Tip of the WeekJuly 07, 2008
In July 2007, the MO HealthNet Division (MHD) initiated a program for pre-certification of specific Durable Medical Equipment (DME) items. The first item to require pre-certification was the small volume nebulizer. Since that time, additional items requiring pre-certification include the following: large volume nebulizers; hospital beds, manual and semi-electric; CPAP and CPAP humidifiers; ultrasonic osteogenesis stimulator; diabetic shoes, inserts and modifications; respiratory assist devices (RAD); and chest wall oscillation devices.
The initiation of the pre-certification of DME is a two-step process. Step one of the pre-certification process must be initiated by an authorized DME prescriber who writes prescriptions for items covered under the DME program. Authorized prescribers include physicians, podiatrists and nurse practitioners who have a collaborative practice agreement with a physician that allows for prescription of such items. The enrolled DME provider will access the pre-certification initiated by the prescriber to complete step two of the pre-certification process. A working relationship between the prescriber and the DME provider is essential. All pre-certification requests must be approved by the MHD.
Providers are encouraged to sign up for the MO HealthNet Web tool CyberAccesssm which automates the pre-certification process. To become a CyberAccess user, providers should contact the ACS-Heritage help desk at 1-888-581-9797 or 573-632-9797, or send an E-mail to MOHealthNetCyberaccess@heritage-info.com. The CyberAccesssm tool allows each pre-certification to automatically reference the individual participant's claim history, including ICD-9-CM diagnosis codes and CPT procedure codes. Requests for pre-certification will also be taken by the MO HealthNet call center at 800-392-8030. The call center is available Monday through Friday, 8:00 am to 5:00 pm, excluding state holidays. Requests for pre-certification must meet medical criteria established by the MHD in order to be approved. The Medical Criteria is published in provider bulletins and posted on the MHD Web site prior to implementation.
An approved pre-certification request does not guarantee payment. Providers must verify participant eligibility on the date of service using the Interactive Voice Response (IVR) at 573-751-2896 or 573-635-8908, or by logging onto the MO HealthNet Web portal.
Please continue to monitor the MHD Web site for updates on this process.
June 30, 2008
The MO HealthNet Division (MHD) wants providers to be reimbursed for their services the first time their claim is submitted. By far, the top claim denials result from providers failing to check participant eligibility. These denials are:
Providers can check eligibility by calling the Interactive Voice Response system at 573-635-8908 or through the Internet at www.emomed.com.
June 23, 2008
The provider claim processing schedule has been updated for fiscal year 2009, which begins July 1, 2008. The schedule lists the dates the cycles are run and their corresponding check dates. This updated schedule can be found on the MO HealthNet Web site at http://www.dss.mo.gov/mhd/providers/index.htm and then choosing the 'Claim processing and payment schedule' link in the left column. This schedule is also displayed at the MO HealthNet billing Web site at www.emomed.com.
Provider reimbursement checks are mailed or directly deposited in to a provider's account twice each month, the 5th and the 20th. If the 5th and/or 20th fall on either a Saturday, Sunday or state holiday, the check is mailed or directly deposited the following working day.
Providers who currently receive paper checks are encouraged to consider the convenience of direct deposit. Provider checks are not forwarded if there is a wrong address on file. With direct deposit, the check is deposited into the appropriate account on the check date. The application for direct deposit is available on the MO HealthNet Provider Manual Web site at http://manuals.momed.com/manuals/ through the 'Forms' option.
June 16, 2008
The Hot Tip titled 'Medicare HMOs and Medicaid' dated January 2, 2007 has been removed from the MHD Web site because the policy is no longer in effect. The hot tip indicated that Missouri Medicaid will not pay any co-payment amounts for Medicare/Medicaid clients that had a Medicare HMO policy.
The new, effective policy was posted in the May 5, 2008 bulletin titled 'MO HealthNet Cost Sharing For Medicare Part C/Medicare Advantage Plans'.
New Policy: For dates of service beginning October 1, 2007, MO HealthNet Division (MHD) will pay 100% of the Medicare Advantage/Part C cost sharing for MO HealthNet participants who are Qualified Medicare Beneficiary (QMB Only) and Qualified Medicare Beneficiary Plus (QMB Plus) participants.
For non-QMB MO HealthNet participants enrolled in a Medicare Advantage/Part C Plan, MHD will process claims in accordance with the established MHD coordination of benefits policy.
If there is no evidence of a written agreement between the patient and the provider in which the patient understands and agrees that MO HealthNet will not be billed for the service(s) and that the patient is fully responsible for the payment for the service(s), the provider cannot bill the patient and must submit a claim to MO HealthNet for reimbursement for the covered service(s).
For specifics and claim filing instructions, please reference the above bulletin.
June 9, 2008
Through the Vaccine for Children (VFC) Program, federally provided vaccines are available at no cost to public and private providers for eligible children ages 0 through 18 years of age. MO HealthNet enrolled providers must participate in the VFC Program administered by the Missouri Department of Health and Senior Services (DHSS) and must use the free vaccine when administering vaccine to qualified MO HealthNet eligible children. Providers are required to enroll as VFC providers with DHSS in order to bill MO HealthNet for the administration of the vaccine. For more information regarding the specific guidelines of the VFC Program contact the following:
VFC ProgramMO HealthNet Managed Care health plan providers must enroll in the VFC Program administered by the DHSS and must use the free vaccine when administering the vaccine to MO HealthNet Managed Care enrollees. The MO HealthNet Managed Care health plans do not receive an additional administration fee as the reimbursement is included in the capitation payment. MO HealthNet Managed Care health plans may have differing payment arrangements with their providers and the VFC administration fee may be included in the capitation payment from the MO HealthNet Managed Care health plan to the provider. However, the MO HealthNet Managed Care health plan's reimbursement to local public health agencies is $5.00 per vaccine component unless otherwise regulated. Providers should contact the appropriate MO HealthNet Managed Care health plan for correct billing procedures.
For more information, providers can reference Section 13.13A of the MO HealthNet Physician manual.
June 02, 2008
The following information is provided by the Family Support Division, Missouri Department of Social Services.
Spenddown is similar to a deductible on an insurance policy. Payment for MO HealthNet services begins the date the spenddown amount is met. The participant can choose to meet his/her spenddown either by:
Expenses that may be used toward meeting a participant's Spenddown are incurred expenses that are not subject to payment by a third party, unless the third party is a public program of a state governmental agency.
Medical expenses that can be used to meet spenddown include:
For additional information, please reference the Family Support Division Memo IM-106 dated September 10, 2002 or contact the local Family Support Division office.
May 27, 2008
The Department of Social Services has launched a new MO HealthNet for Kids Web portal page, www.dss.mo.gov/mhk. This page unites information from various divisions within the Department of Social Services on one convenient page.
Information available on the MO HealthNet for Kids portal page includes how to apply, who is eligible, what benefits are offered and how to find a local provider. It also contains helpful resources such as immunization information and answers to frequently asked questions.
May 19, 2008
MO HealthNet is helping to disseminate information to Medicare Part B providers in the eastern region of the state of Missouri as to specific instructions on filing claims to the new Medicare Part B Contractor effective June 1, 2008.
Please reference the following link: http://www.wpsmedicare.com/mac/transition/moe_cutover.pdf 
Counties in eastern Missouri affected by the change in billing from Pinnacle Business Solutions to Wisconsin Physicians Service (the new Medicare Administrative Contractor for Iowa, Kansas, Missouri and Nebraska) include: Adair, Audrain, Barry, Barton, Bollinger, Boone, Butler, Callaway, Camden, Cape Girardeau, Carter, Cedar, Chariton, Christian, Clark, Cole, Cooper, Crawford, Dade, Dallas, Dent, Douglas, Dunklin, Franklin, Gasconade, Greene, Hickory, Howard, Howell, Iron, Jasper, Jefferson, Knox, Laclede, Lawrence, Lewis, Lincoln, Linn, McDonald, Macon, Madison, Maries, Marion, Miller, Mississippi, Moniteau, Monroe, Montgomery, Morgan, New Madrid, Newton, Oregon, Osage, Ozark, Pemiscot, Perry, Phelps, Pike, Polk, Pulaski, Putnam, Ralls, Randolph, Reynolds, Ripley, St. Charles, Ste. Genevieve, St. Francois, St. Louis City, St. Louis County, Schuyler, Scotland, Scott, Shannon, Shelby, Stoddard, Stone, Sullivan, Taney, Texas, Warren, Washington, Wayne, Webster and Wright.
The remaining counties (western Missouri) transitioned to Wisconsin Physician Service on March 1, 2008.
May 12, 2008
Obtaining forms for service documentation or necessary claim filing is quick and simple. All forms, including Sterilization Consent, HCY Screening, Hospice Election and Second Surgical Opinion can be easily downloaded from the Mo HealthNet Web site at http://www.dss.mo.gov/mhd/providers/index.htm. At this site, click on the 'MO HealthNet Forms' option in the left hand column.
Once completed, information from the forms such as the Sterilization Consent, Medical Necessity, Hysterectomy and Second Surgical Opinion can be entered on-line through the MO HealthNet Billing Web site at www.emomed.com; however, the paper forms must be retained in the patient's file and be available upon request by MO HealthNet.
May 5, 2008
Providers have control over which of their practice addresses are viewed by participants and other providers when the search is made for a practicing provider in a particular area or for a specific service.
With consolidation of provider identifiers, you can maintain the listing of your practice addresses. For example, you have only one National Provider Identifier (NPI), but you may want others to be aware of the different locations at which you practice. Or you may need to update or delete practice location information. You can update the information at the MO HealthNet Billing Web site at www.emomed.com. You must be the enrolled provider or the provider administrator to access the option to maintain addresses.
At www.emomed.com, click on 'Add/Update Provider Practice Locations' to make all changes. Then click on the 'Help' button at the bottom of the page to guide you step-by-step through the process of adding, updating or deleting provider practice locations. Please be sure to select your specialty for each location.
Changing your address at www.emomed.com does not change your enrollment address on the MO HealthNet Provider Master Record. Changes to the Master Record must still be done by contacting the Provider Enrollment Unit via E-mail at providerenrollment@dss.mo.gov.
If you are unsure if your provider practice location(s) is/are shown correctly, you can query the provider information through the MO HealthNet Provider Search link at: https://dssapp.dss.mo.gov/ProviderList/sprovider.asp. After reviewing, if practice locations need to be added or updated, please follow the process above to change.
April 28, 2008
MO HealthNet often receives inquiries from providers regarding Vaccines for Children (VFC) program guidelines and policies. Information specific to MO HealthNet VFC policies is found in Section 13.13.A of the MO HealthNet Physician Provider Manual.
The Bureau of Immunization Assessment and Assurance in the Missouri Department of Health and Senior Services (DHSS) administers the Missouri VFC program. The Bureau uses the following sources of information.
Providers can use the above resources or may call the Bureau of Immunization Assessment and Assurance VFC program at 573/526-5349 or 800/219/3224 regarding specific immunization policies and guidelines. Additional DHSS VFC program information is available at the following Web site: http://www.dhss.mo.gov/Immunizations/VFC-Providers.html. Questions regarding VFC billing and coverage for MO HealthNet participants should be directed to MO HealthNet Provider Communications, 573/751-2896.
April 21, 2008
Enrolled MO HealthNet providers often ask about certain situations that would make the MO HealthNet participant responsible for payment of medical services.
The guidelines for non-covered services are reflected in the Missouri Code of State Regulations 13 CSR 70-4.030 titled “Recipient Liability for Medical Services Not Reimbursable to the Provider by the Medicaid Agency”.
In simple terms, this regulation states that an enrolled provider must accept MO HealthNet reimbursement based on the participant's MO HealthNet benefits unless the MO HealthNet participant agrees in writing, prior to receiving the service, that MO HealthNet will not be billed and the participant accepts financial responsibility for the service. The statement must include the date of service, the service for which the participant has accepted financial responsibility, the participant's signature and the date signed. This should be maintained by the provider in the patient record.
A participant signed statement is not needed for systematically denied amounts reported on the provider remittance advice, such as ineligibility, limited benefits, copayment or spenddown amounts.
If MO HealthNet denies payment for a service because all the policies, rules and regulations of the MO HealthNet program were not followed by the enrolled provider, (such as Prior Authorization or Sterilization Consent Form), the participant is not responsible and cannot be billed for the item or service.
April 14, 2008
General claim billing, claim denials, and participant eligibility questions should be directed to the Provider Communications Unit at 573-751-2896. The Provider Education Unit should be contacted only for program training or questions regarding policy clarification.
With the increased use of group provider numbers and the impending use of National Provider Identifier (NPI) numbers, providers should be aware of which Provider Education representative to contact to receive training. When calling the Provider Education Training Unit, ask for the appropriate representative (shown below). If you need to leave a message be sure to include your name, the provider name, provider/NPI number, telephone number, extension number if necessary and the type of training needed. It is not possible to list all the MO HealthNet programs below, but by providing the pertinent information above, your request for assistance can easily be directed to the appropriate staff.
The names of the Provider Education representatives and some of their training programs are listed below:
Becky — personal care/homemaker-chore, home health, private duty nursing, psychology/counseling, speech/occupational/physical therapy, including these providers within a group or clinic;
Dawn — durable medical equipment, ambulance, adult day care, nursing homes, dental, optical (optometrists), including these providers within a group or clinic;
Roger — nurse practitioners, podiatrists, hospitals, physician/clinics, professional medical billing concerning Federally Qualified Health Centers and Rural Health Clinics;
Carol — Medicare/MO HealthNet crossover claim filing.
Requests for training can be made by E-mail to MHD.ProvTrain@dss.mo.gov or by telephone at 573/751-6683. All information, including a provider/NPI number must be readily available.
April 7, 2008
MO HealthNet's Program Integrity Unit recently discovered instances where physicians and hospitals have improperly billed for vagus nerve stimulation services for medical conditions other than those allowed by MO HealthNet policy.
Vagus nerve stimulation is covered for patients with medically refractory partial onset epileptic seizures for whom surgery is not recommended or for whom surgery has failed.
At this time MO HealthNet does not cover vagus nerve stimulation therapy for treatment resistant depression.
The device is included in the hospital per diem if the surgery is performed in an inpatient hospital setting. If the surgery is performed in an outpatient hospital setting, the device is billable under the outpatient supply code.
More information on vagus nerve stimulation can be referenced in Section 13.75 of the Physician Provider Manual.
March 31, 2008
This Hot Tip was first published on November 28, 2005 but recent inquiries indicate providers continue to have problems regarding billing for postoperative care. Therefore, it is being republished. The postoperative policy is covered in Section 13.41 of the Physician Provider Manual:
Postoperative care includes 30 days of routine follow-up care for those surgical or diagnostic procedures having a MO HealthNet reimbursement amount of $75.00 or more. For counting purposes, the date of surgery is the first day. This policy applies whether the procedure was performed in the hospital, an ambulatory surgical center or an office setting, and applies to subsequent physician visits in any setting (e.g., inpatient and outpatient hospital, office, home, nursing home, etc.). Pain management is considered part of postoperative care. Visits for the purpose of postoperative pain control are not separately reimbursable. Physician [surgeon or physician other than the surgeon] services are audited against claims that have already been paid as well as against those claims currently in process. Supplies necessary for providing the follow-up care in the office, such as splints, casts and surgical dressings in connection with covered surgical procedures that meet the postoperative care policy, may be billed under the appropriate supply code. Attach an invoice if applicable.
Procedures subject to postoperative editing are covered in Section 13.41.B of the Physician Provider Manual.
Sometimes providers fail to use the appropriate modifier when billing for surgical care only or post operative management only. Use modifier 54 with the surgical procedure code to indicate surgical care only. Use modifier 55 with the surgical procedure code to indicate postoperative management only with the date of service being the date of the actual surgery.
March 24, 2008
MO HealthNet Division (MHD) has developed examples of documentation for the Psychology/Counseling program. The examples address treatment of a fictional patient and include a Diagnostic Assessment, Diagnostic Assessment Update, Treatment Plan, Treatment Plan Update, an Individual Therapy Progress Note, and a Family Therapy Progress Note. Though the MHD does not require a specific format for documentation, the examples depict the required content defined by policy in Section 13.6.A through 13.6.A(5) of the Psychology/Counseling Manual. A link to the provider manual can be found at: www.dss.mo.gov/mhd/providers/index.htm. This is the provider page. Scroll to the bottom and click on provider manuals. You will find instructions on this page to direct you to Section 13.
These documentation requirements pertain to all providers rendering psychology/counseling services to any MHD eligible participant regardless of placement, setting, or provider credential. These requirements do not replace or negate documentation or reports required by the Children's Division (CD) for individuals in their care and custody, or those required by other authoritative entities. Providers are expected to comply with the policies and procedures established by CD and those other entities.
For provider and policy issues regarding MHD Clinical Services Program, including Psychology, Pharmacy, The Missouri Rx Plan (MoRX), Exceptions, Chronic Care Improvement (CCIP), and Medical Precertification, E-mail us at: clinical.services@dss.mo.gov.
Questions and comments regarding any other issues should be directed to: ask.MHD@dss.mo.gov.
March 17, 2008
A MO HealthNet participant newly enrolled in a MO HealthNet Managed Care health plan can change health plans, for any reason, during the first 90 days of becoming a Managed Care health plan member.
The participant may also be able to change MO HealthNet Managed Care health plans after 90 days. Some reasons for changing after 90 days include: the participant moved out of the MO HealthNet Managed Care area; the participant's primary care provider is no longer with the person's MO HealthNet Managed Care health plan and is in another MO HealthNet Managed Care health plan; or the participant's specialist or other health care provider from whom the person currently is obtaining services is no longer with the health plan and is in another MO HealthNet Managed Care health plan.
Participants have a 30–day open enrollment period once a year. Members may change MO HealthNet Managed Care health plans during their annual open enrollment period and children in Category of Aid 04 (state care and custody) may change MO HealthNet Managed Care health plans as often as circumstances necessitate.
Participants also have a right to change the primary care provider (PCP) within their MO HealthNet Managed Care health plan at least two times each year. Some MO HealthNet Managed Care health plans may allow more. Children in state custody may change their primary care provider as often as necessary.
March 10, 2008
MO HealthNet covers one pair of lens(es) and frames per participant every two years (during any 24-month period). The date of service for lens(es) and frames is the date they were dispensed, not the date the lens(es) and frames were ordered.
Replacement of a lens(es) is not covered within the 24 months following the date of service of the MO HealthNet purchase unless medically necessary due to a prescription change of at least 0.50 diopters for one eye or 0.50 diopters for each eye. If there is a 0.50 diopter change in one eye, MO HealthNet only replaces the lens for the eye with the 0.50 diopter change, not both eyes. Replacement of frames is not covered during the 24 months following the date of service of the MO HealthNet purchased frames.
In order to bill for replacement lens(es) due to a prescription change, a completed Certificate of Medical Necessity is required. The Certificate of Medical Necessity can be entered as an electronic attachment to the Medical (CMS-1500) claim form at the MO HealthNet billing Web site, www.emomed.com by clicking on the “Medical Nec” link on the claim form. Most of the fields are automatically populated, but the fields for the description of the item or service, reason for the service, provider name and number, and the date prescribed must be completed. Both the old and new prescriptions must be included in the reason field for each replacement lens(es). The participant's new prescription must still be entered in the “Add/View Optical” link on the claim form.
Replacement of lost or broken glasses, frames, or lens(es) is a covered service for participants under the age of 21 with an approved prior authorization for procedure code V2799. The lens(es) prescription and the procedure code(s) of the items being requested must be written on the Prior Authorization Request form in the “Description of Service/Item” field.
March 3, 2008
The Durable Medical Equipment (DME) Bulletin dated June 5, 2007, Volume 29, Number 57, informed DME providers they may submit Prior Authorization (PA) Requests by facsimile (fax) to 573/659-0207. At this time, only DME providers are allowed to fax PA requests. All other providers who dispense or provide services which require prior authorization must continue to submit a paper PA request form.
The completed paper PA request form describing those services or items requiring prior authorization and the reason the services or items are needed, along with any supporting documentation, must be submitted to the following address:
Infocrossing Healthcare ServicesPA requests received at the DME fax number above from non-DME providers will be returned via the fax number through which the request was sent.
Providers may confirm if a procedure code requires prior authorization by using the Fee Schedules link on the MO HealthNet Division Provider page.
February 25, 2008
To be eligible to elect hospice care under MO HealthNet, participants must be certified by a physician as being terminally ill. Participants are considered terminally ill if they have a medical prognosis that their life expectancy is six months or less. Hospice services must be reasonable and necessary for the palliation or management of the terminal illness and related conditions. Participants must elect hospice care and agree to seek only palliative care for the duration of the hospice enrollment. Care may be provided in the home, a nursing facility or in a hospital.
Participants must be made aware that by electing hospice services they waive all rights to MO HealthNet services related to the treatment of the terminal condition and any related conditions for which hospice care was elected, or for services that are equivalent to hospice care, except for services:
A participant or their representative may revoke the election of hospice care at any time by filing a Notification of Termination of Hospice Benefits form with the hospice that includes a signed statement the participant revokes the election for MO HealthNet coverage of hospice care. The effective date of the revocation is the date of the signature unless a subsequent date is designated. The revocation of hospice services is always the participant's choice. A hospice may not revoke an election because the participant is admitted to a hospital or chooses other curative care. The participant must understand when he/she signs the Hospice Election Statement he/she can be financially liable for curative treatment not arranged by the hospice or provided by the attending physician.
The hospice provider is reimbursed for the date of revocation. The MO HealthNet participant resumes MO HealthNet coverage for services related to the terminal illness the day following the day of revocation. Reimbursement for services related to the terminal illness provided on the day of revocation to another entity will be reviewed by the MO HealthNet Division on a case-by-case basis. MO HealthNet providers should direct their claim concerns to the following:
Provider Communications UnitFebruary 18, 2008 Updated 2/20/08
The correct telephone number for the Chronic Care Improvement Program (CCIP) Update is 1-866-464-7147.
The Chronic Care Improvement Program (CCIP) is an enhanced primary care case management program that incorporates the principles of disease management, care coordination and case management to serve fee-for-service patients identified through a risk assessment and disease stratification model. APS Healthcare administers the program on behalf of the MO HealthNet Division.
The CCIP works to improve the health status and decrease complications for patients with chronic illness including asthma, chronic obstructive pulmonary disease (COPD), diabetes, cardiovascular disease and gastroesophageal reflux disease (GERD) and Sickle Cell Disease (SCD). Key CCIP goals include establishment of a health care home, patient empowerment through education and increased self-management of their health status, and utilization of existing community resources and health infrastructures through the coordination of care.
CCIP participants benefit from access to telephonic support from a registered nurse health coach, assistance with social barriers to care, and easy to understand educational materials.
Provider benefits include reinforcing medical treatment plans; assistance with locating community resources; access to an online interactive tool, APS Care Connection®, for pharmacy information, claims history and diagnosis history financial incentives for participation and performance and a link to access Cyber Access sm directly from Care Connection.
CCIP is available to MO HealthNet participants in most areas of the state, including the counties along the I-70 corridor and the northeast and southeast regions of the state.
Enrollment is open continuously for new participants at any time. To refer a participant to CCIP, or to learn more about CCIP or to schedule a visit from a CCIP representative, please call the APS help desk toll free: 1-866-464-7147 or visit http://www.moccip.com/ or http://www.dss.mo.gov/mhd/cs/cci/.
For additional program information, please reference the following MO HealthNet Provider Bulletin: Volume 29 Number 22 – January 16, 2007
February 11, 2008
Claims 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 internal control number and the sum of the service line(s) charge submitted on each split claim becomes the split claim total charge. Currently, a maximum of 28 service lines per claim are processed. All detail lines that exceed the size allowed are split into a separate claim. If a claim denies for more than 25 edits, the claim must be split into multiple claims.
Timely filing, duplicate claim submission, third party liability and spenddown all post an edit for each line and can cause a claim to deny for more edits than the system can process. Providers can avoid this type of claim denial by submitting smaller claims with fewer line details.
MO HealthNet applies editing to Medicare/MO HealthNet crossover claims very similar to that used to process MO HealthNet only claims. The system can only process 25 edits or less on one claim. If the claim denies for more than 25 edits, the crossover claim must be split into multiple claims. When splitting the claim into multiple claims, the claim header charge will be different than the one sent to Medicare because the claim header charge must reflect the total charge of the service lines on the smaller split claim.
Providers can also bill smaller claims to Medicare so that the claim can crossover correctly without being manually split to address more than 25 edits.
Additional information regarding split claims can be found in Section 17.6 of the provider manual located on the Internet at http://www.dss.mo.gov/mhd/providers/index.htm. Information regarding Medicare/MO HealthNet crossover claims can be found in the Crossover Claim Editing Bulletin, Volume 29, Number 8 dated August 21, 2006.
February 4, 2008
Providers continue to question the explanation of the codes shown on their claim confirmation report as well as their remittance advices.
MO HealthNet no longer reports MO HealthNet-specific explanation of benefits and exception message codes on any type of remittance advice. As required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) national standards, administrative code sets such as Claim Adjustment Reason Codes, Remittance Advice Remark Codes and NCPDP Version 5.0 Reject Codes for Telecommunication Standard are used.
Explanations for claim status codes, remittance advice remark codes and claim adjustment reason codes can be found on the Internet at www.wpc-edi.com/codes under the HIPAA-Related Code Lists. A listing of the NCPDP Version 5.0 Reject Codes for Telecommunication Standard can be found in the NCPDP Version 5.Ø Reject Codes For Telecommunication Standard appendix.
More information on HIPAA-Related Code Lists can be referenced in Section 17 (Claims Disposition) of your provider manuals located on the Internet at http://www.dss.mo.gov/mhd/providers/index.htm.
January 28, 2008
Section 13.30.E of the MO HealthNet Hospital Provider Manual addresses the matter of transfers within a hospital.
13.30.E Transfers Within A Hospital
It is improper to submit two claims when a patient is transferred from one part of a hospital to another. The counting of days that are allowable under the length-of-stay (LOS) schedule or Health Care Excel (HCE) approved days is from the date of initial admission for a continuous period of hospitalization. Only one claim may be submitted which covers the full continuous length of stay at the one hospital. This policy includes the following situations:When post payment review shows evidence that the LOS limitation or HCE approved days has been exceeded because two claims where submitted for one continuous stay at the same hospital, recoupments are made.
- Movement from one level of room accommodation to another level.
- Movement from the acute area of the hospital to another area, such as a psychiatric or rehabilitation unit.
- Written discharge from one unit and admission to another unit of the hospital.
Note - If the patient is on spenddown and the hospital stay spans from one month to the next, the hospital must submit a separate claim for each month since spenddown medical expenses are incurred by the patient on a monthly basis.
January 25, 2008
The information below is to provide clarification to the hot tip dated January 14, 2008 regarding information to enter in the surgical field of the hospital claim form.
If it is necessary to use the operating room to perform a procedure during an inpatient hospital stay, the principal procedure field 74 on the UB-04 Claim form must be completed. If more than one procedure is performed, list the other procedures and dates in fields 74a-74e using ICD-9 Surgical Procedure Codes on the inpatient claim form.
If a procedure is performed in the patient's room, in a treatment room, or in another area of the hospital that is not an operating room, do not complete field 74 on the UB-04 inpatient claim form.
If a procedure is entered in field 74 of the inpatient claim form, there must be a revenue code shown for the operating room or labor/delivery room.
For surgical procedures performed in the outpatient/emergency room setting of the hospital, the principal procedure field 74 on the UB-04 Claim form must be completed. If more than one procedure is performed, list the other procedures and dates in fields 74a-74e using CPT Surgical Procedure Codes.
January 21, 2008
Special frames, procedure code V2020-22, are covered under the MO HealthNet Optical Program if medically necessary. Special frames are covered if one or more of the following circumstances apply:
A Certificate of Medical Necessity form is not a required attachment; however documentation of the medical necessity for a special frame must be retained in the participant's file.
January 14, 2008
If it is necessary to use the operating room to perform a surgical procedure, the principal procedure code (field 74) on the UB-04 claim form must be completed or the corresponding field on the electronic layout if billing electronically. If more than one procedure is performed, list the other procedures and dates in fields 74a-74e using CPT-Surgical Procedure Codes.
If a procedure is performed in any area of the hospital that is not an operating room, do not complete field 74 on the UB-04 claim form.
If a procedure is entered in field 74, there must be a revenue code shown for the operating or labor/delivery room.
January 7, 2008
At the request of providers, this hot tip regarding medical eligibility (ME) codes is a duplicate to the one dated December 26, 2006.
MO HealthNet or state funded Medical Assistance 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.
Providers should know that one of the reasons for checking a patient's eligibility before each visit or service is to see what the patient's category of assistance, or ME code is. Checking eligibility is especially critical since many ME code categories have co-pays and limited benefits. But a common question from providers is “Where do we find a list of the ME codes?”
The ME codes and their descriptions are found in the MO HealthNet Provider Manuals, Section 1.1.A, Description of Eligibility Categories.
updated weekly
