The provider should not submit claims solely on the basis of the prior authorization, but must base claims upon documentation of actual services rendered. The participant may have been in the hospital or nursing home during a month, may have been away from the home visiting family or friends, or there may have been other reasons why all services which were prior authorized were not necessary or could not be delivered. The prior authorization merely establishes the maximum number of hours and types of services which may be given to a participant during a time period. All units billed to MO HealthNet must be supported by the documentation of delivery as described in this section.
Pursuant to the above, providers can only bill for actual services rendered. If, for example, a month only has 28 days, the provider cannot provide services on the 29th, 30th or 31st day. Specifically, if a service is authorized to be provided once a day, and the month only has 28 days, then the service can only bill for the days service provided up to a maximum of 28 days.
2. Question: How will MMAC conduct audits with regard to signatures? MMAC has posted guidance on this issue on its website. 3. Question: How will MMAC conduct audits with regard to nurse visits? Specifically, is a pre-printed form acceptable with a short narrative or short notes, and a signature (a form with check boxes), or does the whole form need to be handwritten? A pre-printed form is acceptable with a short narrative or short notes, and a signature. The whole form does not have to be hand-written. If, however, the type of information required to be documented is not susceptible for being captured in a pre-printed form, then the information must be supplied. For example, if the required information is to provide the participant’s vital signs, a “check the box” option would not be acceptable. The participant’s actual vital signs must be documented on the form. 4. Question: Is it acceptable for an LPN to do certain activities on the authorized nurse visit, as opposed to an RN? 13 CRS 70-91.010(6)(0)4 provides: The RN may provide nail care for a diabetic or client with other medically contraindicating conditions, if the recipient is unable to perform this task.Although section 335.099 RSMo states LPNs are “qualified” to perform certain services, it uses the qualifier “as required by the department of social services”. The Department of Social Services requirements include that the LPN’s work be under the direction of an RN. The Missouri State Medicaid Plan specifies that nurse services and personal care oversight are to be provided by an RN. For that reason, the Department of Social Services requires that the LPN’s work be under the direction of an RN. 13 CSR 70-91.010(6)(0)7 provides: The visits authorized under subsection (6) except (6)(0)6 may be carried out by an LPN, if under the direction of an RN.Section 13.8 of the MO HealthNet Medicaid Personal Care Manual states: The authorized nurse visits listed above may be provided by an LPN, if under the direction of an RN, except an RN must perform the on-the-job training and competency testing for advanced personal care aides.In order to comply with the above, MMAC requires documentation to prove that there is an RN on staff with the agency.
