FAQs Regarding the Personal Care Program

The provider should not submit claims solely on the basis of the prior authorization, but must base claims upon documentation of actual services rendered. The participant may have been in the hospital or nursing home during a month, may have been away from the home visiting family or friends, or there may have been other reasons why all services which were prior authorized were not necessary or could not be delivered. The prior authorization merely establishes the maximum number of hours and types of services which may be given to a participant during a time period. All units billed to MO HealthNet must be supported by the documentation of delivery as described in this section.

Pursuant to the above, providers can only bill for actual services rendered. If, for example, a month only has 28 days, the provider cannot provide services on the 29th, 30th or 31st day. Specifically, if a service is authorized to be provided once a day, and the month only has 28 days, then the service can only bill for the days service provided up to a maximum of 28 days.

In order to comply with the above, MMAC requires documentation to prove that there is an RN on staff with the agency.