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MO HealthNet Division1 MO HealthNet Internet Provider Training Program Presented by the Provider Education Unit MO HealthNet Division.

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Presentation on theme: "MO HealthNet Division1 MO HealthNet Internet Provider Training Program Presented by the Provider Education Unit MO HealthNet Division."— Presentation transcript:

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2 MO HealthNet Division1 MO HealthNet Internet Provider Training Program Presented by the Provider Education Unit MO HealthNet Division

3 2 Why Is It Necessary to Check a MO HealthNet Participant’s Eligibility Before Every Service is Provided?

4 MO HealthNet Division3 MO HealthNet Eligibility Can a provider afford to not check a participant’s eligibility before each service is provided? NO!

5 MO HealthNet Division4 MO HealthNet Eligibility MO HealthNet ID Card FRONTBACK Every MO HealthNet participant is issued a MO HealthNet ID card. It could be the older red card or the newer white card shown below.

6 MO HealthNet Division5 MO HealthNet Eligibility Patient’s Responsibility to Advise The back of either card states the following. “You must present this card each time you get medical services.” “You must tell the provider of services if you have other insurance.”

7 MO HealthNet Division6 MO HealthNet Eligibility 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 service, preferably the day of the service. There are several ways to check eligibility:  Internet at the MO HealthNet Web portal,  Interactive Voice Response (IVR) system at 573/ or 573/ ; or,  Batch eligibility through the 271 Eligibility Verification Response.

8 MO HealthNet Division7 MO HealthNet Eligibility Reasons to Check Eligibility 1.Name 2.Eligibility on date of service 3.Medical eligibility code 4.Medicare 5.Commercial insurance 6.MO HealthNet Managed Care enrollment 7.Administrative Lock-in

9 MO HealthNet Division8 MO HealthNet Eligibility Reasons to Check Eligibility 1. Name - You must file your claim with the name on the MHD eligibility file. MHD enrolls with the legal name. Medicare allows persons to enroll with a name other than their legal name. This can result in a crossover claim denying for an invalid name. The provider will need to file a crossover claim through the MO HealthNet Web portal, using the name on the MO HealthNet eligibility file, not the name on the Medicare file.

10 MO HealthNet Division9 MO HealthNet Eligibility Reasons to Check Eligibility 2. Eligibility on the date of service - If the patient is not eligible, you can bill the patient. The patient may be on spenddown and the person has not incurred or reported their expenses to their caseworker. This person becomes eligible the date of service their reported expense meets the monthly spenddown amount. It’s also possible the participant has not paid their monthly spenddown premium to MO HealthNet. A patient who has MO HealthNet pending is not eligible but can be made eligible retroactively.

11 MO HealthNet Division10 MO HealthNet Eligibility Reasons to Check Eligibility 3. Medical Eligibility (ME) Code - Certain ME codes have limited benefits. They include but are not limited to the following: ME codes 58 and 59 which is temporary coverage for pregnant women for routine ambulatory prenatal services only. ME codes 80 and 89, MO HealthNet for Women; and, ME code 55, qualified Medicare beneficiary. Section 1.1.a of the provider manual gives details on the various ME codes including those with limited benefits.

12 MO HealthNet Division11 MO HealthNet Eligibility Reasons to Check Eligibility 4. Medicare - If the person is on Medicare, know this immediately so you can file the claim to Medicare and not to MO HealthNet. Remember, because the person is not 65 does not mean they may not be on Medicare. Medicare eligibility can include persons under 65.

13 MO HealthNet Division12 MO HealthNet Eligibility Reasons to Check Eligibility 5. Commercial Insurance - MO HealthNet is the payer of last resort. If the patient has commercial insurance, you must file to the carrier first and then to MO HealthNet. Your MO HealthNet claim must show either a payment or a denial in order for it to be considered for payment. Certain services and diagnosis codes are exempt from this requirement. These are covered in Section 5.7 of the provider manuals.

14 MO HealthNet Division13 MO HealthNet Eligibility Reasons to Check Eligibility 6. MO HealthNet Managed Care enrollment – You must file your claims to the participant’s managed care health plan. If you are not a contracted plan provider, you cannot bill the health plan unless you have received authorization from the plan. There is an exception to this for family planning services. Otherwise, you cannot bill MO HealthNet nor the participant. Family Planning Exclusion.

15 MO HealthNet Division14 MO HealthNet Eligibility Reasons to Check Eligibility 6. MO HealthNet Managed Care enrollment – continued Some services are provided outside the Managed Care Health Plan program and are detailed in Section 11.7 of the provider manual. Emergency exclusion. Private pay arrangement.

16 MO HealthNet Division15 MO HealthNet Eligibility Reasons to Check Eligibility 7. Administrative Lock-in – Approximately 1,700 participants are locked-in to providers because of improper use of their MO HealthNet benefits. You must have an approved referral on file from the lock-in provider in order for your claim to be paid. If the care is non-emergent and there is no referral, you can bill the patient. Emergency exclusion.

17 MO HealthNet Division16 Eligibility Request Form

18 MO HealthNet Division17 Participant with MHD Only

19 MO HealthNet Division18 Participant with Medicare A, B and C who is QMB Eligible

20 MO HealthNet Division19 MO HealthNet Eligibility Interactive Voice Response (IVR) 573/  Participant Eligibility including TPL, Medicare Part A, Part B, QMB and Part C eligibility.  Last two check amounts.  Claim Status.  Informational Messages.

21 MO HealthNet Division20 MO HealthNet Eligibility Can a provider afford to not check a participant’s eligibility before each service is provided? NO!

22 MO HealthNet Division21 MO HealthNet Eligibility Questions or More Information? If you have questions or would like more information regarding the material in this presentation, please feel free to contact the Provider Education Unit at 573/


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