Determining Eligibility and Benefits

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1MO HealthNetMO HealthNet ID Card Front Page

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2MO HealthNet ID CardBack PagePatients Responsibility to AdviseMO HealthNet

You must present this card each time you get medical services.You must tell the provider of services if you have other insurance3

3Providers Responsibility to CheckOnce the participant tells the provider he/she has MO HealthNet, its the providers responsibility to check the persons eligibility. This must be done before every visit, preferably the day of the visit.MO HealthNet

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4There are several ways to check eligibility:

* Internet at emomed.com or

* IVR (Interactive Voice Response) at 573/751-2896. MO HealthNet

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5Reasons to Check EligibilityName on FileEligibility of date of serviceMedical eligibility/plan codeMedicareCommercial InsuranceMHD Managed Care enrollmentAdministrative Lock-inMO HealthNet

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6Emomed Log on Screen

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8Participant Eligibility

8Eligibility RequestEnter the required information and Submit.

The asterisk (*) indicates required information.

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Submitted Information

Participant InformationMO HealthNet10

101 Active6 InactiveB Co-PaymentD Benefit DescriptionF LimitationsL Primary Care ProviderM Services Restricted to Following ProviderR Other or Additional PayerU Contact Following Entity for Eligibility or Benefit Information.Y - Spenddown www.dss.mo.gov/mhd.providers/index/htm

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Plan Codes/Medical Eligibility (ME) Codes can be found in Section 1.1.A of the General Sections (All) of the State of Missouri MO HealthNet Manuals. MO HealthNet12

www.dss.mo.gov/mhd.providers/index/htm12 The Time Period Qualifier represents the eligibility information.7 Day *34 - MonthMO HealthNet

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13The Time Period Qualifier represents the eligibility information.7 Day34 Month *MO HealthNet

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14Valid values are:MA Medicare Part AMB Medicare Part BMC MO HealthNetHM Health Maintenance Organization (HMO)HN Health Maintenance Organization (HMO) Medicare Risk (Medicare Part C Replacement Plan)OT OtherQM Qualified Medicare BeneficiaryMO HealthNet

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15Spenddown IndicatorSpenddownAmount

Medicare Part A

Medicare Part B

QMB

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Medicare Part C Indicator

Medicare Part CPlanMO HealthNet17

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Medicare Part C Indicator

Medicare Part CPlanMO HealthNet18

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MO HealthNet19Hospice Lock-in

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20Lock-in to Medical Clinic

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21Lock-in to Pharmacy

21The Confirmation NumberYou may print the eligibility screen by clicking on Print.Once you have completed your inquiry, click on Finish.

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22MO HealthNetThird Party Liability (TPL)

If no TPL information is displayed, the participant does not have TPL data on file with MO HealthNet for the date(s) of service requested.

If TPL information is displayed, the insurance company name and address is displayed.

NOTE: If no third party insurance appears on the TPL segment but the participant tells you about commercial insurance, this information must be corrected.

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23MO HealthNetThird Party Liability (Cont)

To update the participants insurance file contact MO HealthNet Third Party Liability Unit at 573/751-2005.

You may also complete and mail in the Insurance Resource Report (TPL-4) form which can be found on the MHD Web site at www.dss.mo.gov/mhd.providers/index/htmUnder Featured Links, scroll to MO HealthNet forms. Click on Insurance Resource Form.

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24Administrative Lock-In (Cont)Participants who are locked-in to another provider for administrative purposes, e.g., abuse, overutilization, etc. must be referred by the lock-in provider for services. The PI-118 referral form is to be completed and signed by the Authorized Lock-In Provider when a referral to another provider is medically necessary. The referral is valid for a maximum of 30 days. The referral form must be attached to each claim or can be entered online on emomed in order for the performing provider to receive payment. MO HealthNet

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25Administrative Lock-in (Cont.)If emergency services are provided, a completed Certificate of Medical Necessity form must be attached to the claim when it is submitted for payment explaining the emergency. The claim must be filed on paper. Medical records verifying the emergency should be attached.MO HealthNet

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26TEMP Eligibility CardMO HealthNet27

27ME CODES 58 & 59Pregnant women who have been determined presumptively eligible for Temporary Medicaid During Pregnancy (TEMP) do not receive a plastic Medicaid ID card but receive a white paper TEMP card.

A TEMP card is issued for a limited period but presumptive eligibility may be extended if the pregnant women applies for public assistance at the county Family Support Division office. The TEMP card may only be used for ambulatory prenatal services. Because TEMP services are limited, providers should verify that the service to be provided is covered by the TEMP card.

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28ME CODES 58 & 59 (Cont)The start date (FROM) is the date the qualified provider issues the TEMP card, and coverage expires at midnight on the expiration date (THROUGH) shown. A TEMP replacement letter (IM-29 TEMP) may also be issued when the TEMP individual has formally applied for Medicaid of MC+ and is awaiting eligibility determination.Third party insurance information does not appear on a TEMP card.MO HealthNet

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29TEMP SERVICE RESTRICTIONS

TEMP services for pregnant women are limited to ambulatory physician, clinic, nurse midwife, diagnostic laboratory, x-ray, pharmacy, and outpatient hospital services. Services other than those listed above may be covered with the attachment of a Certificate of Medical Necessity that testifies that the pregnancy would have been adversely affected without the service. Inpatient services, including miscarriage or delivery, are not covered for TEMP participants.If eligible, temporary coverage will be replaced with full coverage.

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30Womens Health ServicesThe medical eligibility (ME) codes are 80 and 89.The program is available to uninsured women who lost MO HealthNet eligibility 60 days after the birth of a child up to one year (ME Code 80).The expanded program is for uninsured women (ME code 89) who qualify (details in Physician Bulletin, Vol. 31 No. 44 dated February 9, 2009).If a woman has been sterilized or had a hysterectomy, she is not eligible for program services.MO HealthNet31

31SERVICE PACKAGE/BENEFITS

Women's health services include:family planning counseling/education on various methods of birth control;Department of Health and Human Services approved methods of contraception;diagnosis, testing and treatment of a sexually transmitted disease, including pap tests and pelvic exams found during a family planning visit; anddrugs, supplies, or devices related to women's health services described above that are prescribed by a physician or advanced practice nurse (subject to the national drug rebate program requirements).MO HealthNet

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32COVERED DIAGNOSIS CODES

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All services for ME code 80 and 89 must be billed with a primary diagnosis code of V25-V25.9 (family planning) in order for the claims to be paid. While the primary diagnosis code must be family planning, the following diagnosis codes can be listed as secondary.

V723 - V7231..Well Woman ExamV738 V7388.Special Screening Exam for Viral and Chlamydial diseasesV739 V7398.....Unspecified Viral and Chlamydial diseaseV745 V745Venereal Disease

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3305410 -05419..Genital Herpes091 0912...Early Syphilis, symptomatic092 0929...Early Syphilis, latent098 09819.Gonococcal Infections099 0999...Other Venereal Diseases If the woman comes back for additional treatment of a sexually transmitted disease and the visit is NOT related to family planning, the cost for the visit and any treatment or testing is NOT covered and can be billed to the patient. This claim must be billed with a diagnosis code related to treatment of the disease and must NOT be billed with a family planning diagnosis.MO HealthNet

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34Medical Eligibility Code 82Participants with a ME code of 82 only have Pharmacy Medicare Part D wrap-around benefits through the MoRx Program.MO HealthNet

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35Medical Eligibility Code 55For a QMB only participant, MO HealthNet only reimburses providers for Medicare deductible and coinsurance amounts for services covered by Medicare, including providers of services not currently covered by MO HealthNet such as chiropractors and independent therapists. MO HealthNet does not reimburse for non-Medicare services, such as prescription drugs, eyeglasses, most dental services, adult day health care, personal care services, most eye exams performed by an optometrist or nursing care services not covered by Medicare. The medical eligibility code of the participant is 55. MO HealthNet

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36Participant CopaymentInpatient Hospital Copayment will be applied to the first date of admission, except for emergency or transfer inpatient hospital admissions $10.00 Outpatient Hospital $3.00 Case Management $1.00 Physician, M.D. $1.00 Physician, D.O. $1.00 Nurse Midwife $1.00 Nurse Practitioner $1.00 Psychologist $2.00

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www.dss.mo.gov/mhd.providers/index/htm37Additional Copayment RequirementsAdults receiving a limited benefit package shall continue to be required to pay a small portion of the costs of the services provided through the following programs: Dental related to trauma or the treatment of a disease/medical condition Optical related to trauma or the treatment of a disease/medical condition and one eye exam every two years PodiatryMedicaid Program Changes, Vol. 27, No. 26 dated July 12, 2005

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38Exemption to the Copayment RequirementServices provided to participants under nineteen (19) years of age; or participants receiving Medicaid under the following categories of assistance: ME Codes 06, 33, 34, 36, 40, 52, 56, 57, 60, 62, 64, 65, 71, 72, 73, 74, 75, 87, and 88; Services provided to participants residing within a skilled nursing home, an intermediate care nursing home, a residential care home, an adult boarding home or a psychiatric hospital; or participants receiving Medicaid under the following categories of assistance: ME Codes 23 and 41; Services provided to participants who have both Medicare and Medicaid if Medicare covers the service and provides payment for it; or participants receiving Medicaid under the following category of assistance: ME Code 55; Emergency or transfer inpatient hospital admission;

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39Exemptions to Copayment Requirement (Cont.)Emergency services provided in an outpatient clinic or emergency room after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in: Placing the patients health in serious jeopardy; Serious impairment to bodily functions; or Serious dysfunction of any bodily organ or part; Certain therapy services (physical therapy, chemotherapy, radiation therapy, psychotherapy and chronic renal dialysis) except when provided as an inpatient hospital service;

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40Exemptions to Copayment Requirement (Cont.)Services provided to pregnant women who are receiving Medicaid under the following categories of assistance only: ME Codes 18, 43, 44, 45, 58, 59 and 61; Services provided to foster care participants who are receiving Medicaid under the following categories of assistance: ME Codes 07, 08, 28, 29, 30, 37, 49, 50, 51, 63, 66, 67, 68, 69 and 70; Services identified as medically necessary through an Early Periodic Screening, Diagnostic and Treatment (EPSDT) screen; Services provided to persons receiving Medicaid under a category of assistance for the blind: ME Codes 02, 03, 12 and 15; Services provided to MC+ Managed Care enrollees; Family Planning Services;

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41Exemptions to Copayment Requirement (Cont.)Mental Health services provided by community mental health facilities operated by the Department of Mental Health or designated by the Department of Mental Health as a community mental health facility or as an alcohol and drug abuse facility or as a child-serving agency within the comprehensive childrens mental health service system; Medicaid Waiver services; Hospice services; and Personal Care services which are medically oriented tasks having to do with a persons physical requirements, as opposed to housekeeping requirements, which enable a person to be treated by his physician on an outpatient, rather than on an inpatient or residential basis in a hospital, intermediate care facility, or skilled nursing facility.

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42Spenddown ProgramSome participants are eligible for MO HealthNet only on the basis of meeting a monthly spenddown requirement.The participant may choose to meet their spenddown by either :Submitting incurred medical expenses to their Family Support Division (FSD) eligibility specialist ; orPaying the monthly spenddown amount to the MO HealthNet Division (MHD). MO HealthNet43

43Spenddown Program (Cont.)For the months that the participant does not pay-in or submit bills, no MO HealthNet coverage is available.Spendown eligibility can change during the month depending on the spenddown option chosen by the participant and whether payment or medical bills are received.

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44Thank you again for participating in this training program. If you have any questions regarding the information in this presentation, please contact the Provider Education Unit at 573/751-6683. MO HealthNet

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