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PAYMENT ERROR RATE MEASUREMENT (PERM) AUDIT

November 20th, 2023

The Centers for Medicare & Medicaid Services (CMS), in partnership with the States, is measuring improper payments in the Medicaid and Children’s Health Insurance Program (CHIP) programs under their Payment Error Rate Measurement (PERM) process.

 

CMS and its PERM contractors will be sending records requests directly to Missouri Medicaid/CHIP providers for claims billed during state fiscal year 2024. Additional information about the PERM program is addressed on the CMS PERM website (https://www.cms.gov/PERM). Refer to the “Providers” link on the website.

 

Federal regulations require that Medicaid/CHIP providers submit the medical record documentation to support claims for Medicaid/CHIP services to CMS upon request. Providing medical records for Medicaid/CHIP patients does not violate the Health Insurance Portability and Accountability Act (HIPAA). Patient authorization is not required to respond to this request. CMS and its contractors will comply with the Privacy Act federal regulations governing the sharing and transmission of Protected Health Information (PHI).

 

Questions regarding the PERM audit may also be directed to the State PERM representative Joyce Chandler at 573-751-7993 or please email MMAC.PERMAUDITS@DSS.MO.GOV.

 

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Family Care Safety Registry (FCSR) Fee Increase

May 1st, 2023

Family Care Safety Registry (FCSR) Fee Increase: 

 

Effective May 1, the FCSR registration fee will increase to $15.00 due to the Highway Patrol’s name-based criminal record search fee increasing to $15. The fee increase results from statute and is required by the Patrol. The registration and background screening system (BSEES) is being updated to charge the new fee for online registrations, along with a credit card processing fee of $0.55, for a total of $15.55. Click for more information about the FCSR.

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PRESCRIBING PROVIDER NPI REQUIREMENT

September 20th, 2018

Current state and federal regulations (13 CSR 65-2 and 42 CFR § 455.410) require Ordering, Prescribing, or Referring (OPR) 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.  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 such items or services.

 

Drug claims with a date of service on or after October 14, 2018, will deny unless the prescriber is actively enrolled with MO HealthNet.

 

All outpatient or medical claims billed using the National Drug Codes (NDC) with the appropriate HCPCS or CPT procedure code for the medication administered must also contain an actively enrolled MO HealthNet prescriber.  This includes but is not limited to C-codes, G-codes, J-codes, Q-codes, S-codes and non-VFC vaccination CPT codes.  For medications billed on outpatient claims the attending provider is treated as the prescriber and for medical claims the rendering provider is used.

 

In addition, effective October 14, 2018, MO HealthNet will no longer accept a Drug Enforcement Administration (DEA) number in the “Prescribing Provider ID” field on drug claims.  Providers must submit the actively enrolled prescribing provider’s NPI in the “Prescribing Provider ID” field.  Claims submitted with a date of service on or after the effective date with a DEA number in the “Prescribing Provider ID” field will deny.

 

The Missouri Medicaid Audit and Compliance Unit (MMAC) provides an OPR Application that can be downloaded (link) or utilized as a fillable PDF form (link).  MMAC’s provider enrollment personnel will expedite all OPR applications received.  Please fax completed applications to (573) 634-3105.

 

Authorization for emergency medications only may be obtained by contacting Pharmacy and Clinical Services at (573) 751-6963.  Prescribers should immediately submit an OPR application to MMAC or a subsequent override authorization may be denied.

 

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DEADLINE FOR ENROLLMENT OF MANAGED CARE ORGANIZATION NETWORK PROVIDERS

September 13th, 2018

The “Medicaid and CHIP Managed Care Final Rule” and 42 CFR 438.602(b)(1), require states to screen and enroll, and periodically revalidate, all network providers of Managed Care Organizations (MCOs); including Ordering, Prescribing, and Referring (OPR) providers.  This requirement was effective January 1, 2018.  Missouri Medicaid Audit & Compliance (MMAC) enrolls all health care providers for the Missouri Medicaid program operated by MO HealthNet.

 

The MCOs contracted with MO HealthNet have been notified that their network providers need to be enrolled with MMAC, or have submitted an enrollment application to MMAC, by the close of business on October 31, 2018.  The MCOs have been directed to remove any of their network providers who have not submitted an enrollment application to MMAC by that date.

 

Providers enrolled with any of the three MCOs contracted with MO HealthNet, but who are not yet enrolled with MMAC, should do so before the deadline.  MMAC has streamlined MCO network provider application forms for individual providers (Individual Application) or organizational providers (Organizational Application).  Providers completing the MCO network provider enrollment application will not submit claims to MO HealthNet, nor will they be required to provide any services to Medicaid Fee for Service participants.

 

Providers who are enrolled with MCOs under more than one National Provider Identifier (NPI) will need to make sure each of those NPI numbers are enrolled with MMAC.

 

Any questions regarding enrolling with MMAC as a MCO Network Provider should be submitted to MMAC.ProviderEnrollment@dss.mo.gov

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TELEHEALTH PROVIDER BULLETIN

February 2nd, 2018

A Provider Bulletin on “Telehealth” is now available online at: https://dss.mo.gov/mhd/providers/pages/bulletins.htm 

For provider and policy issues regarding MHD Clinical Services Programs, including Pharmacy, The Missouri Rx Plan (MORx), Psychology, Exceptions, and Medical Precertifications, email MHD at: clinical.services@dss.mo.gov.

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MO HEALTHNET ENROLLMENT OF FEDERALLY QUALIFIED HEALTH CENTERS

November 8th, 2017

Effectively immediately, the Missouri Medicaid Audit and Compliance Unit (MMAC) is changing our policy regarding the enrollment of Federally Qualified Health Centers (FQHCs) and “FQHC look-alikes”.  Previously, MMAC required FQHCs to be enrolled with Medicare before applying for enrollment with MO HealthNet.  Recent analysis determined there is no federal or state requirement for a FQHC to be enrolled with Medicare and Missouri’s policy was not consistent with how other states are enrolling FQHCs in their Medicaid programs.

 

Effective immediately, a FQHC applying for enrollment with MO HealthNet must submit, from among the following, a copy of the current Notice of Grant Award from Public Health Services (PHS): 1) Section 329-Migrant Health Centers, 2) Section 330-Community Health Centers or 3) Section 340-Services to Homeless Individuals.

 

Non-federally funded health centers, which the Secretary of the Department of Health and Human Services has designated as a FQHC (“FQHC look-alikes”), must submit a copy of the letter from PHS designating the facility as an “FQHC look-alike” or as a non-federally funded health center.

 

Non-federally funded health centers that the Secretary of the Department of Health and Human Services determines may, for good cause, qualify through waivers of the PHS requirements, must submit a copy of the letter from PHS designating the facility as an “FQHC look-alike.” Waivers may be granted for up to two (2) years.

 

All other requirements for a provider applying for enrollment with MO HealthNet as a FQHC remain the same.

 

Any questions regarding this change of policy for the enrollment of FQHCs should be directed to the MMAC Provider Enrollment Unit at 573-751-3399 or MMAC.ProvderEnrollment@dss.mo.gov

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NOTICE: ORDERING, PRESCRIBING OR REFERRING PROVIDERS

October 11th, 2017

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 (MHD) began 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.

 

Effective November 1, 2017, claims for Durable Medical Equipment (DME), Home Health, Independent Laboratories, and Radiology (Imaging) providers will deny unless the OPR provider’s National Provider Identifier (NPI) is listed on the claim, and the OPR provider is actively enrolled with MO HealthNet.

 

DME providers – The claims system will not recognize referring providers submitted in the Ordering provider field until additional systems work has been completed.  Put the NPI of ordering providers in the referring provider field until further notice.

 

Home Health – The claims system will not recognize referring providers submitted in the attending provider field until additional systems work has been completed.  Put the NPI of attending providers in the referring provider field until further notice.

 

Independent Laboratory – Put the NPI of the referring physician or non-physician practitioner in the referring provider field.

 

Radiology (Imaging) – Put the NPI of the referring physician or non-physician practitioner in the referring provider field.

 

In order to assist with this process, the Missouri Medicaid Audit and Compliance Unit (MMAC) provides an OPR Application that can be downloaded (link) or utilized as a fillable PDF form (link).

 

MMAC’s provider enrollment personnel will expedite all OPR applications received.

 

For more information please choose “Providers” from the MMAC home page, and then choose “Provider Enrollment” and then choose “Ordering, Prescribing, and Referring” providers.

 

Please submit any questions to MMAC.ProviderEnrollment@dss.mo.gov

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ENROLLMENT OF MANAGED CARE NETWORK PROVIDERS

September 14th, 2017

Beginning January 1, 2018, according to federal regulation 42 CFR 438.602, states must screen and enroll, and periodically revalidate, all network providers of managed care organizations (MCOs).  This requirement applies to ordering, prescribing, and referring “OPR” providers in the managed care setting, as well.

 

This requirement does not cause managed care network providers to see Fee-For-Service (FFS) Medicaid clients.  Providers who are already enrolled with MO HealthNet as a FFS or OPR provider do not need to submit another application as a MCO Network Provider.

 

Missouri Medicaid Audit & Compliance has created two enrollment application forms for MCO network providers to enroll with MO HealthNet as a non-participating provider.  Click here for the individual physician or non-physician practitioner provider application and here for the organizational provider application.

 

MCO network providers may begin submitting their MO HealthNet applications to MMAC immediately.

 

Please submit any questions you may have to MMAC.ProviderEnrollment@dss.mo.gov

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MEDICAID PROVIDER EMERGENCY PREPAREDNESS

August 2nd, 2017

On September 8, 2016 the Federal Register posted the final rule Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. The regulation went into effect on November 16, 2016. The purpose of the rule is to ensure providers have adequate plans in place for natural and man-made disasters, and to promote coordination with federal, state, county, and local emergency preparedness systems.

 

The core elements of the rule include risk assessment and emergency planning, a communication plan, policies and procedures, and training.

 

Additional information may be found at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Emergency-Prep-Rule.html and at  https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Downloads/EP-Rule-Table-Provider-Type.pdf

 

You can read the full text at https://www.federalregister.gov/documents/2016/09/16/2016-21404/medicare-and-medicaid-programs-emergency-preparedness-requirements-for-medicare-and-medicaid

 

Please contact Missouri Medicaid Audit and Compliance at MMAC.General@dss.mo.gov  with any questions.

 

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REMINDER: NOTICE OF OPPORTUNITY TO COMMENT: EXECUTIVE ORDER 17-03 – DSS RULE REVIEW

July 25th, 2017

Missouri Medicaid Audit and Compliance (MMAC), as part of the Department of Social Services (DSS) and in response to Governor Eric Greitens’ Executive Order 17-03, encourages public input on DSS’ Administrative Rules.

 

Please click here to view the dates, times, and locations for upcoming opportunities to comment on MMAC and other DSS rules.  The link will also provide you with information regarding how to comment on the rules, on-line, instead of in person, if you wish.

 

Please contact MMAC at MMAC.General@dss.mo.gov with any questions.

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Contact Information

    Missouri Medicaid Audit and Compliance
    PO Box 6500, Jefferson City, MO 65102-6500
    Phone: 573 751-3399
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