Some MO HealthNet participants are restricted (or locked-in) to a provider or providers, such as a certain physician/clinic and/or pharmacy, where the participant can receive treatment or services. A provider checking patient eligibility is given the names and phone numbers of the lock-in providers. Payment of services for a locked-in participant cannot be made to other providers, except for emergency services or authorized referral services.
Claims for emergency services must be submitted on a paper claim form with an attached Certificate of Medical Necessity and/or medical records documenting the emergency circumstances.
When a physician is the designated/authorized provider, they are responsible for the participant's primary care and for making necessary referrals to other providers as medically indicated. When a referral is necessary to other providers, the lock-in provider must complete a Medical Referral Form of Restricted Recipient (PI-118), and send it to each provider to whom the participant is referred.
The referral form must contain the NPI (and taxonomy code if appropriate) for the provider to whom the patient was restricted on the date of service. For example, if the participant is locked into a clinic, you must use the clinic's NPI (and taxonomy code if appropriate) on either the paper form or the electronic form. Do not put the physician's individual NPI on the referral form, as the information will not match the MO HealthNet lock-in file. The NPI on the claim from the provider who received the referral must match the NPI on the referral form.
The information from the form can then be submitted by the treating provider(s) via the Internet on the MO HealthNet Web portal, or the form can be mailed to Wipro Infocrossing Healthcare Services, PO Box 5900, Jefferson City, MO 65102.
The referral form is good for 30 days from the date of service or appointment. A new referral form must be submitted if additional care is required after the 30 days.