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

MO HealthNet Division 1

MO HealthNet Internet Provider Training Program

Presented by the Provider Education UnitMO HealthNet Division


Why Is It Necessary to

Check a MO HealthNet Participant’s Eligibility Before Every Service is

Provided?


MO HealthNet Eligibility

Can a provider afford to not check

a participant’s eligibility before each service is provided?

NO!



MO HealthNet ID Card

FRONT BACK

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.



Patient’s Responsibility to AdviseThe 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.”



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,

www.emomed.com; Interactive Voice Response (IVR) system at 573/751-2896 or

573/635-8908; or,Batch eligibility through the 271 Eligibility Verification

Response.



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




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, www.emomed.com, using the name on the MO HealthNet eligibility file, not the name on the Medicare file.




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.




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.




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.




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.




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.




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.




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.


www.emomed.com Eligibility Request Form


Participant with MHD Only


Participant with Medicare A, B and C who is QMB Eligible



Interactive Voice Response (IVR)

573/635-8908

Participant Eligibility including TPL, Medicare Part A, Part B, QMB and Part C eligibility.

Last two check amounts. Claim Status. Informational Messages.



Can a provider afford to not check

a participant’s eligibility before each service is provided?

NO!



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 573/751-6683.

Documents

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