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Determining Eligibility and Benefits

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Presentation on theme: "Determining Eligibility and Benefits"— Presentation transcript:

1 Determining Eligibility and Benefits
MO HealthNet

2 MO HealthNet ID Card Front Page

3 MO HealthNet ID Card Back Page Patient’s Responsibility to Advise
“You must present this card each time you get medical services.” “You must tell the provider of services if you have other insurance MO HealthNet

4 Provider’s Responsibility to Check
Once the participant tells the provider he/she has MO HealthNet, it’s the provider’s responsibility to check the person’s eligibility. This must be done before every visit, preferably the day of the visit. MO HealthNet

5 There are several ways to check eligibility:. Internet at emomed
There are several ways to check eligibility: * Internet at or * IVR (Interactive Voice Response) at 573/ MO HealthNet

6 Reasons to Check Eligibility
Name on File Eligibility of date of service Medical eligibility/plan code Medicare Commercial Insurance MHD Managed Care enrollment Administrative Lock-in MO HealthNet

7 Emomed Log on Screen MO HealthNet

8 Participant Eligibility
MO HealthNet

9 Eligibility Request Enter the required information and “Submit”.
The asterisk (*) indicates required information. MO HealthNet

10 Submitted Information
Participant Information MO HealthNet

11 1 – Active 6 – Inactive B – Co-Payment D – Benefit Description F – Limitations L – Primary Care Provider M – Services Restricted to Following Provider R – Other or Additional Payer U – Contact Following Entity for Eligibility or Benefit Information. Y - Spenddown MO HealthNet

12 Plan Codes/Medical Eligibility (ME) Codes can be found in Section 1. 1
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 HealthNet

13 The Time Period Qualifier represents the eligibility information.
7 – Day * 34 - Month MO HealthNet

14 The Time Period Qualifier represents the eligibility information.
7 – Day 34 – Month * MO HealthNet

15 HM – Health Maintenance Organization (HMO)
Valid values are: MA – Medicare Part A MB – Medicare Part B MC – MO HealthNet HM – Health Maintenance Organization (HMO) HN – Health Maintenance Organization (HMO) Medicare Risk (Medicare Part C – Replacement Plan) OT – Other QM – Qualified Medicare Beneficiary MO HealthNet

16 Spenddown Indicator Spenddown Amount Medicare Part A Medicare Part B
QMB MO HealthNet

17 Medicare Part C Indicator
Plan MO HealthNet

18 Medicare Part C Indicator
Plan MO HealthNet

19 Hospice Lock-in MO HealthNet

20 Lock-in to Medical Clinic
MO HealthNet

21 Lock-in to Pharmacy MO HealthNet

22 The Confirmation Number
You may print the eligibility screen by clicking on “Print”. Once you have completed your inquiry, click on “Finish”. MO HealthNet

23 Third 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. MO HealthNet

24 Third Party Liability (Cont)
To update the participant’s “insurance” file contact MO HealthNet Third Party Liability Unit at 573/ You may also complete and mail in the Insurance Resource Report (TPL-4) form which can be found on the MHD Web site at Under Featured Links, scroll to MO HealthNet forms. Click on Insurance Resource Form. MO HealthNet

25 Administrative 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

26 Administrative 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

27 TEMP Eligibility Card MO HealthNet

28 ME CODES 58 & 59 Pregnant 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. MO HealthNet

29 ME 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

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. MO HealthNet

31 Women’s Health Services
The 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 HealthNet

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; and drugs, 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

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 Exam V738 – V7388……….Special Screening Exam for Viral and Chlamydial diseases V739 – V7398…….....Unspecified Viral and Chlamydial disease V745 – V745…………Venereal Disease MO HealthNet

34 091 – 0912…………...Early Syphilis, symptomatic
………..Genital Herpes 091 – 0912…………...Early Syphilis, symptomatic 092 – 0929…………...Early Syphilis, latent 098 – 09819………….Gonococcal Infections 099 – 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

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

36 Medical Eligibility Code 55
For 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

37 Participant Copayment
Inpatient 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 MO HealthNet

38 Additional Copayment Requirements
Adults 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 Podiatry Medicaid Program Changes, Vol. 27, No. 26 dated July 12, 2005 MO HealthNet

39 Exemption to the Copayment Requirement
Services 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; MO HealthNet

40 Exemptions 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 patient’s 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; MO HealthNet

41 Exemptions 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; MO HealthNet

42 Exemptions 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 children’s mental health service system; Medicaid Waiver services; Hospice services; and Personal Care services which are medically oriented tasks having to do with a person’s 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. MO HealthNet

43 Spenddown Program Some 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 ; or Paying the monthly spenddown amount to the MO HealthNet Division (MHD). MO HealthNet

44 Spenddown 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. MO HealthNet

45 Thank you again for participating in this training program
Thank 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/ MO HealthNet

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