Missouri Department of Social Services
221 West High Street • P.O.
Box 1527 •
Jefferson City, MO 65102-1527
This information applies to MO HealthNet and MO HealthNet fee-for-service providers only. MO HealthNet managed care health plans are responsible for providing information to their providers in accordance with MO HealthNet managed care contracts.
Providers can check MO HealthNet policy changes by visiting the Provider Bulletins page.
Providers can also choose to be notified by E-mail each time the MO HealthNet Web site is updated by subscribing to MO HealthNet News.
Providers may contact one of the following Interactive Active Voice Response System (IVR) telephone numbers for MO HealthNet program assistance:
These numbers are available for MO HealthNet providers to call with inquiries, concerns, or questions regarding proper claim filing instructions, claims resolution and disposition, and participant eligibility file problems. The IVR provides answers to such questions as participant eligibility, last two check amounts, and claim status using a touch-tone telephone.
Written inquiries are also handled by the Provider Communications Unit and can be mailed to the following address:
Provider Communications UnitThe following contacts are also available to assist providers:
Call or send an E-mail for help in establishing the required electronic claims format, network communication, assistance with the MO HealthNet billing Web site and other simple help tips.
Most MO HealthNet provider applications are available through the MO HealthNet Web site and must be completed online. This site contains applications and requirements for enrollment. Information for current providers is also available for those who may need to change an address or make other changes. Please read the instructions carefully.
For additional information see Frequently Asked Provider Enrollment Questions.
Call this number to report injuries sustained by MO HealthNet participants, problems obtaining a response from an insurance carrier, or unusual situations concerning third party insurance coverage.
Provider representatives are available to train providers and other groups on proper billing practices as well as educating them on MO HealthNet programs and policies. Call this number to discuss training options. Any scheduled training workshops are posted on the MHD provider page.
This toll free number is available to MO HealthNet participants regarding their requests for access to providers, eligibility questions, covered/non-covered services or unpaid medical bills.
Call the toll free number for emergency requests or fax non-emergency requests to initiate a request for essential medical services or an item of equipment that would not normally be covered under the MO HealthNet program.
This toll free number has several menu options. Call this number to obtain overrides to point of sale pharmacy claims that are rejecting because of clinical edits, such as "Refill Too Soon" and "Step Therapy". Prior authorization for certain drugs or diabetic supplies can also be obtained at this number.
Web site for Pharmacy Program Information:
www.heritage-info.com/mocaidrxThe MO HealthNet Division maintains an Internet Web site. Provider manuals, bulletins, fee schedule, forms, training booklets, hot tips, and frequently asked questions are located on this Web site.
Use this Web site for claim submissions; eligibility verification; claim, prior authorization, and attachment status; and check amount inquiries. Several files are available for download including claims processing schedule and the last four remittance advices.
A new function has been added to the 2896 telephone number. When you call the number, you no longer get a busy signal but instead you are automatically transferred to the IVR. Anytime during the IVR options, you may select "0" to speak to the next available specialist. Your call will be put into a queue and will be answered in the order it was received.
This information is available from the following sources:
MO HealthNet claims are processed by Infocrossing Healthcare Services, Inc. via a computer claims processing system. The computer claims processing system is programmed to look for required information through a series of edits. If the required information is not present, the claim will be denied with a Claim Adjustment Reason Code or Remittance Advice Remark Code.
All claims processed by MO HealthNet are listed on the provider's remittance advice. The remittance advice lists the Claim Adjustment Reason Codes and Remittance Remark Codes showing why the claim failed. You can download a narrative definition of Claim Adjustment Reason Codes and Remittance Advice Remark Codes used by MO HealthNet on the Washington Publishing Company Web site.
A new feature on the MO HealthNet billing Web site at www.emomed.com allows the retrieval of previously submitted claims. When the claim is retrieved, the fields will automatically be populated with the information entered on the original claim. Users may modify or correct previously submitted information, then resend the claim for payment. This function is available for virtually all claims originally submitted electronically or on paper. A bulletin dated March 20, 2007 contains more detailed information about the retrieval and resubmission of claims through EMOMED.
PLEASE NOTE: There are exceptions to claims that can be retrieved and resubmitted.
This information is provided in Section 4 of the provider manuals.
The Department of Social Services issues a permanent MO HealthNet identification card for each MO HealthNet participant. Issuing a permanent card instead of mailing a card each month saves printing and postage fees.
An identification card does not show eligibility dates or any other information regarding restrictions of benefits or third party resource information. This information could change at any time. Providers must verify the participant's eligibility status before rendering services as the identification card only contains the participant's identifying information (identification number, name, and date of birth). As stated on the card, holding the card does not certify eligibility or guarantee benefits. Additional information is provided in Section 1 of the provider manuals.
MO HealthNet eligibility may be verified through the following eligibility verification system 24 hours per day, 7 days per week:
A MO HealthNet Eligibility (ME) code indicates the eligibility group or category of assistance under which an individual is eligible. Some eligibility groups or categories of assistance have benefit restrictions. Please see Section 1 of your provider manuals for a description of the ME codes and explanation of benefit restrictions.
Not all services covered under the MO HealthNet program are covered by Medicare. Examples are most dental services, hearing aids, adult day health care, or personal care. 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 Medicare has denied a service. The provider may submit a claim to MO HealthNet, using the proper claim form for consideration of reimbursement if MO HealthNet covers the service.
Providers can submit MO HealthNet claims electronically that require a TPL or Medicare denial remittance advice. This is done with the 837 transaction or the MO HealthNet Internet forms located at www.emomed.com. If the 837 transaction is chosen, please refer to the Implementation Guides for assistance.
To bill through the MO HealthNet billing Web site, select the appropriate billing form (CMS-1500, UB- 04, Nursing Home, etc.) and complete your data for the MO HealthNet claim. Each form will have a field titled, "Other Payer". Click on the "Add/Edit" button. This will bring you to the "Other Payer" header attachment. A header attachment is required for every claim. Follow the instructions on the Help page to complete this form. The code you enter in the "Filing Indicator" field will determine if the attachment is linked to the TPL or the Medicare coverage. The "Paid Date" will tie the Header and the Detail attachments together to enable accurate processing. Enter the Reason and/or Remark Codes and the amount assigned to them exactly as you have received them on your remittance advice. If you have received a denial on a detail line, you will need to click on the "Add/Edit" button under the "Other Payer" column. This will bring up the attachment you will need to complete for that detail line. The same directions apply for the completion of the header attachment and the detail attachment. If you have a Medicare denial and a TPL denial, you will be required to add a second "Other Payer" header attachment and related detail attachment. When all attachments have been created as electronic transactions, the option of filing a paper denial will end.
Some crossover claims cannot be processed in the usual manner for one of the following reasons:
If claims are not received automatically from the contractor and you have waited sixty days since receiving your Medicare payment or you know your contractor does not forward claims to MO HealthNet, you will need to file a crossover claim. Providers have two electronic options in billing these crossover claims. The 837 transaction or the MO HealthNet billing Web site Internet claim process must be utilized to achieve consideration of payment for crossover claims. In using the 837 transaction, you will need to consult your Implementation Guides to determine the correct billing procedures or contact your billing agent. MO HealthNet staff cannot assist you with this type of billing.
Internet crossover claim forms for Part A (hospital and nursing home) and Part B (professional services) are located at www.emomed.com. You will be asked to enter data just as you billed it to Medicare and the corresponding adjudication data (i.e., Reason and remarks codes, amounts assigned to these codes, etc.) you received on your Medicare Remittance Advice. The instructions for these forms are located under the HELP key and detailed field instructions are built into the forms.
MO HealthNet will be applying editing to the electronic crossover claim submissions very similar to that used to review MO HealthNet claims. One such edit will look at Medicare allowed procedures compared to MO HealthNet coverage status. If a service covered by Medicare is not covered by MO HealthNet, the cost sharing amounts (coinsurance and deductibles) will not be reimbursed to providers as crossover payment. The exception to this policy will be those Medicare/MO HealthNet clients who are also covered by the Qualified Medicare Beneficiary (QMB) program. MO HealthNet will be responsible for these charges even if MO HealthNet does not cover the service.
If the participant cannot tell you the name of the pharmacy that filled their last prescription, the provider may call the Pharmacy Help Desk toll free at 1-800-392-8030.
MO HealthNet staff do not have the capability to reverse claims. Only the billing provider may reverse a point of sale claim. This policy assures the provider that no unauthorized person will have access to his or her submitted claims. Please note that claims may now be reversed up to 45 days from the original date of service. After 45 days, the provider must submit a paper or Internet adjustment.
Many times a provider may learn of a change in insurance information prior to the MO HealthNet agency since the provider has an immediate contact with their patients. If the provider learns of new insurance information or of a change in the third party liability (TPL) information, he/she may submit the information to the MO HealthNet agency to be verified and updated on the participant's eligibility file.
The provider may report this new information to the MO HealthNet agency using the MO HealthNet Insurance Resource Report form (TPL-4). Complete the form as fully as possible to facilitate the verification of the information. Providers wanting confirmation of the state's response should indicate as such on the TPL-4 form and ensure the provider's name and address information is completed in the spaces provided. (Reference: MO HealthNet Provider Manual General Chapters, Section 5.8)
Providers are required to seek pre-certification for certain diagnostic and ancillary procedures and services ordered by a healthcare provider unless provided in an inpatient hospital or emergency room setting. Services requiring pre-certification can be found on the Medical Pre-Certification Criteria Documents page.
Inpatient hospital admissions must be certified by Health Care Excel (HCE), the organization responsible for admission certification. Their telephone number is 1-800-766-0686. A list of services exempt from admission certification can be found in the MO HealthNet Hospital Manual Section 13.31.A
A Sterilization Consent Form is required for all claims containing the following procedure codes: 55250, 58600, 58605, 58611, 58615, 58670, and 58671. The MO HealthNet participant must be at least 21 years of age at the time the consent is obtained and must be mentally competent. The participant must have given informed consent voluntarily in accordance with federal and state requirements.
The Sterilization Consent Form must be completed and signed by the participant at least 31 days, but not more than 180 days, prior to the date of the sterilization procedure. There must be 30 days between the date of signing and the surgery date. The day after the signing is considered the first day when counting the 30 days. There are provisions for emergency situations that are referenced in Section 10.2.E(1) of the provider manual.
You may check the status of your Prior Authorization Request through the MO HealthNet billing Web site. Prior authorizations generally take four to six weeks to obtain. 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 assistance, managed care, etc., that limit or restrict coverage still apply and restricted services provided to participants are not reimbursed.
Please remember, 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.
Please refer to Section 8 of your provider manual for more information regarding prior authorizations.
MO HealthNet may require one or more of the following attachments for each covered procedure code: Certificate of Medical Necessity, Oxygen and Respiratory Equipment Medical Justification Form (OREMJ), or the supplier's invoice of cost. For a complete list of the MO HealthNet covered DME procedure codes that indicate their required attachment(s), please refer to Section 19 of your DME provider manual or to the MO HealthNet fee schedule.
Each user must apply for a user identification (ID) and password prior to accessing the Web site. The application can be completed online and access is available immediately upon receiving the ID and password. Apply online and complete all required fields and submit. After you receive your user ID and password, you can log onto www.emomed.com and begin using the site.
05/02/08