Missouri Medicaid Audit and Compliance (MMAC) is responsible for administering and managing Medicaid (MO HealthNet) audit and compliance initiatives and managing and administering provider enrollment contracts under the MO HealthNet program. MMAC is charged with detecting, investigating and preventing fraud, waste and abuse of MO HealthNet.
MO HealthNet Fraud, Waste and Abuse
- How do I report MO HealthNet fraud?
MO HealthNet fraud, waste, and abuse can be committed by both providers and participants of MO HealthNet. Provider fraud is generally the result of an intentional misrepresentation of services rendered. Participants may also engage in behavior that results in defrauding MO HealthNet.
MMAC investigates allegations of fraud, waste, and abuse. One of the most important roles a person can play in combating MO HealthNet fraud is to take the initiative to report fraud. For more information on what providers and participants can do to help, visit MMAC Combating Fraud.
- What happens when an allegation of fraud is reported?
MMAC investigators are responsible for conducting investigations into allegations of fraud, waste, and abuse by providers and participants. Investigators conduct interviews with witnesses as well as those suspected of violating state regulation, state statute, and federal regulations.
In the event the investigation reveals a credible allegation of fraud by a provider, MMAC will forward the information to the Medicaid Fraud Control Unit (MFCU), or other prosecutorial entity for review.
If the investigation reveals probable cause of fraud by a participant, MMAC will forward the information to the Department of Social Services (DSS), Division of Legal Services (DLS) for review.
- How are providers monitored for compliance with the MO HealthNet program?
The Provider Review section of MMAC monitors the MO HealthNet program compliance by providers. The Provider Review section conducts onsite and desk reviews of post-payment MO HealthNet claims to ensure appropriate payments were made and that providers are billing and providing services in accordance with federal and state regulations and MO HealthNet requirements. For more information, visit Provider Reviews.
- What types of providers can enroll as MO HealthNet providers?
For full list of provider types being enrolled, please visit: https://www.emomed.com/enrollprovider/ManageProvider/
- What is the difference between a Fee-For-Service (FFS) provider and a Managed Care provider?
FFS providers serve people with disabilities, seniors (age 65+), blind and visually impaired adults and women (under age 65) with breast or cervical cancer.
Managed Care providers serve pregnant women and newborns, children (birth to age 18), families and adults (age 19-64) without disabilities.
- How does a provider apply to be a MO HealthNet Fee-For-Service provider?
MMAC is responsible for enrolling MO HealthNet providers. To enroll as a MO HealthNet provider, providers should complete a MO HealthNet Enrollment Application or email Provider Enrollment at MMAC.ProviderEnrollment@dss.mo.gov. Additional information can be found at Provider Enrollment.
All questions regarding provider enrollment should be sent to MMAC.ProviderEnrollment@dss.mo.gov.
- Where can I find information about applying to be a Managed Care provider?
To enroll as a MO HealthNet Managed Care provider, refer to the Managed Care Provider Toolkit for contact information for each of the health plans.
- Who would a provider contact for technical assistance with accessing eMOMED when applying to be a MO HealthNet provider?
The provider should contact the eMOMED helpdesk at (573) 635-3559 for technical assistance.
- How would a provider reset their password for eMOMED when applying to be a MO HealthNet provider?
The provider should use reset password function on eMOMED or contact eMOMED helpdesk at: (573) 635-3559 for assistance
- Do I have to pay the fee in order to enroll as a MO HealthNet provider?
Individual providers such as physicians, dentists, and Advanced Practice Registered Nurses (APRNs) do not pay a fee to be enrolled with MMAC.
Per State and federal regulations (13 CSR 65-2 and 42 CFR 455.460) institutional Medicaid providers, including small clinics, must pay a fee to become a MO HealthNet provider. For more information, review Application Fee.
- What are institutional Medicaid providers?
Institutional providers are defined as an organization created by an individual or individuals to conduct business, engage in a trade or partake in similar activities.
- What is a 13-provider type?
This is an individual enrollment with MO HealthNet. In these instances, the performing provider is listed under an entity that is already enrolled and active with MMAC.
- What is a 03-provider type?
For individual providers, this type of enrollment is completed when the entity they are associated with is not enrolled or active as a MO HealthNet provider with MMAC.
- How do I switch from a 13-provider type to a 03-provider type?
The provider must submit via fax to (573) 634-3105 the Provider Update Request and include the following supporting documents:
1) A copy of one of the following IRS documents which includes the pre-printed providers legal name and Tax ID number:
- CP-575 (Employer Identification (EIN) Confirmation) Letter
- 147C (EIN Verification) Letter
- Letter or document from the Internal Revenue Service (IRS) with the providers Tax ID number and legal name pre-printed
NOTE: A W-9 or computer printed forms ARE NOT ACCEPTABLE.
MMAC no longer accepts Employer’s Quarterly Federal Tax Return (Form 941) as it is no longer preprinted by the IRS.
2) Completed Business Organizational Structure form and its supporting documents
3) For direct deposit, please provide the Electronic Funds Transfer (EFT) Authorization Agreement and a pre-printed voided check OR a letter from the bank that includes a pre-printed routing number and account number.
The following will not be accepted to establish direct deposit:- Direct deposit slips
- Letters from the provider to the bank
- Checks that have been physically cut or altered
- Checks or bank letters where the legal name, address, bank routing, and account numbers are hand written
MMAC may request additional information.
- How do I switch from 03-provider type to a 13-provider type?
The provider must submit via fax to (573) 634-3105 the Provider Update Request, which must be signed by the individual provider.
- Why does MMAC request the Social Security Numbers, dates of birth, Employer Identification Numbers and addresses for individuals and entities listed on the Business Organizational Structure (BOS) form?
13 CSR 65-2.020(3) states all providers, fiscal agents, and managed care entities are required to disclose the name, address, date of birth, and Social Security Number of any managing employees of the applying provider.
In accordance with 13 CSR 65-2.020, providers must provide a list of the legal names, dates of birth, and social security numbers of any managing member(s) and/or persons with 5% or greater ownership. This information should be listed on the BOS form.
Failure to fully disclose all persons and/or entities with legal ownership or control could result in administrative sanctions being imposed by MMAC, up to and including denial or termination of a MO HealthNet participation agreement.
- How does a provider receive assistance with completing the Business Organizational Structure (BOS) form?
If a provider needs assistance completing the BOS form, they should contact MMAC via MMAC.PROVIDERENROLLMENT@dss.mo.gov or call (573) 751-3399 and a MMAC staff member will assist them.
- What types of signatures are accepted by MMAC?
All forms submitted to MMAC must have an original hand signature or a verifiable DocuSign, Adobe Sign, or Hello Sign signature. For more information, refer to Electronic Signature Requirements.
- Who can sign the Title XIX (Medicaid) Participation Agreement?
For individual provider enrollments, the individual provider must sign the Title XIX (Medicaid) Participation Agreement.
For institutional providers, either the owner or managing employee that was listed on the Business Organizational Structure (BOS) form must sign the Title XIX (Medicaid) Participation Agreement.
13 CSR 65-2.010(25) defines managing employee, and 13 CSR 65-2.010(40) defines ownership.
- Can a provider delete their online enrollment application ?
Yes, a provider may delete their online MO HealthNet Enrollment Application prior to it being submitted to MMAC. Once the application has been submitted, it cannot be deleted. If you need assistance with deleting the application, please contact the eMOMED helpdesk at (573) 635-3559.
- How long can a provider except the processing time to be once they submit their completed MO HealthNet Enrollment Application?
After a provider submits their completed MO HealthNet Enrollment Application and required documentation, processing time may take up to six weeks.
- How does a provider determine the status of their MO HealthNet Enrollment Application to become a MO HealthNet provider?
Providers may submit an enrollment application inquiry to MMAC at MMAC.PROVIDERENROLLMENT@dss.mo.gov.
- Can a provider request that their application to become a MO HealthNet provider be expedited?
Yes, the provider may request an expedited process. However, the provider must provide a valid reason for the request, such as an access to care issue. For questions or to request an expedited process, email MMAC.ProviderEnrollment@dss.mo.gov.
- Can a provider request that their enrollment effective date as a MO HealthNet provider by backdated?
Yes, the backdating request is included in the MO HealthNet Enrollment Application. If the provider fails to indicate a backdating request on the application, they should send the request to MMAC.PROVIDERENROLLMENT@dss.mo.gov. MMAC cannot back date more than 365 days.
- How does a provider determine if they are enrolled as a MO HealthNet provider?
Once the provider is enrolled, they will received an approval letter. The approval letter will contain the effective date and the Medicaid ID as well as the program the provider is enrolled in. Providers may utilize the MO HealthNet Provider Search to review the published information MMAC has on file.
- Where does a MO HealthNet provider find their Medicaid ID and effective date?
Approval letters from MMAC will contain the effective date and the Medicaid ID as well as the program a provider is enrolled in. The provider may send an inquiry to MMAC for this information, however MMAC will only release the information to personnel listed as the contact person for the enrollment. Providers may utilize the MO HealthNet Provider Search to review the published information MMAC has on file
Revalidation for MO HealthNet Providers
- How often does a provider have to revalidate as a MO HealthNet provider?
State and federal regulations require enrolled MO HealthNet providers to revalidate their enrollment at least every five years. Visit Revalidating Providers for more information.
- How does a provider find their revalidation date?
Providers and their authorized representatives can visit eMOMED to determine their revalidation due dates.
General Claim Questions
- For questions regarding prior authorization, fee schedules, and other claim issues, who would a provider contact?
Provider Communications is available to assist providers with questions about proper claim filing, claims resolution or disposition, participant eligibility and verification. Contact Provider Communications via eMOMED or by calling (573) 751-2896.
For prior authorizations, fee schedules, and additional claims and billing information, visit the MHD website, Claims & Billing and Education & Training.
Revised October 2024