Current state and federal regulations (13 CSR 65-2 and 42 CFR 455.410) require ordering, prescribing or referring (OPR) providers to enroll with Medicaid, even if they do not accept Medicaid. In response, MO HealthNet has begun implementing changes in the claims processing system to deny all claims that require an order, prescription or referral from a physician or other licensed health care professional unless that physician or provider has an active enrollment record on file.
The Mo Healthnet Remittance Advices for Pharmacy, Durable Medical Equipment (DME), Independent Laboratory medical claims, Imaging medical claims, and Home Health claims contain the following alert when the ordering, prescribing, or referring provider on the claim is not an actively enrolled provider:
N613 Alert: Although this was paid, you have billed with an ordering provider that needs to update their enrollment record. Please verify that the ordering provider information you submitted on the claim is accurate and if it is, contact the ordering provider instructing them to update their enrollment record. Unless corrected, a claim with this ordering provider will not be paid in the future.
In the future, the alert will appear on all institutional claims. Afterward, the claims processing system will begin to deny the affected claims. In order to ensure that future claims are not denied, the ordering, prescribing, or referring providers must be enrolled with MO HealthNet. In order to ease this process, the Missouri Medicaid Audit and Compliance Unit (MMAC) provides an
Ordering, Prescribing, and Referring (OPR) Provider Application. MMAC’s provider enrollment personnel will expedite all OPR applications received.
If you have any questions please contact MMAC.ProviderEnrollment@dss.mo.gov
Missouri State Regulation requires documentation of a pharmacist’s offer to counsel, for all MO HealthNet participants’ prescriptions. The regulation states, “Documentation of Offer to Counsel: The pharmacist shall document for each MO HealthNet patient’s prescription in a uniform fashion, whether the offer to counsel was accepted or refused by the patient or the patent’s agent. “ Click here to read the regulation: 13 CSR 70-20.310(7).
Additionally, pharmacies must obtain the signature of the participant or his/her representative, and the relationship of the representative to the participant. Participants living in long-term care facilities such as nursing facilities, ICF/MR facilities, and psychiatric residential treatment facilities are granted an exemption from this requirement.
The signature log serves as verification that the participant received the prescription dispensed. One signature per prescription is required, and electronic signatures are acceptable. Providers must make the signature log and offer to counsel available upon request by MO HealthNet or MMAC. For shipped or delivered prescriptions, the pharmacy must obtain the signature of the participant or his/her representative and their relationship to the participant. More information about signature log requirements is found in the MO HealthNet Pharmacy Manual. Click here to access the manual.
Please contact Missouri Medicaid Audit and Compliance (MMAC) at MMAC.PROVIDERREVIEW@DSS.MO.GOV if you have any questions.
In February, 2016, the Missouri Medicaid Audit and Compliance Unit (MMAC) posted a prescription fraud alert on its website. Click here to view the full post.
Some of these fraudulent prescriptions are still being presented to Missouri pharmacies. If your pharmacy is presented with a fraudulent prescription, please call your local law enforcement agency. If the fraudulent transaction involves a Medicaid participant, please continue to contact MMAC in addition to your local law enforcement agency.
Contact MMAC at MMAC.Lockin@dss.mo.us with any questions or concerns.
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 $554.00, and it will increase to $560.00 on January 1, 2017.
Click here to read more about the application fee and hardship waivers.
Extended Women’s Health Services cover family planning-related services, pregnancy testing, sexually transmitted disease testing and treatment, including pap tests and pelvic exams, and follow-up services. They are covered by MO HealthNet for uninsured women who are 18-55 years of age with a Modified Adjusted Gross Income for the household size that does not exceed 201% of the Federal Poverty Level (FPL). The Medicaid Eligibility (ME) Code is “80/89”.
House Bill No. 2011, 2016 Regular Session, is the appropriations bill for the Missouri Department of Social Services for State Fiscal Year 2017. Section 11.550 of HB2011 is specific to Extended Women’s Health Services, and prohibits the disbursement of any funds, directly or indirectly, to subsidize abortion services or procedures or administrative functions, and also prohibits the use of any funds to pay an organization that provides abortion services. Qualified organizations, however, shall not be disqualified from receiving funds because of an affiliation with an organization that provides abortion services as long as the two organizations are independent of one another. The bill states that the independent affiliate providing the abortion services must be separately incorporated from any organization receiving these funds.
Missouri Medicaid Audit and Compliance (MMAC) is notifying all providers that may potentially be affected by this restriction. Providers will be notified via e-mail addresses that are on file with MMAC as well as by US Mail.
Organizations that are equipped to provide abortion services will be provided with an attestation that allows them to indicate they do not provide abortion services, if they do not. The organization will attest on behalf of any affiliated providers who submit 80/89 claims, if applicable. The attestation may be returned to DSS in order to ensure no interruption in claims processing for 80/89 claims. Affiliated organizations will also receive an informational letter so they are aware of the restriction and its potential impact on their reimbursement for 80/89 claims. This change does not affect any other Medicaid funding.
Please contact MMAC at MMAC.ProviderEnrollment@dss.mo.gov
The Missouri Medicaid Audit and Compliance Unit (MMAC) is providing the following reminders for physicians and laboratories that are enrolled in MO HealthNet and for hospitals that bill for non-enrolled laboratory services.
The MO HealthNet provider manual for physicians sets forth the following requirements:
An outside laboratory performing outpatient laboratory services must bill MO HealthNet for the services when the laboratory is an enrolled MO HealthNet provider. A hospital may bill MO HealthNet for outpatient laboratory services performed by a non-MO HealthNet enrolled outside laboratory. Physician offices may bill for initial drug screens performed at point of care, and hospital laboratories may bill for screenings they performed, but both cannot be billed. It shall be the responsibility of the ordering physician to coordinate with the performing laboratory for the billing of drug screen tests. Providers should not routinely bill for the quantification of drug classes. Providers should only bill for the quantification of a drug class or a confirmatory drug test if there is a positive screen for the drug class to be quantified. Quantification or confirmatory drug tests for a specific substance may be ordered if medically necessary. Documentation of medical necessity must be recorded in the patient medical record.
