Current state and federal regulations (13 CSR 65-2 and 42 CFR 455.410) require ordering, prescribing or referring (OPR) providers to enroll with Medicaid, even if they do not accept Medicaid. In response, MO HealthNet has begun implementing changes in the claims processing system to deny all claims that require an order, prescription or referral from a physician or other licensed health care professional unless that physician or provider has an active enrollment record on file.
The Mo Healthnet Remittance Advices for Durable Medical Equipment (DME), Independent Laboratory medical claims, Imaging medical claims, and Home Health claims contain the following alert when the ordering, prescribing, or referring provider on the claim is not an actively enrolled provider:
N613 Alert: Although this was paid, you have billed with an ordering provider that needs to update their enrollment record. Please verify that the ordering provider information you submitted on the claim is accurate and if it is, contact the ordering provider instructing them to update their enrollment record. Unless corrected, a claim with this ordering provider will not be paid in the future.In November 2017, the claims will begin to deny unless the ordering, prescribing, or referring provider information is on the claim, and the provider is enrolled with MO HealthNet.
In order to assist with this process, the Missouri Medicaid Audit and Compliance Unit (MMAC) provides an Ordering Prescribing and Referring Enrollment Application [OPR]
MMAC’s provider enrollment personnel will expedite all OPR applications received.
For more information, please choose “Providers” from the MMAC home page, and then choose “Provider Enrollment” and then choose “Ordering, Prescribing and Referring Enrollment Application [OPR]” providers.
Please submit any questions to MMAC.ProviderEnrollment@dss.mo.gov
Missouri Medicaid Audit and Compliance (MMAC), as part of the Department of Social Services (DSS) and in response to Governor Eric Greitens’ Executive Order 17-03, encourages public input on DSS’ Administrative Rules.
Please click here to view the dates, times, and locations for upcoming opportunities to comment on MMAC and other DSS rules. The link will also provide you with information regarding how to comment on the rules, on-line, instead of in person, if you wish.
Please contact MMAC at MMAC.General@dss.mo.gov with any questions.
Beginning January 1, 2018, according to federal regulation 42 CFR 438.602, states must screen and enroll, and periodically revalidate, all network providers of managed care organizations. This requirement applies to ordering, prescribing, and referring “OPR” providers in the managed care setting, as well.
This requirement does not cause managed care network providers to see Fee For Service Medicaid clients.
Missouri Medicaid Audit and Compliance (MMAC) is working with the MO HealthNet Division and the managed care health plans to provide a streamlined process for enrolling managed care network providers that have not yet enrolled with MO HealthNet.
Please submit any questions you may have to MMAC.ProviderEnrollment@dss.mo.gov
Missouri Medicaid Audit and Compliance (MMAC), as part of the Department of Social Services (DSS) and in response to Governor Eric Greitens’ Executive Order 17-03, encourages public input on DSS’ Administrative Rules.
Please view the News Release from DSS. The News Release contains information about DSS’ Administrative Rules, including where to view them, how to comment, and the time and location of public hearings.
Learn more about the Administrative Rules review at https://nomoredtape.com/
Please submit any questions to MMAC.General@dss.mo.gov
Extended Women’s Health Services cover family planning-related services, pregnancy testing, sexually transmitted disease testing and treatment, including pap tests and pelvic exams, and follow-up services. They are covered by MO HealthNet for uninsured women who are 18-55 years of age with a Modified Adjusted Gross Income for the household size that does not exceed 201% of the Federal Poverty Level (FPL). The Medicaid Eligibility (ME) Code is “80/89”.
Funding for the Extended Women’s Health Services program has transferred from the Department of Social Services to the Department Health and Senior Services (DHSS), per HB 10 of the 2017 Regular Session of the General Assembly. Specifically, Section 10.714 states, “none of the funds appropriated herein may be expended to directly or indirectly subsidize abortion services as defined in Section 170.015, RSMo. or procedures or administrative functions and none of the funds appropriated herein may be paid or granted to an organization that provides abortion services. An otherwise qualified organization shall not be disqualified from receipt of these funds because of its affiliation with an organization that provides abortion services, provided that the affiliated organization that provides abortion services is independent of the qualified organization. An independent affiliate that provides abortion services must be separately incorporated from any organization that receives these funds.”
Providers equipped to provide abortion services (hospitals, ambulatory surgical centers equipped to provide abortion services, and clinics) will receive letters regarding this restriction and will be required to submit an attestation in order to receive Extended Women’s Health Services “80/89” funding. This restriction does not affect any other MO HealthNet billing.
The attestations will continue to be sent to Missouri Medicaid Audit and Compliance (MMAC) so they may update the provider file and provide the MO HealthNet Division with current provider enrollment information.
