Diagnosis Code Requirements for Pharmacy Claims
Starting June 1, 2026, MO HealthNet will no longer offer manual overrides for pharmacy claims rejected due to missing or incorrectly formatted ICD-10 diagnosis codes under the Diagnosis Code Required Policy Edit, as found in the Pharmacy Clinical Edits and Preferred Drug Lists. This update means that claims for agents included in the Diagnosis Code Required Policy Edit must include a valid, billable ICD-10 code to be processed successfully.
Please ensure the correct, billable ICD-10 diagnosis code is included on the POS transaction for these edited agents. Claims must meet the NCPDP Telecommunication Standard by entering the diagnosis code in field 492-DO, without a decimal point. If your pharmacy software currently adds a decimal, it is not fully NCPDP-compliant for MO HealthNet billing. This is a configuration issue that your software vendor can help resolve. We encourage pharmacies to reach out to their vendor or system provider as soon as possible to confirm support for NCPDP field 492-DO. Ask them to set up your system so that the decimal point is removed from the diagnosis code before submitting claims.
Note: The exact diagnosis code must be obtained from the prescriber and is subject to audit.
Contact Pharmacy Administration at 573-751-6963 or MHD.PharmacyAdmin@dss.mo.gov with questions.