When you verify eligibility for a MO HealthNet participant, you may be surprised to learn the participant has commercial insurance, which includes Medicare Part C plans, in addition to MO HealthNet benefits. Individuals who have commercial health insurance may still be eligible for MO HealthNet benefits. Commercial insurance will always be the first source of payment as MO HealthNet is the payor of last resort.
MO HealthNet providers billing pharmacy claims with reimbursement issues must contact Pharmacy and Clinical Services at (573) 751-6963 prior to dispensing. Reimbursement will be reviewed and if MO HealthNet determines a pricing update is needed, it will be made effective the date of review. If additional review is necessary, the provider must submit the MAC Pricing Inquiry Worksheet. The worksheet may only be submitted when instructed by MO HealthNet and only for the drug(s) specified.
MO HealthNet providers billing vaccines for dual eligible participants shall bill Medicare for all vaccines. Vaccine coverage under Medicare Part B includes the pneumococcal, influenza, and Hepatitis B vaccines for individuals at high or intermediate risk, and vaccines directly related to the treatment of an injury or direct exposure to a disease or condition. Other vaccines not covered by Part B are covered by Medicare Part D (pharmacy benefit). When a provider cannot bill the Part D plan directly, the vaccine should be dispensed at a pharmacy.
Consistent with the Managed Care health plan contract, all participants enrolled with Aetna Better Health of Missouri (Aetna) will be transitioned to a new Managed Care health plan effective May 1, 2017. However, for Aetna participants in an inpatient hospital setting that will extend beyond April 30, 2017 coverage will continue under Aetna until discharged. The MO HealthNet Division is asking that providers, participants or the Managed Care health plans contact the following with the admission date and/or the discharge date:
Effective May 1, 2017, the MO HealthNet Managed Care program is offered statewide to all 114 counties and the City of St. Louis. Approximately 240,000 participants, who previously were enrolled in the MO HealthNet Fee-For-Service (FFS) program, are transitioned to a Managed Care health plan. These new Managed Care participants join about 500,000 existing Managed Care participants, amounting to an estimated 740,000 Missourians in the Managed Care program.
MO HealthNet Division (MHD) still uses day specific eligibility.
The MHD recently informed providers of the new Emomed functionality allowing them to view participant information and Managed Care enrollment up to 31 days in the future.
The recent change to Emomed was “technical only” and does not reflect a change in eligibility policy.
The MO HealthNet Division (MHD) Provider Education staff will be conducting additional webinar trainings regarding the expansion of state-wide Managed Care, effective May 1, 2017. Currently, there are four webinars scheduled for February 22 and 28, 2017, and March 9 and 30, 2017, from 9:00 AM to 11:00 AM.
The MO HealthNet Division (MHD) Provider Education staff conducts yearly general program workshops. Instructions on how to register are outlined on the workshop schedule.
If a provider has registered for a workshop and cannot attend for any reason, contact MHD Provider Education Unit to cancel the registration. The Provider Education staff may be contacted by phone at (573)-751-6963, or by email at MHD.provtrain@dss.mo.gov.
The MO HealthNet Webinar Training Conference schedule for the 1st Quarter has been updated. We will not offer training for the following programs during the 1st quarter: Local Public Health Agency, Outpatient Hospital, Medical Clinics and Physicians, Inpatient Hospital, Rural Health Clinic Independent, and Rural Health Clinic Provider-Based. The above programs will be included in the 2nd quarter webinar schedule that will be posted in early March 2017.
Please access the 1st Quarter 2017 Webinar Trainings to register.
Provider Education staff are now part of the Clinical Services Unit. Requests for provider training may be directed to the Provider Education representatives by calling (573) 751-6963 or by email: mhd.provtrain@dss.mo.gov. The Provider Education representatives offer training and education on proper billing methods and procedures for MO HealthNet claims.
