May 20, 2013

The majority of all items in the MO HealthNet Durable Medical Equipment (DME) program have an established allowed amount; however there are items that continue to require manual pricing.  Section 19 of the MO HealthNet DME provider manual contains a list of all covered procedure codes.  Manually priced items are noted in the "Allowed Amount" column with a 'MP' and in many cases have 'IOC' (Invoice of Cost) in the "Reimbursement Guidelines" column.

In order to price these claims correctly, providers need to provide accurate and up-to-date information.  An invoice of cost can be submitted electronically through an attachment within the CMS-1500 claim form on the eMomed billing web site or may be submitted as a paper attachment to the CMS-1500 claim form.  Orthotics, prosthetics, ostomy supplies, HCY items (Healthy, Children & Youth), and any other item requiring an invoice, is reimbursed at the provider's cost plus 20%.  Should a provider bill their actual cost and attach a valid invoice, MO HealthNet would only reimburse the provider their cost as the system cannot reimburse a dollar amount greater than the provider's billed amount.  Examples are provided for your convenience.

1. Unit Cost - $100     Billed Charge - $150     Reimbursement - $120
2. Unit Cost - $100     Billed Charge - $105     Reimbursement - $105

Please keep in mind a provider's billed charge should be their usual and customary charge to the public.