Exceptions Process FAQs

For additional information, review the Exceptions Provider Manual and the MHD Exceptions page.

What is a MO HealthNet Exception Request?

Under certain conditions of medical need, the MO HealthNet Division (MHD) may authorize payment for a MO HealthNet-eligible participant to receive an essential medical service or item of equipment that otherwise exceeds the benefits and limitations of any one of the various medical service programs administered by MHD. Under specific criteria and on a case-by-case basis, an administrative exception may be made to limitations and restrictions set by MHD policy.

For information regarding the process or requirements for an exception request, and restricted or prohibited exception requests, refer to the Exceptions Provider Manual. 

Is there information available that explains the Exceptions Process criteria and requirements?

Yes, additional information is available in the Exceptions Provider Manual. Review other program-specific Provider Manuals for additional information. 

Who can submit a request for an exception?

Exception requests are only accepted from authorized healthcare prescribers licensed as a physician, physician assistant, or advanced practice nurse.

How do I contact the MO HealthNet Division (MHD) with a question about the Exception Process?

Provider should call 800-392-8030, option 4, for assistance with Exceptions. Completed request forms may be faxed to MHD at 573-522-3061.

Participants with questions about the Exception Process may contact Participant Services at 800-392-2161

What are the business hours of operation for the Exception Request Unit?

Hours are 8:00 am to 5:00 pm Monday through Friday, excluding state and federal holidays.

Is there a special form for the Exception Process?

Yes, the Exception Request forms are located on the Provider Forms page. Providers should choose the appropriate Exception Request form for the service/device.

Will the review of the submitted Exception Request be completed if the provider is unable to complete all the fields on the Exception Request form?

If the form is not completed, it will be returned to the prescriber with a request to supply all necessary information. For assistance in completing an Exception Request form, refer to the Exceptions Provider Manual or contact 800-392-8030, option 4. 

Where do I locate the codes required on the Exception Request form?

For requested durable medical equipment (DME) and supplies, the current version of the Health Care Procedure Coding System (HCPCS) must be utilized.

For professional services, coding must be consistent with the Current Procedural Terminology (CPT) coding system.

Codes should be available by contacting the supplier or by purchasing the appropriate coding book.

How long will the review process for an Exception Request take?

Reviews for Exception Requests are completed within five working days of receipt by the MO HealthNet Division (MHD).

Who will receive the notice of the Exception Request decision?

If the Exception Request is approved, the prescriber, the participant, and the service provider for the approved request will be notified.

If the Exception Request is denied, only the prescriber and the participant will receive the notification letter.

If the prescriber completes and submits an Exception Request form, can the provider call to get it reviewed faster?

No, requests will be processed within five working days of receipt by the MO HealthNet Division (MHD).

Can the prescriber call to discuss the denial of an Exception Request?

While phone calls to 800-392-8030, option 4 are permissible for clarification purposes, any additional information for review reconsideration must be submitted by the prescriber via fax to the MHD Exceptions Request Unit at 573-522-3061. The additional information may include MO HealthNet participant information.

What if the prescriber receives a denial and wants additional information to be considered?

Any information submitted in writing by the prescriber via fax to the MHD Exceptions Unit at 573-522-3061, including MO HealthNet participant information, will be reviewed. Requests submitted for additional review will be processed within five working days of receipt by the MO HealthNet Division (MHD).

If an Exception Request is returned or denied, why is the notice sent to the prescriber and not the supplier?

Until an exception approval has been given and agreement notification to cover the item has been mailed to the supplier, requests for additional information are sent to the prescriber because they are considered to be the care coordinator. There is often a need for additional clinical information and/or clarification. As care coordinator, the prescriber has all medical record documentation to justify the need for the requested item.

Revised August 2024