The Provider Enrollment Unit is responsible for enrolling new providers in accordance with 13 CSR 70-3, maintaining provider records, and answering provider inquiries related to enrollment for all MO HealthNet provider types. The Provider Enrollment staff is authorized and required to determine when new provider numbers are issued or when a current provider number will be updated.
After a MO HealthNet provider number has been issued it must be used with all transactions pertaining to MO HealthNet. If a separate provider number has been issued for different location/practices, the provider is responsible to ensure the appropriate provider number is used when billing. Learn more about provider enrollment.
ContractsThe Contracts staff reviews proposals submitted by entities who wish to contract with MMAC to provide In-Home Services (IHS) or Consumer Directed Services (CDS) to participants authorized by the Department of Health and Senior Services (DHSS).
RevalidationsState and federal regulations require all currently enrolled Medicaid providers to revalidate their enrollment at least every five (5) years.
State and federal regulations (13 CSR 65.2 and 42 CFR 455.414) require all enrolled Medicaid providers to do certain things:
Revalidate their information at least every five (5) years Certain providers must pay an application fee Providers must be screened according to categorical risk level Ordering, referring, and prescribing providers must be enrolledPlease click on “Providers” at the top of this page, and choose “Provider Enrollment” to see further information on each one of these categories.
In March, 2014, MMAC posted an update to the RAC (Recovery Audit Contractor) and MIC (Medicaid Integrity Contractor) activities on its website. See the archived post here March 2014 RAC and MIC update. Cognosante, LLC is the RAC for Missouri. Section 6411 of the Affordable Care Act, Expansion of Recovery Audit Contractor (RAC) Program, amends section 1902(a)(42) of the Social Security Act and requires states to contract with a RAC vendor and allows states to reimburse contractors who assist in the identification and recovery of improper payments.
Should you receive any communication from an entity representing itself on behalf of Missouri Medicaid Audit and Compliance (MMAC), or Cognosante, and you are concerned about the legitimacy of the person or company, you should contact MMAC at (573) 751-3399 to verify the communication or request is legitimate.
In 2015, the RAC will finish its work on outstanding pharmacy and durable medical equipment (DME) audits, and will begin conducting audits of hospital billing submitted by enrolled Missouri hospital providers. The RAC may request documentation to support billing of outpatient encounters, including professional and facility services in the emergency room. The RAC will review paid claims for proper billing of both professional and facility services, and the appropriate utilization of facility resources, such as supplies and facility charges. Documentation requests may include requests for itemized statements, medical records, medication administration records, radiology interpretations, and laboratory results to support the claims submitted for payment.
MO HealthNet reimburses eligible participants or nonemergency medical transportation (NEMT) providers for medically necessary transportation only if a participant does not have access to transportation services that are available free of charge. For more guidance on the NEMT program and its other requirements, please read the regulation (13 CSR 70-5.010) at https://www.sos.mo.gov
The MO HealthNet Division also has information about NEMT services on their website at https://dss.mo.gov/mhd/participants/pages/medtrans.htm
MO HealthNet also covers ambulance services for eligible participants if they are emergency services and transportation is made to the nearest appropriate hospital. Further information about the Emergency Ambulance Program is located in 13 CSR 70-6.010 at https://www.sos.mo.gov
MMAC encourages providers, who may call on behalf of participants, to be familiar with the program rules and requirements.
