MO HealthNet Division (MHD) and Missouri Medicaid Audit & Compliance (MMAC) contract with HMS to conduct commercial insurance disallowance audits on various provider types, including pharmacies. For the current cycle of pharmacy audits, HMS and MMAC sent audit letters which included questioned claims of less than $100. Subsequently, HMS and MMAC decided to exclude all claims under $100. Pharmacies that received audit letters and only had claims of less than $100 will receive notification their audit is being cancelled. Pharmacies that received audit letters for claims both above and below $100 will be notified the claims less than $100 are being carved out of their audit. If you have already submitted those claims to the commercial insurance carrier, please continue to process the claims. If you have received a denial from the carrier for those claims, you can resubmit the claim to MO HealthNet for repayment.
MMAC will be sending letters as soon as possible to the pharmacies with claims that are being removed from this cycle.
If you have any additional questions, please contact MMAC at 573-522-5633 or via email at MMAC.FINANCIAL@DSS.MO.GOV