staff. Each CMC is educated on the policies and procedures specific to MO HealthNet or the health plan to which they are assigned. Care Management specializes in working with participants needing such services as dialysis, cancer treatments, high-risk obstetrics, behavioral health, transplants, hospital discharges, and other specialized services. CMCs can set transportation for normal appointment requests with five (5) calendar days notice. CMCs will help arrange transportation for urgent trip requests. CMCs provide trip coordination for recurring appointments. MTM shall authorize out-of-state travel based on state approval. CMCs will work with referring physicians to ensure the correct documentation is received. The CMC will then complete the necessary travel arrangements. CMCs will assist in the prior-authorization process for long distance trip requests. CMCs will coordinate with participants and dialysis facilities, as well as the Missouri Kidney Program (MoKP), to ensure transportation to critical care dialysis treatment. CMCs will assist the participant in arranging meals and lodging when specific criteria are met. CMCs will assist the participant with the Americans with Disabilities Act (ADA) application process if they are a candidate for these services.
22.17.B. QUALITY MANAGEMENT DEPARTMENT (QM) MTM Quality Service Coordinators (QSCs) field and document incoming grievances and issues regarding MTM staff and transportation providers. Grievances are forwarded to the appropriate transportation provider and/or department within MTM. A grievance response shall be submitted to QM by the transportation provider and/or appropriate MTM department within 72 hours. The QSC will document the response and provide education so the issue will not repeat. All grievances are forwarded to MO HealthNet per contract requirements. QM monitors all transportation providers to keep the grievance rate below 3% monthly. If the 3% threshold is met or exceeded, QM will place the transportation provider on a corrective action plan. If the grievance is associated with staff at MTM, a performance improvement plan will be executed as indicated.
22.17.C. CUSTOMER SERVICE CENTER (CSC) Participants and facility staff may contact the Customer Service Center to schedule transportation 24 hours a day, 7 days a week, including all holidays. The CSC is open 24 hours a day, 7 days a week, to handle urgent same or next day appointment scheduling and hospital discharges. Customer Service Representatives (CSRs) can answer questions regarding which services are covered.
22.17.D. WHAT IS CARE MANAGEMENT (CM)? The Care Management Department provides medical facilities, social workers, and case managers with a single point of contact at MTM for the transportation coordination of all participants under their care. This type of direct contact ensures special transportation services are booked in a timely and appropriate manner, improving client satisfaction. Care Management Coordinators (CMCs) establish relationships with social workers and hospital staff. Special transportation includes coordination of services for dialysis patients, drug and alcohol programs, psychiatric outpatient treatment programs, reimbursement for mileage, meals, and lodging, and out of state travel. If a participant has a recurring appointment at a facility, Care Management can program the NET Management System to automatically generate transportation requests for up to 90 days at a time, with the exception of dialysis appointments which can be set for six (6) months at a time. This reduces the time facilities spend requesting transportation on a weekly basis. When the recurring request is made, the facility will be advised of the end date, and either the facility or the participant, will be responsible for contacting MTM to request an extension if needed. The facility must contact MTM when the participant is discharged from a program, becomes ineligible for MO HealthNet services, or has a schedule change. Notifying MTM of cancellations or adjustments to recurring appointments helps MTM keep resources available for all MO HealthNet participants. Transportation to MO HealthNet services is verified by MTM. When participants schedule transportation to a facility for MO HealthNet covered services, MTM is contractually bound to verify the participant did attend their appointment. If MTM is unable to verify that the participant attended, MTM will cancel the trip request. Each morning before the facility opens for business, MTMs computer system will automatically send a fax to the facility for all participants scheduled for that day. The facility can indicate scheduled, scheduled but did not attend, or not scheduled and return the fax to MTM at the end of each day. MTM staff is cross trained to assist other members of the Care Management Department. If the designated CMC is out of the office, backup staff will monitor the faxes, voice messages, and emails to ensure that all urgent requests are responded to in a timely manner. Facilities will receive a response to a request within one (1) business day.
22.17.E. CARE MANAGEMENT OUTREACH MTM provides outreach and education to facilities and advocacy groups on NEMT programs and MTMs program management. MTM can meet with facility staff before start-up of operations and provide on-going support as needed or requested to ensure service satisfaction. In-service training on the following topics is available as requested or needed: Department Programs Dialysis Transportation Urgent Transportation Arranging Transportation for MO HealthNet participants Care Management Coordinators also provide education and training on MTMs services to facility staff, case managers, and social workers. Care Management disseminates educational materials and has in-service training available for any facility, staff, or social service department that requests education on MO HealthNet services, rights, and responsibilities. The Care Management Department has a dedicated toll-free number, as well as a local telephone number, for the medical community to access the department directly. MTM Care Management Coordinators Local Phone Number: (636) 695-5720 Dedicated Toll Free Number: (888) 561-8747 ext. 5720 MTM Care Management Manager Sherry Moore Email: smoore@mtm-inc.net Toll Free: (888) 561-8747 Ext. 5641 Dedicated Fax: (877) 406-0658 Contact: Melissa Whitmore Email: mwhitmore@mtm-inc.net Toll Free: (888) 561-8747 Ext. 5720 Dedicated Fax: (877) 406-0658 Contact: Mellissa Workman Email: mworkman@mtm-inc.net Toll Free: (888) 561-8747 Ext. 5730 Dedicated Fax: (877) 406-0658 Contact: Ana Underwood Email: aunderwood@mtm-inc.net Toll Free: (888) 561-8747 Ext. 5793 Dedicated Fax: (877) 406-0658 General Manual Production - 04/30/2012
MTM Education, Training & Outreach Manager Anna Lee Email: alee@mtm-inc.net Toll Free: (888) 561-8747 Ext 5532 Cell: (636) 614-6135 Dedicated Fax: (877) 406-0658 22.17.F. WHAT IS QUALITY MANAGEMENT (QM)? MTMs Quality Management Department monitors all aspects of MTMs operational departments (Care Management, Call Center, Quality Management, and Network Management) and executes MTMs formal Quality Management Program, Work Plan, and Compliance Program. The scope of the QM Program includes: Credentialing transportation providers Audits and site reviews to ensure transportation provider compliance Management of complaints and grievances Fraud and abuse investigation and reporting Incident and accident monitoring, reporting, and prevention Systematic oversight of Customer Service Centers MTMs Quality Management Department must ensure that participants are treated with respect and that any issues, concerns, or grievances about service provided by MTM staff or a contracted transportation provider are properly resolved. A facility can file a grievance, or address any issues regarding service by contacting: MTM, Inc. Quality Management Department Toll Free: (866) 436-0457 Fax: (866) 343-0998 Mail: 16 Hawk Ridge Dr., Lake St. Louis, MO 63367 MTM After Hours Contact Customer Service Center Toll Free: (866) 269-5927 22.17.G. WHAT IS THE CUSTOMER SERVICE CENTER (CSC)? MO HealthNet participants have a toll-free number to reach the Customer Service Center (CSC): Customer Service Center Toll Free: (866) 269-5927 General Manual Production - 04/30/2012
Customer Service Representatives (CSRs) help the participant schedule his or her appointment. MTM CSRs field calls from participants and facilities and assist with transportation requests for standard and urgent appointment requests. CSRs also provide information regarding which services are covered. If facility staff is unable to reach a designated Care Management Coordinator, the Customer Service Center is available to handle the requests. 22.17.H. ARRANGING TRANSPORTATION FOR FACILITIES The facility MAY call to schedule transportation to medical appointments and must provide the following information: 1) MO HealthNet ID # 2) Pick up address 3) Telephone number 4) Date of birth 5) Date and time of appointment(s) 6) Type of appointment(s) 7) Doctors name 8) Facility name 9) Complete doctor/facility address 10) Doctor/facility telephone number Request for transportation services for a routine medical appointment must be at least five (5) calendar days in advance of the appointment. Urgent trips, follow-up appointments, and discharges can be set up with less than five days notice. If a facility calls for urgent/same day trips, MTM will confirm that it is an urgent trip and then set the trip up according to guidelines. The participant must use the closest appropriate medical facility/provider unless a health care provider has referred the participant outside of the immediate community. Out-of-state trip requests to non-bordering states require prior authorization from MO HealthNet. Care Management will coordinate the approval effort. Trip requests to bordering states must fall within the travel standards and will follow the same policies as in state requests. Meals and lodging requests require prior authorization from Care Management. Participant must provide all devices/tools necessary for travel (i.e. wheelchairs).
22.17.I. HOW DOES A FACILITY REQUEST TRANSPORTATION? A facility can schedule transportation one of four ways: By phone: Call the MO HealthNet Care Management Coordinator, Mellissa Whitmore, at (888) 561-8747 ext 5720 or the Customer Service Center at (866) 269-5927 to set up transportation via telephone. By fax: MTM has facility forms available upon request that can be completed and faxed to (877) 406-0658. The forms go to a confidential fax and a Care Management Coordinator will follow up with the facility when transportation has been arranged. A Care Management Coordinator will respond via phone or fax within 24 business hours to confirm a request has been received and processed. By e-mail: Facilities may e-mail a Care Management Coordinator listed in Section 22.17.E. All email containing PHI must be sent using encrypted email systems. Online Trip Management: A facility may be able to use the MTM Online Trip Management (OTM) program to set transportation up via the internet. A Care Management Coordinator can assist facilities on the OTM system and provide facility staff training on its use. 22.17.J. FORMS COMPLETED BY FACILITIES Transportation Request Form The information provided on this form will allow THE CMC to enter all trip information into MTMs system and schedule transportation. This form can be faxed directly to a CMC for any trip that is more than five (5) calendar days out. A facility scheduling urgent transportation should call a CMC directly to ensure the request is received. Approved Distance Authorization Form For all trip requests outside of the set travel standards, the Approved Distance Authorization Form must be completed by the referring medical provider and returned to MTM Care Management for approval. The form can be obtained from MTM. Meals and Lodging (Ancillary Services) When a participant has an appointment that meets criteria in Section 22.3, MTM may authorize meal and lodging requests. MTM will provide prior authorization for all requests for these services. Daily Attendance Verification Form Facilities will receive a Daily Attendance Verification Form. This form will list the participant scheduled for appointments for the day. All MO HealthNet services must be General Manual Production - 04/30/2012
verified. Facilities will need to verify each participants attendance status (i.e. arrived, did not arrive, was not scheduled) and fax the completed form to MTM at (888) 240-6579. Although trip requests for recurring units will be authorized for periods of 90 days (or six (6) months for dialysis), these trips still require verification. 22.17.K. SCHEDULING URGENT TRIPS A facility may call MTMs CMC, Mellissa Whitmore at (888) 561-8747 ext 5720 or the Customer Service Center at (866) 269-5927 to schedule transportation via the phone for urgent trips. 22.17.L. SCHEDULING A HOSPITAL DISCHARGE The MTM Customer Service Center is open 24 hours a day, seven (7) days a week for urgent trips and hospital discharges. Contact a Customer Service Representative at (866) 269-5927 to arrange discharge transportation. 22.17.M. TRANSPORTATION RESTRICTIONS Public Transit
A participant can be excluded from public transit for: 9 9 9 9 9 9 9 Pregnancy after the 8th month High risk pregnancy High risk cardiac condition Severe breathing problems Living more than three (3) blocks from a bus stop Medical provider location is more than 3 blocks from a bus stop Any other circumstance in which utilization of public transit/bus token/pass may not be medically appropriate.
If a participant states he/she cannot ride the bus, the trip information is escalated to the Care Management department for review. If it is determined that further information is necessary, the Care Management department will contact the participant and/or medical provider. Ambulatory (sedan/cab, van/mini-bus, etc.) 9 Includes wheelchair transfer when a participant can transfer from wheelchair to a vehicle seat, with the wheelchair collapsed and placed in the trunk. Wheelchair Lift Equipped Vehicle 9 For participants who are unable to transfer to a vehicle seat or whose wheelchair does not collapse. Stretcher
Section 22 - Non-Emergency Medical Transportation (NEMT) 9 Stretcher transportation is available for participants who are bed-bound and must travel in a prone or supine position. Unlike ambulance transportation, stretcher transportation providers do not provide any medical care or monitoring during the transport. Participants who can use a wheelchair are not eligible for stretcher transportation. Non-Emergency Ambulance 9 Non-emergency ambulance transportation is available for participants who are bedbound, must travel in a prone or supine position and require life sustaining medical care or monitoring as needed during the transport. Participants who can use a wheelchair are not eligible for ambulance transportation.
22.17.N. AMERICAN WITH DISABILITIES ACT (ADA) CERTIFICATION All participants that are certified for ADA transportation shall continue to utilize the available ADA transportation. In situations where the ADA provider is unable to transport, MTM will provide transportation to eligible services. If a participant qualifies for ADA certification, MTM will assist the participant in the ADA application process. MTM will be able to direct the participant to the appropriate certification facility and shall transport the participant during the application process. 22.17.O. PARTICIPANT ASSISTANCE DURING TRANSPORT A participant may bring someone as an escort at no cost in the following situations: Participants under the age of 17 must be accompanied by a parent/guardian, relative or other adult. Participants under 21 years old may be accompanied by a parent/guardian, relative, or other adult. Participants that cannot travel independently or need assistance due to age, illness, or a physical or mental disability may provide a parent/guardian, relative, or other adult. MTM may require verification from the medical provider. If the participant does not speak English, someone to interpret. 22.17.P. WHAT MTM WILL DO IF A CAREGIVER IS NOT AVAILABLE If a transportation provider notifies MTM that no one is home when they attempt to return an adult with impairments who is able to transport without an escort or attendant, but is unable to be alone at home for long periods of time, the MTM employee will: Attempt to contact a family member using the main phone number and the alternate phone number listed in the participants file. Instruct the transportation provider to take participant to the closest police department if the facility is closed. Document the circumstances, actions taken, and outcomes. Immediately notify MTM management on duty. General Manual Production - 04/30/2012
Inform the Manager of Quality Management of the situation the next business day for a complete follow-up. The Manager of Quality Management will determine any necessary action to be taken, including notification of MO HealthNet.
22.17.Q. FILING A GRIEVANCE A grievance may be filed verbally or in writing by a participant, their representative, or facility by contacting: MTM, Inc. Quality Management Department Toll Free: (866) 436-0457 Fax: (866) 343-0998 Mail: 16 Hawk Ridge Dr., Lake St. Louis, MO 63367 END OF SECTION
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Section 23 - Claim Attachment Submission and Processing
SECTION 23 - CLAIM ATTACHMENT SUBMISSION AND PROCESSING

23.1 23.2 CLAIM ATTACHMENT SUBMISSIONS .................................................................................2 OXYGEN AND RESPIRATORY EQUIPMENT MEDICAL JUSTIFICATION FORM
(OREMJ) ....................................................................................................................................................3 23.3 CERTIFICATE OF MEDICAL NECESSITY FOR DURABLE MEDICAL
EQUIPMENT PROVIDERS ONLY ........................................................................................................3 23.4 ELECTRONIC PA REQUEST AND CLAIM ATTACHMENTS SUBMISSION VIA
THE INTERNET .......................................................................................................................................4 23.5 CLAIM ATTACHMENT REMITTANCE ADVICE ................................................................4 CERTIFICATE OF MEDICAL NECESSITY .........................................................................4 SECOND SURGICAL OPINION FORM ...............................................................................6 (STERILIZATION) CONSENT FORM ..................................................................................7 ACKNOWLEDGMENT OF RECEIPT OF HYSTERECTOMY INFORMATION ...............7 MEDICAL REFERRAL FORM OF RESTRICTED PARTICIPANT (PI-118) ......................8 OXYGEN AND RESPIRATORY EQUIPMENT MEDICAL JUSTIFICATION FORM
23.5.A 23.5.B 23.5.C 23.5.D 23.5.E 23.5.F
(OREMJ) 8
SECTION 23 - CLAIM ATTACHMENT SUBMISSION AND PROCESSING

This section of the manual provides examples and instructions for submitting claim attachments. This section also contains instructions for the Claim Attachment Remittance Advice, which is the document used to inform the provider of the status of each attachment.
23.1 CLAIM ATTACHMENT SUBMISSIONS

Six claim attachments required for payment of certain services are separately processed from the claim form. The six attachments are: Second Surgical Opinion Form (Sterilization) Consent Form Acknowledgment of Receipt of Hysterectomy Information Medical Referral Form of Restricted Participant (PI-118) Oxygen and Respiratory Equipment Medical Justification Form Certificate of Medical Necessity (only for the Durable Medical Equipment Program) These attachments should not be submitted with a claim form. These attachments should be mailed separately to: Infocrossing Healthcare Services P.O. Box 5900 Jefferson City, MO 65102 These attachments may also be submitted to Infocrossing Healthcare Services via the Internet when additional documentation is not required. The web site address for these submissions is www.emomed.com. The data from the attachment is entered into MO HealthNet Management Information System (MMIS) and processed for validity editing and MO HealthNet program requirements. Refer to specific manuals for program requirements. The status of the attachment(s) is reflected on a Claim Attachment Remittance Advice (RA) (Refer to Section 23.5) similar to claim disposition. Providers do not need to alter their claim submittal process or wait for an attachment to be finalized on an Claim Attachment Remittance Advice before submitting the corresponding claim(s) for payment. A claim for services requiring one of the listed attachments remains in suspense for up to 60 days. When an attachment can be systematically linked to the claim, the claim continues processing for adjudication. If after 60 days a match is not found, the claim denies for the missing attachment. General Manual Production - 04/30/2012 2
Example: Surgery that requires a Second Surgical Opinion Form is performed on a MO HealthNet participant, during an inpatient hospitalization, on December 5, 2001. The hospital submits a claim on December 21, 2001, without the Second Surgical Opinion Form. This claim does not deny based on the lack of the Second Surgical Opinion Form but suspends for up to 60 days. The system periodically checks to determine if an approved attachment can be located to link to the hospitals claim. The physician submits the Second Surgical Opinion Form on December 22, 2001 and a claim on December 24, 2001. The data from the attachment is entered into the system and subsequently finalized in the system on December 31, 2001. During the next cycle the hospitals and the physicians claims are linked to the attachment, and both claims continue through the adjudication process. An approved attachment is valid only for the procedure code indicated on the attachment. If a change in procedure code occurs, a new attachment must be submitted incorporating the new procedure code.
23.2 OXYGEN AND RESPIRATORY EQUIPMENT MEDICAL JUSTIFICATION FORM (OREMJ)

The data from the OREMJ is entered into MMIS and processed for validity editing and MO HealthNet program requirements. Providers are required to include the correct modifier (NU, RR, RP) in the procedure code field with the corresponding procedure code. Once an OREMJ has been submitted and approved for 12 months from the prescription date, providers are not required to submit the OREMJ with each claim submission or resubmission when the information on the claim matches the criteria on the OREMJ. The claims link up with the approved OREMJ and continue to process.
23.3 CERTIFICATE OF MEDICAL NECESSITY FOR DURABLE MEDICAL EQUIPMENT PROVIDERS ONLY
The data from the Certificate of Medical Necessity for DME services is entered into MMIS and processed for validity editing and MO HealthNet program requirements. DME providers are required to include the correct modifier (NU, RR, RP) in the procedure code field with the corresponding procedure code. Once the Certificate of Medical Necessity has been submitted by a DME provider and is approved for six months from the prescription date, any claim matching the criteria on the Certificate of Medical Necessity for that time period can be processed for payment, without a Certificate of Medical Necessity attached. This includes all monthly claim submissions and any resubmissions. 3 General Manual Production - 04/30/2012
23.4 ELECTRONIC PA REQUEST AND CLAIM ATTACHMENTS SUBMISSION VIA THE INTERNET
Providers may submit PA Requests (Refer to Section 8.2) and certain claim attachments via the Internet. The claim attachments available for submission via the Internet include: Second Surgical Opinion Form; (Sterilization) Consent Form; Acknowledgment of Receipt of Hysterectomy Information; Medical Referral Form of Restricted Participant (PI-118), OREMJ and Certificate of Medical Necessity (for Durable Medical Equipment providers only) when additional documentation is not required. The web site address for these submissions is www.emomed.com.
23.5 CLAIM ATTACHMENT REMITTANCE ADVICE

The Claim Attachment Remittance Advice (RA) reflects the status of the attachment(s). When an attachment is approved, no EOB(s) or Exception(s) is reflected on the applicable line of the attachment status RA page. When an attachment is denied, the relevant EOB(s) and Exception(s) is indicated on the RA. Unless prohibited by the applicable program, the attachment can be corrected or additional information supplied on the attachment and resubmitted for consideration. 23.5.A CERTIFICATE OF MEDICAL NECESSITY
The Claim Attachment Remittance Advice example references the field explanations by light italic bracketed numbers for the purpose of illustration. These numbers do not appear on the Claim Attachment Remittance Advice received by the provider. The following lists the fields found on the Certificate of Medical Necessity Claim Attachment Remittance Advice: FIELD REFERENCE & NAME 1. Provider Identifier 2. Attachment Name 3. Remittance Advice Date 4. Remittance Advice Number 5. Page 6. Participant Name EXPLANATION OF FIELD The provider's number. 9-digit MO HealthNet
The name of the attachment. The financial cycle date. The Claim Attachment Remittance Advice number. The Claim Attachment Remittance Advice page number. The participant's last name and first name. NOTE: If the participant's name and identification number are not on file, only the first two letters of the last name and first letter of the first name appear. 4 Production - 04/30/2012
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7. MO HealthNet I.D. 8. Attachment Internal Control Number(ICN)
The participant's 8-digit MO HealthNet identification number. The 13-digit number assigned to the attachment for identification purposes. The first two digits of an ICN indicate the type of attachment: 01Second Surgical Opinion Form 02Medical Referral Form of Restricted Participant (PI-118) 03(Sterilization) Consent Form 07Certificate of Medical Necessity 08Oxygen and Respiratory Equipment Medical Justification Form (OREMJ) 09Acknowledgment of Receipt Hysterectomy Information of
9. Service Date From 10. Service Date To (Thru) 11. Proc Code/Mod1/Mod2 12. Msg/Sys Inf
The initial date of service in MMDDYY format. The final date of service in MMDDYY format. The procedure modifier(s). code, including any
A message code(s) for the line. When an attachment is approved, no EOB(s) or Exceptions(s) are reflected on the line. For a description of the code, reference the last page of the Remittance Advice.
13. Edit Message Numbers (Nbrs) A list of all the edits the attachment failed, if the reason(s) for denial cannot all be explained by the Message Code in field 12. If edit numbers are printed in this area, they indicate errors for which the attachment will fail again if resubmitted unchanged. For a description of the code, reference the last page of the Remittance Advice. 5 Production - 04/30/2012
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14. Category Totals
Each category (i.e., Second Surgical Opinion Form, Medical Referral Form of Restricted Participant (PI-118), (Sterilization) Consent Form, Certificate of Medical Necessity, Oxygen and Respiratory Equipment Medical Justification Form (OREMJ), Acknowledgment of Receipt of Hysterectomy Information) has separate totals for number of attachments. This total appears on the final page for that category. The grand total of all the Category Totals. This field appears after the Category Totals for whichever category is the final one for the Remittance Advice. Not applicable to the Certificate of Medical Necessity Claim Attachment Remittance Advice.
15. Provider Totals
16-17.
23.5.B
SECOND SURGICAL OPINION FORM
The Claim Attachment Remittance Advice example references the field explanations by light italic bracketed numbers for the purpose of illustration. These numbers do not appear on the Claim Attachment Remittance Advice received by the provider. Section 23.5.A contains the explanation for most of the fields on a Claim Attachment Remittance Advice. The following lists the field areas found on the Second Surgical Opinion Claim Attachment Remittance Advice: FIELD REFERENCE & NAME 1-8. 9-10. EXPLANATION OF FIELD Reference Section 23.5.A. Not applicable to the Second Surgical Opinion Claim Attachment Remittance Advice. Reference Section 23.5.A. Reference Section 23.5.A. The date the performed. surgical procedure was 6 Production - 04/30/2012
11. Proc Code1/Mod1/Mod2 Proc Code2/Mod1/Mod2 12-15. 16. Date of Surgery
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17.
Not applicable to the Second Surgical Opinion Claim Attachment Remittance Advice
23.5.C
(STERILIZATION) CONSENT FORM
The Claim Attachment Remittance Advice example references the field explanations by light italic bracketed numbers for the purpose of illustration. These numbers do not appear on the Claim Attachment Remittance Advice received by the provider. Section 23.5.A contains the explanation for most of the fields on a Claim Attachment Remittance Advice. The following lists the field areas found on the (Sterilization) Consent Form Claim Attachment Remittance Advice: FIELD REFERENCE & NAME 1-8. 9-11. 12-15. 16. 17. EXPLANATION OF FIELD Reference Section 23.5.A. Not applicable to the (Sterilization) Consent Form Claim Attachment Remittance Advice. Reference Section 23.5.A. Reference Section 23.5.B. Not applicable to the (Sterilization) Consent Form Claim Attachment Remittance Advice.
23.5.D
ACKNOWLEDGMENT OF RECEIPT OF HYSTERECTOMY INFORMATION
The Claim Attachment Remittance Advice example references the field explanations by light italic bracketed numbers for the purpose of illustration. These numbers do not appear on the Claim Attachment Remittance Advice received by the provider. Section 23.5.A contains the explanation for most of the fields on a Claim Attachment Remittance Advice. The following lists the field areas found on the Acknowledgment of Receipt of Hysterectomy Information Claim Attachment Remittance Advice: FIELD REFERENCE & NAME 1-8. 9-11. EXPLANATION OF FIELD Reference Section 23.5.A. Not applicable to the Acknowledgment of Receipt of Hysterectomy Information Claim Attachment Remittance Advice. 7 Production - 04/30/2012
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12-15. 16.
Reference Section 23.5.A. Not applicable to the Acknowledgment of Receipt of Hysterectomy Information Claim Attachment Remittance Advice. Date of participant/participant's representative's signature in month/day/year format.
17. Sign-Date
23.5.E
MEDICAL REFERRAL FORM OF RESTRICTED PARTICIPANT (PI-118)
The Claim Attachment Remittance Advice example references the field explanations by light italic bracketed numbers for the purpose of illustration. These numbers do not appear on the Claim Attachment Remittance Advice received by the provider. Section 23.5.A contains the explanation for most of the fields on a Claim Attachment Remittance Advice. The following lists the field areas found on the PI-118 Claim Attachment Remittance Advice: FIELD REFERENCE & NAME 1-8. 9-11. 12-15. 16. 17. Sign-Date EXPLANATION OF FIELD Reference Section 23.5.A. Not applicable to the PI-118 Attachment Remittance Advice. Reference Section 23.5.A. Not applicable to the PI-118 Attachment Remittance Advice. Claim Claim
Date of authorized provider's signature in month/day/year format.
23.5.F
OXYGEN AND RESPIRATORY EQUIPMENT MEDICAL JUSTIFICATION FORM (OREMJ)
The Claim Attachment Remittance Advice example references the field explanations by light italic bracketed numbers for the purpose of illustration. These numbers do not appear on the Claim Attachment Remittance Advice received by the provider. Section 23.5.A contains the explanation for the fields on the Oxygen and Respiratory Equipment Medical Justification Form Claim Attachment Remittance Advice.

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STATE OF MISSOURI

BEHAVIORAL HEALTH SERVICES MANUAL

Section 1 - Client Conditions of Participation

SECTION 1 - PARTICIPANT CONDITIONS OF PARTICIPATION

1.1.A(1) 1.1.A(2) 1.1.A(3) 1.1.A(4) 1.1.A(5) 1.1.A(6) 1.1.A(7) 1.1.A(8)

1.2.C(1) 1.2.C(2) 1.2.C(3) 1.2.C(4) 1.2.C(5) 1.2.C(6) 1.2.C(7) 1.2.D

Section 1 - Client Conditions of Participation

1.5.C(1) 1.5.D 1.5.E 1.5.F 1.5.G 1.5.H

1.5.H(1) 1.5.H(2) 1.5.H(3) 1.5.I 1.5.J

1.5.K(1) 1.5.K(2) 1.5.K(3) 1.5.K(4) 1.5.L

1.5.L(1) 1.5.L(2) 1.5.M

MO HEALTHNET COVERAGE FOR INMATES OF A PUBLIC INSTITUTION .............32 2 Production - 04/30/2012

Section 1 - Client Conditions of Participation

1.5.M(1) 1.5.M(2) 1.5.N

MO HealthNet Coverage Not Available ........................................................................33 MO HealthNet Benefits .................................................................................................34

VOLUNTARY PLACEMENT AGREEMENT, OUT-OF- HOME CHILDREN'S SERVICES .............................................................................................................................34

1.5.N(1) 1.5.N(2) 1.5.N(3)

1.6.B(1) 1.6.B(2) 1.6.B(3) 1.6.B(4) 1.6.B(5) 1.6.B(6) 1.6.B(7) 1.6.C 1.6.D

1.7.A(1) 1.7.A(2) 1.7.A(3) 1.7.B 1.7.C 1.7.D 1.7.E 1.7.F

1.8 TRANSPLANT PROGRAM ...........................................................................................................46 General Manual Production - 04/30/2012 3

Section 1 - Client Conditions of Participation

1.8.A 1.8.B 1.8.C 1.8.D 1.8.E 1.8.F

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Section 1 - Client Conditions of Participation

18, 43, 44, 45, 61

10, 19, 21, 24, 26

Section 1 - Client Conditions of Participation

23, 41 28, 49, 67 33, 34 81

1.1.A(2) ME CODE 05, 06

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Section 1 - Client Conditions of Participation

Section 1 - Client Conditions of Participation

Section 1 - Client Conditions of Participation

Section 1 - Client Conditions of Participation

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Section 1 - Client Conditions of Participation

MO HEALTHNET AND MO HEALTHNET MANAGED CARE ID CARD

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Section 1 - Client Conditions of Participation

FORMAT OF MO HEALTHNET ID CARD

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Section 1 - Client Conditions of Participation

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Section 1 - Client Conditions of Participation

Breast or Cervical Cancer Treatment Presumptive Eligibility

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Section 1 - Client Conditions of Participation

AUTOMATIC MO HEALTHNET ELIGIBILITY FOR NEWBORN CHILDREN

Section 1 - Client Conditions of Participation

Section 1 - Client Conditions of Participation

Section 1 - Client Conditions of Participation

PARTICIPANTS WITH RESTRICTED/LIMITED BENEFITS

Section 1 - Client Conditions of Participation

Section 1 - Client Conditions of Participation

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Section 1 - Client Conditions of Participation

Home Birth Services for the MO HealthNet Managed Care Program

Section 1 - Client Conditions of Participation

Section 1 - Client Conditions of Participation