MMAC continues to receive questions from MO HealthNet providers about whether gifts of “nominal value” violate federal or state Medicaid kickback statutes or regulations. Gifts of nominal value are things like calendars, mugs, pens, refrigerator magnets, small plants, and gift certificates for a small amount. The Department of Health and Human Services (HHS) Office of Inspector General (OIG) has issued advisory opinions indicating gifts of “nominal value” do not violate federal Medicare or Medicaid regulations. The OIG interprets “nominal value” as having a retail value of no more than $15 per item or $75 in aggregate per participant on an annual basis. Click here for the OIG Policy Statement Regarding Gifts of Nominal Value.
§191.905.2 RSMo parallels the federal anti-kickback statute. The state statute prohibits knowingly offering or paying, or soliciting or receiving in a manner whatsoever, remuneration (anything of value) in exchange for referring another person for health care services or for purchasing or furnishing of health care. The statute provides for an exception for discounts that are properly disclosed and accounted for in cost reports. The statute also incorporates the safe harbors provided for in federal regulations as additional exceptions.
With regard to written complaints or hot-line calls that a particular Missouri Medicaid provider is violating federal or state anti-kickback statutes, MMAC will adhere to OIG’s advisory option in determining whether a violation has likely occurred and/or whether further investigation is needed.
All MO HealthNet providers are required to keep their enrollment information current.
13 CSR 70-3.020 Title XIX Provider Enrollment
(7) The provider shall advise the single state agency, in writing, on enrollment forms specified by the single state agency, of any changes affecting the provider’s enrollment records within ninety (90) days of the change, with the exception of change of ownership or control of any provider which must be reported within thirty (30) days.
Changes can be reported to MMAC by using the Provider Update Request Form found here.
Home & Community Based Providers should use the Change Request form found here.
Please follow the submission instructions provided within the forms.
CDS vendors are required by 19 CSR 15-8.400(7)(J) to submit an annual audit performed by a Missouri licensed CPA within 150 days of the end of the vendor’s fiscal year. The majority of CDS vendors’ fiscal years run January 1 – December 31, making the audit due May 31st.
Pursuant to Executive Orders 20-02, 20-04, and 20-10, the Director of the Missouri Department of Health and Senior Services (DHSS) has waived 19 CSR 15-8.400(7)(J) to the extent necessary to extend the annual audit submission deadline until August 31, 2020. To see the DHSS Director’s waiver authorization click here.
MMAC is taking preventive measures and cancelling all Provider Update Meetings scheduled for June 2-4, 2020.
To allow for social distancing, MMAC is researching alternative delivery formats for the Provider Update Meetings scheduled for October. We will announce any changes well in advance of those meetings.
For more information regarding HCBS Update Meetings:
https://mmac.mo.gov/providers/hcbs-provider-certification-training/annual-provider-update-meeting
Thank you for your patience as we respond to the current Covid-19 State of Emergency.
On March 18, 2020, MO HealthNet published the following hot tip:
To expedite provider enrollment into the MO HealthNet program (Missouri’s Medicaid program), Missouri Medicaid Audit & Compliance (MMAC) is providing same day or overnight approvals of most new provider enrollment applications for physicians, advanced practice nurses, and other licensed practitioners. Visit https://mmac.mo.gov/providers/ for more information.
On March 25, 2020, CMS approved the State of Missouri’s Federal Section 1135 Waiver Request.
In accordance with that waiver, MMAC will continue expediting most new provider enrollments for the duration of the public health emergency. This includes enrolling new providers that want to join the networks of one or more of MO HealthNet’s three managed care organizations.
In some cases, MMAC is provisionally enrolling providers. If applying providers are missing a piece of information normally required for enrollment, MMAC will provisionally approve the application with an effective date no earlier than March 1, 2020, to allow for claims processing.
No enrolled MO HealthNet providers will be terminated for not revalidating timely for the duration of the public health emergency.
If you have questions about your MO HealthNet provider application, please email:
MMAC.ProviderEnrollment@dss.mo.gov
Questions regarding revalidation can be directed to:
MMAC.Revalidation@dss.mo.gov
In order to provide expedited service for enrolling providers into the MO HealthNet program (Missouri’s Medicaid program), Missouri Medicaid Audit & Compliance (MMAC) will provide same day or overnight approvals of most new provider enrollment applications for physicians, advanced practice nurses, and other licensed practitioners.
Visit https://mmac.mo.gov/providers/ for more information.
The MO HealthNet Division is responding to an outbreak of respiratory disease caused by a novel (new) coronavirus. The virus has been named “SARS-CoV-2” and the disease it causes has been named “coronavirus disease 2019” (abbreviated “COVID-19”). MO HealthNet providers who test patients for COVID-19 may bill using the newly created HCPCS codes U0001 and U0002.
HCPCS code U0001 is used specifically for CDC testing laboratories to test patients for SARS-CoV-2. HCPCS code U0002 allows laboratories to bill for non-CDC laboratory tests for SARS-CoV-2.
The MO HealthNet claims processing system will accept these codes on April 1, 2020 for dates of service on or after February 4, 2020.
Click here for more information on coronavirus from the Missouri Department of Health & Senior Services.
State and federal regulations (13 CSR 65-2 and 42 CFR 455.460) require Missouri Medicaid Audit and Compliance (MMAC) to collect an application fee from all new and revalidating “Institutional” Medicaid providers. “Individual” providers such as physicians, dentists and other individual non-physician practitioners are not required to pay the application fee.
The application fee is currently set at $586.00, and it will increase to $595.00 on January 1, 2020.
To read more about the application fee and hardship waivers
The Medicare Access and CHIP Reauthorization Act (MACRA) requires CMS to remove Social Security Numbers (SSNs) from the current SSN-based Health Insurance Claim Number (HICN) and issue a new Medicare card with a Medicare Beneficiary Identification (MBI) number.
CMS has finalized mailing the new Medicare Beneficiary ID cards with the new MBI numbers to participants. Therefore, all Missouri Dual eligible Medicaid and Medicare participants have received their new cards.
All Medicare claims submitted after January 1, 2020, are required to use the new MBI number. Those claims filed with the participant’s old HICN will reject for a mismatch of DCN/MBI combination not found in the MMIS.
This notice pertains to MO HealthNet providers who submit claims to Medicare for Missouri Dual Eligible (Medicare/Medicaid) participants, resulting in a “crossover” claim being generated to MO HealthNet for the portion Medicare does not pay. If you have questions, please contact the MO HealthNet Provider Education Unit at mhd.provtrain@dss.mo.gov or (573) 751-6683.
Effective: November 1, 2019
Applies to: Hospitals, Mental Health Hospitals, State Institution Long Term Care facilities, Nursing Homes, Private Home-ICF/IDs, Home Health agencies, Rural Health Clinics, and Hospice claims.
All claims submitted to MO HealthNet must have the National Provider Identifier (NPI) on them. All claims must also have the (NPI) of the Ordering, Prescribing, Referring, or Attending (OPRA) physician or other professional on them, and the OPRA professional must be enrolled with MO HealthNet. Claims missing this information will deny effective November 1, 2019.
Background: Current state and federal regulations (13 CSR 65-2 and 42 CFR 455.410) require Ordering, Prescribing, Referring, or Attending (OPRA) physicians or other professionals providing services under the state plan or under a waiver of the plan to be enrolled as participating providers with the state Medicaid agency (MO HealthNet). Federal regulation 42 CFR 455.440 requires all Medicaid claims for payment of items and services that were ordered, prescribed or referred to contain the National Provider Identifier (NPI) of the physician or other professional who ordered, prescribed, or referred the item or service. In response, MO HealthNet (MHD) began implementing changes in the claims processing system to deny all claims that require an OPRA physician or other licensed health care professional unless that physician or provider is actively enrolled with MO HealthNet and the NPI is included on the claim.
Timeline:
Effective November 1, 2017, claims for Durable Medical Equipment (DME), Home Health, Independent Laboratories, and Radiology (Imaging) services began denying if the OPRA provider’s National Provider Identifier (NPI) was not listed on the claim, and the OPRA provider was not actively enrolled with MO HealthNet. Effective October 14, 2018, all other provider types began receiving a warning message on claims that did not contain the OPRA’s NPI, or if the OPRA provider was not enrolled with MO HealthNet. The warning message is on your remittance advice, and it says, “Attending physician provider/license number missing.”
Effective November 1, 2019, the warning phase will end and claims will deny if the NPI of the OPRA physician or other professional is not listed on the claim and the OPRA provider is not actively enrolled with MO HealthNet. The claim types this affects are Hospitals, Mental Health Hospitals, State Institution Long Term Care facilities, Nursing Homes, Private Home-ICF/IDs, Home Health agencies, Rural Health Clinics, and Hospice agencies.
Also effective November 1, 2019, for provider claim types not required to submit the NPI of an OPRA physician or other professional, but who choose to submit one anyway, claims will deny if the OPRA provider is not actively enrolled with MO HealthNet. If the provider claim types that are not required to submit the NPI of an OPRA provider leave the field blank, the claim will not deny. For example, a dental claim does not require an ordering provider and will not deny if an OPRA is not listed on the claim. However, if the dental claim does list a referring or other OPRA provider, that OPRA provider must be actively enrolled with MO HealthNet or the claim will deny.
MMAC analyzed claims that were submitted over recent months. Some providers that are required to submit the NPI of the Attending physician or other professional have been receiving the warning messages, but continue to submit claims without the NPI.
See the chart below for the provider types and claim types that need to list the NPI of the Attending physician or other professional:
PROVIDER
Attending NPI Required?
Claim Types Billed Hospitals Always required Inpatient
Outpatient
Drug Mental Health Hospitals Always required Inpatient State Institutions LTC Always required Inpatient
NH Nursing Homes Always required NH Private Home – ICF/ID Always required NH Home Health Always required Home Health Rural Health Clinics Always required Outpatient
Drug Hospice Always required Outpatient
Provider types affected: Hospitals, Mental Health Hospitals, State Institution Long Term Care Facilities, Nursing Homes, Private Home-ICF/IDs, Home Health agencies, Rural Health Clinics, and Hospice agencies
Please direct any billing or claims questions to the help desk at 573-635-3559.
For information about how to enroll as a non-billing, OPRA provider, please email the Missouri Medicaid Audit & Compliance Enrollment Unit at MMAC.ProviderEnrollment@dss.mo.gov.
