MO HealthNet (MHD) and Missouri Medicaid Audit and Compliance (MMAC) are contracted with Health Management Systems (HMS) to conduct post payment reviews of claims for Hospital and Long Term Care facility Credit Balance Audits and the Commercial Insurance Disallowance Audit Cycles.
MO HealthNet is the payer of last resort with all other insurances being primary to Medicaid. The Long Term Care Audits and Hospital Credit Balance Audits are designed to assist providers in identifying when another insurer has paid and Medicaid is due a refund due to a coordination of benefits billing error.
The Commercial Insurance Disallowance Cycles are post payment reviews conducted by HMS to identify Liable Third Party resources that should have been billed prior to MO HealthNet. HMS conducts a data match between the MO HealthNet participant eligibility data and the information they receive from the Commercial Carriers to identify insurers that may have been unknown to the provider at the time of service. As part of Medicaid reclamation, the provider is instructed to bill the commercial plan identified for payment of the claim. The Commercial Insurance Disallowance Audit Cycles are conducted every 90 days for medical and pharmacy claims.
HMS, acting on behalf of MMAC/MHD, has been instructed to send all audit notices via mail to the providers address on record with MMAC. MO HealthNet providers should ensure HMS audit notices are being routed to the correct person or office within their organization.
If you have any questions, comments or concerns about this update, please contact MMAC/HMS Audits at 573-751-3399 OR Via Email at MMAC.Financial@dss.mo.gov
MO HealthNet providers can verify their addresses on file by sending an email to
MMAC.ProviderEnrollment@dss.mo.gov