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MEDICAID ENROLLMENT APPLICATION FEE FOR 2019

December 26th, 2018

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 $569.00, and it will increase to $586.00 on January 1, 2019.

 

Click here to read more about the application fee and hardship waivers

 

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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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IMPORTANT MESSAGE – OPIOID PRESCRIPTION INTERVENTION PROGRAM

March 7th, 2018

MO HealthNet Providers, please read this important message:

 

In an effort to address Missouri’s emergent opioid crisis, the Departments of Social Services, Health and Senior Services and Mental Health are expanding upon  the Opioid Prescription Intervention (OPI) Program. The OPI Program helps ensure MO HealthNet participant safety by enforcing national standards through the use of Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioids for chronic pain. For more information about the OPI Program, please reference the MO HealthNet provider OPI webpage and Governor Greitens’ press release.

 

Providers whose prescribing habits recently fell outside the CDC guidelines will receive a letter in the mail regarding the OPI program.  If you do not receive a letter, that means you are prescribing within the guidelines.

 

In addition, on March 6, 2018,  MO HealthNet will implement the following revisions to the short-acting opioid and short-acting combination opioid clinical edits.  The revisions to the edits are listed below:

  • Initial Rx for Opioid-Naïve participants will be limited to 50 MME’s
  • Acute opioid therapy will be limited to 60 days AND
  • Acute opioid therapy is not to exceed 90 MME’s
  • Opioid therapy > 60 days will be considered Chronic and will require a PA
  • Chronic Non-Malignant Pain (CNMP) diagnoses have been streamlined AND
  • PA for CNMP will be limited to approved diagnoses only

 

DSS and MO HealthNet are committed to providing consultation, training, and assistance in an effort to improve a providers’ compliance with CDC opioid prescription guidelines. Please contact MMAC.OPICompliance@dss.mo.gov if you have questions.

 

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

 

Questions and comments regarding any other issues should be directed to: ask.MHD@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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NEW STATE REGULATION REGARDING ELECTRONIC SIGNATURES FOR THE MO HEALTHNET PROGRAM

November 8th, 2017

On November 30, 2017, a new state rule (13 CSR 65-3.050) will be effective for electronic signatures in the MO HealthNet Program.  The new rule establishes the basis on which health care providers and participants under Missouri Title XIX programs may use electronic signatures when validating services rendered and received.

 

As defined in the new rule, an “electronic signature” means  a  computer data compilation of any symbol or series of  symbols  executed,  adopted,  or  authorized by an individual with the intent to be the legally binding equivalent of the individual’s handwritten signature.  The use of biometrics does not constitute an electronic signature; however, biometrics may be used as part of electronic signature verification.  A signature stamp or typing the name of the provider or participant on a form does not constitute an electronic signature.  If a law or regulation requires a signature to be in writing,  an  electronic  signature  shall  satisfy such law for MO HealthNet purposes.

 

Providers are not required to conduct business electronically, but if they choose to do so – they need to comply with the requirements of the new electronic signature rule.  The new rule does not eliminate the requirement for certain Home and Community Based Services (HCBS) providers to utilize telephony/electronic visit verification.

 

All providers are encouraged to review the requirements of the new rule.  There are specific requirements for any electronic signature system, including (but not limited to) the tracking of:  (1) User log-in and log-out dates and times; (2) User identification; (3) Device Identification; (4) Dates and times when records are created, updated, viewed, or modified; and (5) The process of affixing an electronic signature shall require at  least two (2) distinct identification components, such as an identification code and a password.

 

Any questions regarding the proper use of electronic signatures for services that will be billed to MO HealthNet should be directed to Missouri Medicaid Audit & Compliance (MMAC) at 573-751-3399 or MMAC.General@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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ORDERING, PRESCRIBING, AND REFERRING (OPR) PROVIDER UPDATE

July 27th, 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  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 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 November, 2017, the claims will begin to  deny unless the ordering, prescribing, or referring provider information is on the claim, and the provider is enrolled with MO HealthNet.

 

In order to assist with this process, the Missouri Medicaid Audit and Compliance Unit (MMAC) provides an

Ordering, Prescribing, and Referring (OPR) Provider Application.  This form is fillable.

 

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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EXTENDED WOMEN’S HEALTH SERVICES PROGRAM UPDATE:

July 12th, 2017

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”.

 

Funding for the Extended Women’s Health Services program has transferred from the Department of Social Services to the Department Health and Senior Services (DHSS), per HB 10 of the 2017 Regular Session of the General Assembly.  Specifically, Section 10.714 states, “none of the funds appropriated herein may be expended to directly or indirectly subsidize abortion services as defined in Section 170.015, RSMo. or procedures or administrative functions and none of the funds appropriated herein may be paid or granted to an organization that provides abortion services. An otherwise qualified organization shall not be disqualified from receipt of these funds because of its affiliation with an organization that provides abortion services, provided that the affiliated organization that provides abortion services is independent of the qualified organization. An independent affiliate that provides abortion services must be separately incorporated from any organization that receives these funds.”

 

Providers equipped to provide abortion services (hospitals, ambulatory surgical centers equipped to provide abortion services, and clinics) will receive letters regarding this restriction and will be required to submit an attestation in order to receive Extended Women’s Health Services “80/89” funding.  This restriction does not affect any other MO HealthNet billing.

 

The attestations will continue to be sent to Missouri Medicaid Audit and Compliance (MMAC) so they may update the provider file and provide the MO HealthNet Division with current provider enrollment information.

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UPDATE/REMINDER: CHANGES IN REIMBURSEMENT FOR EXTENDED WOMEN’S HEALTH SERVICES

February 25th, 2017

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.

 

**UPDATE**

 

Any organization that was sent an attestation and has not returned it to DSS was notified by MMAC via US Mail on February 24, 2017.  This follow up was to ensure the organizations received the attestations, and that they are reminded to return the attestations if they plan to do so.  These organizations were informed that in order to ensure no interruption in billing for 80/89 services, attestations must be received by 5:00, Friday, March 3, 2017.

 

This update serves as an additional reminder to all providers that received attestations that the updated timeline to ensure no interruption in billing for 80/89 services is 5:00 p.m., Friday, March 3, 2017.

 

Providers that submit attestations after March 3, 2017 may still resubmit claims that were originally denied because an attestation was not on file prior to the March 3 deadline. This means that any previously submitted claims that were denied because an attestation was not on file may be resubmitted, reprocessed and paid once the attestation is on file.  However, claims may not be resubmitted if the provider was not in compliance with the language of HB2011 on the dates of service corresponding to the claims.

 

All other MO HealthNet funding is not affected by this process. Providers that do not submit attestations will only experience an effect on their 80/89 billing.

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MMAC PARTICIPANT LOCK-IN PROGRAM AND THE MO HEALTHNET FEE-FOR-SERVICE PARTICIPANT HANDBOOK

December 29th, 2016

The Missouri Medicaid Audit and Compliance Unit (MMAC)  is responsible for reviewing participants who may be subjecting the Medicaid program to fraud, waste and abuse. This includes a review of a variety of factors which include:

  • The number of physicians prescribing services to a particular participant;
  • The number of pharmacies used to obtain prescriptions;
  • The frequency of refills or overlapping prescriptions;
  • The number of emergency room visits, and
  • The services received.

 

If a MO HealthNet participant is found to be misutilizing MO HealthNet benefits, the individual can be restricted to a physician/clinic, pharmacy, or both in accordance with 13 CSR 70-4.070, and may also be referred to the appropriate authorities for possible healthcare fraud investigation and prosecution.

 

If you suspect a participant is abusing Missouri Medicaid, you may report the suspicion to mmac.lockin@dss.mo.gov. It is helpful if you can provide the MO HealthNet participant’s name, Medicaid DCN, address, date of birth and/or social security number, and a complete description of the complaint.  You can find further information regarding the Lock-In program at https://mmac.mo.gov/participants/participant-lock-in/

 

The Department of Social Services MO HealthNet Fee-For-Service Participant Handbook advises MO HealthNet participants of the following:

 

Committing MO HealthNet fraud or abuse is against the law. Fraud is a dishonest act done on purpose. Examples of participant fraud are:

  • Letting someone else use your MO HealthNet health insurance card
  • Getting prescriptions with the intent of abusing or selling drugs
  • Using forged documents to get services

 

 

Abuse is an act that does not follow good practices.  Examples of participant abuse are:

  • Going to the emergency room for a condition that is not an emergency
  • Misusing or abusing equipment that is provided by MO HealthNet
  • Getting services from multiple providers of the same kind
  • Trying to get more services than are necessary

 

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

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Contact Information

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