The Provider Enrollment Unit is responsible for enrolling new providers in accordance with 13 CSR 70-3, maintaining provider records, and answering provider inquiries related to enrollment for all MO HealthNet provider types. The Provider Enrollment staff is authorized and required to determine when new provider numbers are issued or when a current provider number will be updated.
After a MO HealthNet provider number has been issued it must be used with all transactions pertaining to MO HealthNet. If a separate provider number has been issued for different location/practices, the provider is responsible to ensure the appropriate provider number is used when billing. Learn more about provider enrollment.
ContractsThe Contracts staff reviews proposals submitted by entities who wish to contract with MMAC to provide In-Home Services (IHS) or Consumer Directed Services (CDS) to participants authorized by the Department of Health and Senior Services (DHSS).
RevalidationsState and federal regulations require all currently enrolled Medicaid providers to revalidate their enrollment at least every five (5) years.
State and federal regulations (13 CSR 65.2 and 42 CFR 455.414) require all enrolled Medicaid providers to do certain things:
Revalidate their information at least every five (5) years Certain providers must pay an application fee Providers must be screened according to categorical risk level Ordering, referring, and prescribing providers must be enrolledPlease click on “Providers” at the top of this page, and choose “Provider Enrollment” to see further information on each one of these categories.
In March, 2014, MMAC posted an update to the RAC (Recovery Audit Contractor) and MIC (Medicaid Integrity Contractor) activities on its website. See the archived post here March 2014 RAC and MIC update. Cognosante, LLC is the RAC for Missouri. Section 6411 of the Affordable Care Act, Expansion of Recovery Audit Contractor (RAC) Program, amends section 1902(a)(42) of the Social Security Act and requires states to contract with a RAC vendor and allows states to reimburse contractors who assist in the identification and recovery of improper payments.
Should you receive any communication from an entity representing itself on behalf of Missouri Medicaid Audit and Compliance (MMAC), or Cognosante, and you are concerned about the legitimacy of the person or company, you should contact MMAC at (573) 751-3399 to verify the communication or request is legitimate.
In 2015, the RAC will finish its work on outstanding pharmacy and durable medical equipment (DME) audits, and will begin conducting audits of hospital billing submitted by enrolled Missouri hospital providers. The RAC may request documentation to support billing of outpatient encounters, including professional and facility services in the emergency room. The RAC will review paid claims for proper billing of both professional and facility services, and the appropriate utilization of facility resources, such as supplies and facility charges. Documentation requests may include requests for itemized statements, medical records, medication administration records, radiology interpretations, and laboratory results to support the claims submitted for payment.
MO HealthNet reimburses eligible participants or nonemergency medical transportation (NEMT) providers for medically necessary transportation only if a participant does not have access to transportation services that are available free of charge. For more guidance on the NEMT program and its other requirements, please read the regulation (13 CSR 70-5.010) at https://www.sos.mo.gov
The MO HealthNet Division also has information about NEMT services on their website at https://dss.mo.gov/mhd/participants/pages/medtrans.htm
MO HealthNet also covers ambulance services for eligible participants if they are emergency services and transportation is made to the nearest appropriate hospital. Further information about the Emergency Ambulance Program is located in 13 CSR 70-6.010 at https://www.sos.mo.gov
MMAC encourages providers, who may call on behalf of participants, to be familiar with the program rules and requirements.
Missouri Medicaid Audit & Compliance (MMAC) will begin implementing new provider enrollment procedures during 2015 to comply with federal laws requiring all Medicaid providers to revalidate their state enrollments at least every five years. Other changes will include conducting pre-enrollment site visits for certain provider types and collecting a federally mandated enrollment application fee from institutional providers (individual physicians, dentists and individual non-physician practitioners are exempt from paying the fee).
Providers can ensure receiving information in a timely manner by making sure we have your current address, telephone number(s), e-mail address and the name of your primary contact person. Please submit any changes or updated information to MMAC by downloading the “Provider Update Request” form at https://mmac.mo.gov/providers/provider-enrollment/new-providers/provider-enrollment-forms. The completed forms can be scanned and sent by e-mail to mmac.providerenrollment@dss.mo.gov or they can be faxed to the Provider Enrollment Unit at (573) 751-5065.
Be sure to check MMAC’s website regularly to get information on upcoming changes and other helpful tips for MO HealthNet providers.
The Missouri Medicaid Audit & Compliance (MMAC) Provider Enrollment Unit (PEU) has processed several applications for enrolling Physician Assistants. PEU personnel assign provider numbers and create the appropriate electronic accounts, permitting the new providers to begin submitting claims for health care services provided to Medicaid participants. At this time, MO HealthNet Division and its fiscal agent are still completing required system work to enroll and reimburse Physician Assistants.
Once MMAC receives notification that the system work is complete, PEU personnel will assign the provider number and finalize creation of the enrollment records. MMAC will backdate the effective date of the new Medicaid provider enrollments to the date the applications were originally received. In the meantime, providers can continue getting reimbursed under their current billing arrangements, or they can hold their claims until their provider numbers have been assigned. MO HealthNet permits providers to file claims for reimbursement up to one year after the services were actually provided.
Effective August 28, 2014, licensed Physician Assistants will be able to submit enrollment applications to become Medicaid providers. These applications will not be immediately processed.
Until the necessary work is completed for the Physician Assistants applications to be processed and the enrollment to actually take place, Physician Assistants may still provide services and bill under their collaborating physician’s number.
The instructions and application forms are available on this web site in PDF format under the “Provider Enrollment Applications and Forms” tab. Applicants should print out the application forms and mail them to the MMAC Provider Enrollment Unit after they are completed, along with the required documentation listed on the forms.
Per 13 CSR 70-3.020, MMAC will notify providers within 60 days of receipt of their applications when it appears the applications will not be processed within 90 days of receipt. At this time, MMAC believes that MMAC and MO HealthNet will be able to process these applications and enroll the Physician Assistants by the end of the first quarter of 2015. At that time, MMAC will begin accepting these applications in electronic format.
Section 6411 of the Affordable Care Act, Expansion of Recovery Audit Contractor (RAC) Program, amends section 1902(a)(42) of the Social Security Act and requires states to contract with a RAC vendor and allows states to reimburse contractors who assist in the identification and recovery of improper payments.
Missouri contracted with Cognosante, LLC in December, 2011 to serve as Missouri’s RAC.
Also, as part of the Deficit Reduction Act of 2006, the Medicaid Integrity Program was established. This program utilizes Medicaid Integrity Contractors (MICs) to analyze Medicaid claims data to identify high-risk areas and potential vulnerabilities, as well as conduct post-payment audits.
Missouri’s MIC is Health Integrity, LLC. The MICs are assigned by geographic location.
Both the RAC and the MIC may utilize subcontractors. A list of the contractors’ and subcontractors’ names is located below. Should you receive any communication from an entity representing itself on behalf of Missouri Medicaid Audit and Compliance (MMAC), or one of the companies listed below, and you are concerned about the legitimacy of the person or company, you should contact MMAC at (573) 751-3399 to verify the communication or request is legitimate.
Currently, Missouri’s MIC is conducting audits of Missouri hospice providers. The MIC may request documentation that supports Medicaid-enrolled participants’ eligibility for hospice, and other documents to ensure proper billing.
The Missouri RAC is preparing to conduct audits of enrolled Missouri pharmacy providers. The RAC will be reviewing paid claims for proper billing, and to ensure the claims were not paid twice (duplicate billing) and that proper quantities were billed. They may request documentation to include items such as a copy of the original prescription, the dispensing record, documentation of offer to counsel, and the signed delivery record.
The RAC is also preparing to conduct audits of enrolled Missouri durable medical equipment providers. The RAC will be reviewing paid claims for proper billing, and to ensure the claims were not paid twice (duplicate billing). They may request documentation to include items such as precertification and prior authorization forms and supporting documentation, prescriptions, physician’s orders, invoices, proof of delivery, and certificate of medical necessity.
Medicaid Integrity Contractor (MIC): Health Integrity, LLC
Recovery Audit Contractor (RAC): Cognosante, LLC
RAC Subcontractors:
Recovery Audit Specialists LLC
CDR Associates
Missouri Regulation 13 CSR 70-3.020 (7) requires providers to inform the state of any changes affecting their MO HealthNet enrollment records. These changes, including change of address, are to be reported by the provider on specific forms within 90 days of the change (except for change of ownership or control, which must be reported within 30 days). In addition, section 2.2 of the MO HealthNet Provider Manual requires providers to notify the Provider Enrollment Unit (PEU) of a change of address.
In Missouri, these updates and changes are reported to the PEU at Missouri Medicaid Audit and Compliance (MMAC).
In accordance with the regulation above, the PEU at MMAC inactivates enrolled providers whose mail has been returned to MMAC or MO HealthNet as undeliverable. This action suspends providers’ claims for 180 days, during which time the claims are neither paid nor denied. If the provider does not submit an address update form to PEU by the end of the 180 days, the provider’s claims will then be denied. This is done to help ensure provider enrollment records are accurate. Upon receipt and processing of the required form for updates, provider numbers are reactivated by the PEU.
In order to update your address with Provider Enrollment, please submit a Provider Update Request form. If you know your enrollment has already been made inactive due to undeliverable mail, write RETURNED MAIL in the upper right hand corner of the Update Request form. This will alert Provider Enrollment staff to forward any mail that has been returned.
The complete regulation is located at https://www.sos.mo.gov/adrules/csr/csr.asp and the MO HealthNet Provider Manuals are located at https://mydss.mo.gov/mhd/provider-manuals.
