STATE OF MISSOURI MANUAL PRIVATE DUTY NURSING

STATE OF MISSOURI

PRIVATE DUTY NURSING MANUAL

Private Duty Nursing

SECTION 1-PARTICIPANT CONDITIONS OF PARTICIPATION ........................................13 1.1 INDIVIDUALS ELIGIBLE FOR MO HEALTHNET, MANAGED CARE OR STATE FUNDED BENEFITS ........................................................................................................................13

1.1.A DESCRIPTION OF ELIGIBILITY CATEGORIES .............................................................13 1.1.A(1) MO HealthNet ...............................................................................................................13 1.1.A(2) MO HealthNet for Kids.................................................................................................14 1.1.A(3) Temporary MO HealthNet During Pregnancy (TEMP)................................................16 1.1.A(4) Voluntary Placement Agreement for Children .............................................................16 1.1.A(5) State Funded MO HealthNet .........................................................................................16 1.1.A(6) MO Rx...........................................................................................................................17 1.1.A(7) Women's Health Services .............................................................................................17 1.1.A(8) ME Codes Not in Use ...................................................................................................18

1.2 MO HEALTHNET AND MO HEALTHNET MANAGED CARE ID CARD......................18 1.2.A FORMAT OF MO HEALTHNET ID CARD .......................................................................19 1.2.B ACCESS TO ELIGIBILITY INFORMATION.....................................................................20 1.2.C IDENTIFICATION OF PARTICIPANTS BY ELIGIBILITY CODES ...............................20 1.2.C(1) MO HealthNet Participants ...........................................................................................20 1.2.C(2) MO HealthNet Managed Care Participants..................................................................20 1.2.C(3) TEMP ............................................................................................................................20 1.2.C(4) Temporary Medical Eligibility for Reinstated TANF Individuals ................................21 1.2.C(5) Presumptive Eligibility for Children .............................................................................21 1.2.C(6) Breast or Cervical Cancer Treatment Presumptive Eligibility ......................................21 1.2.C(7) Voluntary Placement Agreement ..................................................................................21 1.2.D THIRD PARTY INSURANCE COVERAGE ......................................................................22 1.2.D(1) Medicare Part A, Part B and Part C ..............................................................................22

1.3 MO HEALTHNET, STATE FUNDED MEDICAL ASSISTANCE AND MO HEALTHNET MANAGED CARE APPLICATION PROCESS .................................................22 1.4 AUTOMATIC MO HEALTHNET ELIGIBILITY FOR NEWBORN CHILDREN ...........23

1.4.A NEWBORN INELIGIBILITY ..............................................................................................24 1.4.B NEWBORN ADOPTION ......................................................................................................24 1.4.C MO HEALTHNET MANAGED CARE HEALTH PLAN NEWBORN ENROLLMENT..24 1.5 PARTICIPANTS WITH RESTRICTED/LIMITED BENEFITS ..........................................25 1.5.A LIMITED BENEFIT PACKAGE FOR ADULT CATEGORIES OF ASSISTANCE .........25 1.5.B ADMINISTRATIVE PARTICIPANT LOCK-IN .................................................................27 1.5.C MO HEALTHNET MANAGED CARE PARTICIPANTS .................................................27

1.5.C(1) Home Birth Services for the MO HealthNet Managed Care Program ..........................29 1.5.D HOSPICE BENEFICIARIES ................................................................................................29 1.5.E QUALIFIED MEDICARE BENEFICIARIES (QMB) .........................................................30 1.5.F WOMEN'S HEALTH SERVICES PROGRAM (ME CODES 80 and 89)...........................31 1.5.G TEMP PARTICIPANTS........................................................................................................31

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Private Duty Nursing

1.5.G(1) TEMP ID Card ..............................................................................................................32 1.5.G(2) TEMP Service Restrictions ...........................................................................................33 1.5.G(3) Full MO HealthNet Eligibility After TEMP .................................................................33 1.5.H PROGRAM FOR ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) .....................33 1.5.I MISSOURI'S BREAST AND CERVICAL CANCER TREATMENT (BCCT) ACT ..........34 1.5.I(1) Eligibility Criteria ...........................................................................................................34 1.5.I(2) Presumptive Eligibility ...................................................................................................35 1.5.I(3) Regular BCCT MO HealthNet .......................................................................................35 1.5.I(4) Termination of Coverage ................................................................................................36 1.5.J TICKET TO WORK HEALTH ASSURANCE PROGRAM ................................................36 1.5.J(1) Disability ........................................................................................................................36 1.5.J(2) Employment ...................................................................................................................36 1.5.J(3) Premium Payment and Collection Process.....................................................................36 1.5.J(4) Termination of Coverage................................................................................................37 1.5.K PRESUMPTIVE ELIGIBILITY FOR CHILDREN..............................................................37 1.5.K(1) Eligibility Determination ..............................................................................................38 1.5.K(2) MO HealthNet for Kids Coverage ................................................................................38 1.5.L MO HEALTHNET COVERAGE FOR INMATES OF A PUBLIC INSTITUTION ...........39 1.5.L(1) MO HealthNet Coverage Not Available .......................................................................40 1.5.L(2) MO HealthNet Benefits .................................................................................................40 1.5.M VOLUNTARY PLACEMENT AGREEMENT, OUT-OF- HOME CHILDREN'S SERVICES ......................................................................................................................................41 1.5.M(1) Duration of Voluntary Placement Agreement ..............................................................41 1.5.M(2) Covered Treatment and Medical Services....................................................................41 1.5.M(3) Medical Planning for Out-of-Home Care.....................................................................41 1.6 ELIGIBILITY PERIODS FOR MO HEALTHNET PARTICIPANTS ................................42 1.6.A DAY SPECIFIC ELIGIBILITY ............................................................................................43 1.6.B SPENDDOWN.......................................................................................................................44 1.6.B(1) Notification of Spenddown Amount .............................................................................45 1.6.B(2) Notification of Spenddown on New Approvals ............................................................45 1.6.B(3) Meeting Spenddown with Incurred and/or Paid Expenses............................................45 1.6.B(4) Meeting Spenddown with a Combination of Incurred Expenses and Paying the Balance .....................................................................................................................................................46 1.6.B(5) Preventing MO HealthNet Payment of Expenses Used to Meet Spenddown ...............46 1.6.B(6) Spenddown Pay-In Option ............................................................................................47 1.6.B(7) Prior Quarter Coverage .................................................................................................47 1.6.B(8) MO HealthNet Coverage End Dates .............................................................................48 1.6.C PRIOR QUARTER COVERAGE .........................................................................................48 1.6.D EMERGENCY MEDICAL CARE FOR INELIGIBLE ALIENS ........................................48 1.7 PARTICIPANT ELIGIBILITY LETTERS AND CLAIMS CORRESPONDENCE...........49 1.7.A NEW APPROVAL LETTER ................................................................................................50 1.7.A(1) Eligibility Letter for Reinstated TANF (ME 81) Individuals .......................................50

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Private Duty Nursing

1.7.A(2) BCCT Temporary MO HealthNet Authorization Letter ...............................................50 1.7.A(3) Presumptive Eligibility for Children Authorization PC-2 Notice.................................50 1.7.B REPLACEMENT LETTER...................................................................................................51 1.7.C NOTICE OF CASE ACTION................................................................................................51 1.7.D PARTICIPANT EXPLANATION OF MO HEALTHNET BENEFITS ..............................51 1.7.E PRIOR AUTHORIZATION REQUEST DENIAL ...............................................................52 1.7.F PARTICIPANT SERVICES UNIT ADDRESS AND TELEPHONE NUMBER.................52 1.8 TRANSPLANT PROGRAM ......................................................................................................52 1.8.A COVERED ORGAN AND BONE MARROW/STEM CELL TRANSPLANTS ................53 1.8.B PATIENT SELECTION CRITERIA.....................................................................................53 1.8.C CORNEAL TRANSPLANTS................................................................................................53 1.8.D ELIGIBILITY REQUIREMENTS ........................................................................................53 1.8.E MANAGED CARE PARTICIPANTS...................................................................................54 1.8.F MEDICARE COVERED TRANSPLANTS ..........................................................................54 SECTION 2-PROVIDER CONDITIONS OF PARTICIPATION ...............................................56 2.1 PROVIDER ELIGIBILITY .......................................................................................................56 2.1.A QMB-ONLY PROVIDERS...................................................................................................56 2.1.B NON-BILLING MO HEALTHNET PROVIDER ................................................................56 2.1.C PROVIDER ENROLLMENT ADDRESS ............................................................................56 2.1.D ELECTRONIC CLAIM/ATTACHMENTS SUBMISSION AND INTERNET AUTHORIZATION ........................................................................................................................57 2.1.E PROHIBITION ON PAYMENT TO INSTITUTIONS OR ENTITIES LOCATED OUTSIDE OF THE UNITED STATES..........................................................................................57 2.2 NOTIFICATION OF CHANGES..............................................................................................57 2.3 RETENTION OF RECORDS ....................................................................................................58 2.3.A ADEQUATE DOCUMENTATION......................................................................................58 2.4 NONDISCRIMINATION POLICY STATEMENT ................................................................58 2.5 STATE'S RIGHT TO TERMINATE RELATIONSHIP WITH A PROVIDER.................59 2.6 FRAUD AND ABUSE ................................................................................................................59 2.6.A CLAIM INTEGRITY FOR MO HEALTHNET PROVIDERS ............................................60 2.7 OVERPAYMENTS .....................................................................................................................60 2.8 POSTPAYMENT REVIEW .......................................................................................................61 2.9 PREPAYMENT REVIEW .........................................................................................................61 2.10 DIRECT DEPOSIT AND REMITTANCE ADVICE ............................................................62 2.11 NATIONAL CORRECT CODING INITIATIVE .................................................................63 SECTION 3 - STAKEHOLDER SERVICES .................................................................................64 3.1 PROVIDER SERVICES .............................................................................................................64 3.1.A MHD TECHNICAL HELP DESK ........................................................................................64 3.2 Missouri Medicaid Audit & Compliance (MMAC)..................................................................64 3.2.A PROVIDER ENROLLMENT UNIT.....................................................................................65 3.3 PROVIDER COMMUNICATIONS UNIT ...............................................................................65 3.3.A INTERACTIVE VOICE RESPONSE (IVR) SYSTEM .......................................................65

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Private Duty Nursing

3.3.A(1) Using the Telephone Key Pad.......................................................................................72 3.3.B MO HEALTHNET SPECIALIST .........................................................................................72 3.3.C INTERNET ............................................................................................................................73 3.3.D WRITTEN INQUIRIES ........................................................................................................74 3.4 PROVIDER EDUCATION UNIT..............................................................................................75 3.5 PARTICIPANT SERVICES.......................................................................................................75 3.6 PENDING CLAIMS ....................................................................................................................76 3.7 FORMS .........................................................................................................................................76 3.8 CLAIM FILING METHODS ....................................................................................................76 3.9 CLAIM ATTACHMENT SUBMISSION VIA THE INTERNET..........................................76 3.10 Pharmacy & Clinical Services Unit..........................................................................................76 3.11 Pharmacy and Medical Pre-certification Help Desk ..............................................................77 3.12 Third Party Liability (TPL)......................................................................................................77 SECTION 4 - TIMELY FILING......................................................................................................78 4.1 TIME LIMIT FOR ORIGINAL CLAIM FILING ..................................................................78 4.1.A MO HEALTHNET CLAIMS ................................................................................................78 4.1.B MEDICARE/MO HEALTHNET CLAIMS ..........................................................................78 4.1.C MO HEALTHNET CLAIMS WITH THIRD PARTY LIABILITY.....................................78 4.2 TIME LIMIT FOR RESUBMISSION OF A CLAIM .............................................................79 4.2.A CLAIMS FILED AND DENIED ..........................................................................................79 4.2.B CLAIMS FILED AND RETURNED TO PROVIDER .........................................................79 4.3 CLAIMS NOT FILED WITHIN THE TIME LIMIT .............................................................80 4.4 TIME LIMIT FOR FILING AN INDIVIDUAL ADJUSTMENT..........................................80 4.5 DEFINITIONS .............................................................................................................................81 SECTION 5-THIRD PARTY LIABILITY .....................................................................................83 5.1 GENERAL INFORMATION.....................................................................................................83 5.1.A MO HEALTHNET IS PAYER OF LAST RESORT ............................................................83 5.1.B THIRD PARTY LIABILITY FOR MANAGED CARE ENROLLEES...............................84 5.1.C PARTICIPANTS LIABILITY WHEN THERE IS A TPR ...................................................86 5.1.D PROVIDERS MAY NOT REFUSE SERVICE DUE TO TPL ............................................86 5.2 HEALTH INSURANCE IDENTIFICATION ..........................................................................87 5.2.A TPL INFORMATION ...........................................................................................................87 5.2.B SOLICITATION OF TPR INFORMATION ........................................................................87 5.3 INSURANCE COVERAGE CODES.........................................................................................88 5.4 COMMERCIAL HEALTH CARE PLANS..............................................................................89 5.5 MEDICAL SUPPORT ................................................................................................................90 5.6 PROVIDER CLAIM DOCUMENTATION REQUIREMENTS ...........................................90 5.6.A EXCEPTION TO TIMELY FILING LIMIT.........................................................................90 5.7 THIRD PARTY LIABILITY BYPASS .....................................................................................91 5.8 MO HEALTHNET INSURANCE RESOURCE REPORT (TPL-4).....................................92 5.9 LIABILITY AND CASUALTY INSURANCE.........................................................................92 5.9.A TPL RECOVERY ACTION..................................................................................................93

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