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CODE OF STATE REGULATIONS 1JOHN R. ASHCROFT (4/30/18)Secretary of State

Rules ofDepartment of Social Services

Division 70—MO HealthNet DivisionChapter 3—Conditions of Provider Participation,

Reimbursement and Procedure ofGeneral Applicability

Title Page

13 CSR 70-3.020 Title XIX Provider Enrollment ...............................................................3

13 CSR 70-3.030 Sanctions for False or Fraudulent Claims for MO HealthNet Services ...............5

13 CSR 70-3.040 Duty of Medicaid Participating Hospitals and Other Vendors to Assist in Recovering Third-Party Payments ......................................................11

13 CSR 70-3.050 Obtaining Information From Providers of Medical Services ..........................11

13 CSR 70-3.060 Medicaid Program Payment of Claims for Medicare Part B Services (Rescinded August 11, 1988) ..............................................................11

13 CSR 70-3.100 Filing of Claims, MO HealthNet Program ...............................................11

13 CSR 70-3.105 Timely Payment of MO HealthNet Claims ...............................................13

13 CSR 70-3.110 Second Opinion Requirement Before Nonemergency Elective Surgical Operations (Rescinded June 30, 2011) ...................................................14

13 CSR 70-3.120 Limitations on Payment of Out-of-State Nonemergency Medical Services..........14

13 CSR 70-3.130 Computation of Provider Overpayment by Statistical Sampling.......................15

13 CSR 70-3.140 Direct Deposit of Provider Reimbursement...............................................16

13 CSR 70-3.150 Authorization To Receive Payment for Medicaid Services .............................17

13 CSR 70-3.160 Electronic Submission of MO HealthNet Claims and Electronic Remittance Advices.........................................................................................17

13 CSR 70-3.170 Medicaid Managed Care Organization Reimbursement Allowance...................18

13 CSR 70-3.180 Medical Pre-Certification Process..........................................................20

13 CSR 70-3.190 Telehealth Services............................................................................20

13 CSR 70-3.200 Ambulance Service Reimbursement Allowance..........................................23

2 CODE OF STATE REGULATIONS (4/30/18) JOHN R. ASHCROFT

Secretary of State

13 CSR 70-3.210 Electronic Retention of Records ............................................................24

13 CSR 70-3.220 Electronic Health Record Incentive Program.............................................24

13 CSR 70-3.230 Payment Policy for Provider Preventable Conditions ...................................25

13 CSR 70-3.240 MO HealthNet Primary Care Health Homes.............................................27

13 CSR 70-3.250 Payment Policy for Early Elective Delivery ..............................................30

13 CSR 70-3.260 Payment Policy for Asthma Education and In-Home Environmental Assessments ...................................................................................31

Title 13—DEPARTMENT OFSOCIAL SERVICES

Division 70—MO HealthNet DivisionChapter 3—Conditions of ProviderParticipation, Reimbursement andProcedure of General Applicability

13 CSR 70-3.020 Title XIX ProviderEnrollment

PURPOSE: This rule establishes the basis onwhich providers and vendors of health careservices under the MO HealthNet programmay be admitted to or denied enrollment inthe program and lists the grounds upon whichenrollment may be denied.

(1) The following definitions will be used inadministering this rule:

(A) Affiliates—Persons having an overt,covert, or conspiratorial relationship so thatany one of them directly or indirectly controlsor has the power to control another;

(B) Applying provider—Any person whohas submitted a provider enrollment applica-tion or request for enrollment in the MOHealthNet program;

(C) Closed-end provider agreement—Anagreement that is for a specific period of timenot to exceed twelve (12) months and thatmust be renewed in order for the provider tocontinue to participate in the MO HealthNetprogram;

(D) Fiscal agent—An organization undercontract to the state MO HealthNet agencyfor providing services in the administration ofthe MO HealthNet program;

(E) Limited provider agreement—Thegranting of MO HealthNet enrollment to anapplying provider by the single state agencyupon the condition that the applying providerperform services, deliver supplies, or other-wise participate in the program only in adher-ence to or subject to specially set out condi-tions agreed to by the applying provider priorto enrollment;

(F) Medicaid agency or the agency—Thesingle state agency administering or supervis-ing the administration of a state Medicaidplan;

(G) Open-end provider agreement—Anagreement that has no specific terminationdate and continues in force as long as it isagreeable to both parties;

(H) Participation—The ability and authori-ty to provide services or merchandise to eli-gible MO HealthNet participants and toreceive payment from the MO HealthNet pro-gram for the services or merchandise;

(I) Provider—Any person having an effec-tive, valid, and current written providerenrollment application and application for

provider direct deposit with the MO Health-Net agency for the purpose of providing ser-vices to eligible participants and obtainingreimbursement excluding, for the purposes ofthis rule only, all persons receiving reim-bursement in their capacity as owners oroperators of a licensed nursing home;

(J) Provider enrollment application—Asigned writing utilizing forms specified by thesingle state agency, containing all applicableinformation requested and submitted by aprovider of medical assistance services forthe purpose of enrolling in the MO HealthNetprogram;

(K) Person—Any natural person, partner-ship, corporation, not-for-profit corporation,professional corporation, or other businessentity;

(L) Termination from participation—Theending of participation in the Medicaid pro-gram; and

(M) Application for provider directdeposit—A signed writing utilizing formsspecified by the single state agency containingall applicable information requested and sub-mitted by a provider of medical assistanceservices for the purpose of having MOHealthNet checks automatically deposited toan authorized bank account.

(2) Duties of the Single State Agency.(A) Upon receiving a provider enrollment

application and application for provider directdeposit, the single state agency shall recordreceipt of the applications and conduct what-ever lawful investigation which, in the discre-tion of the MO HealthNet agency, is neces-sary to verify, supplement, or change theinformation contained in the application.

(B) If, in the discretion of the MO Health-Net agency, further information is neededfrom the applying provider to verify or sup-plement a provider enrollment application orapplication for direct deposit, the MOHealthNet agency shall immediately make aclear and precise request to the provider forthe information and inform the prospectiveprovider whether or not the applications willbe withheld pending receipt of the requestedinformation.

(C) The single state agency, within ninety(90) calendar days after receiving an applica-tion, shall complete its investigation anddetermine whether to deny or allow enroll-ment of the applying provider. The MOHealthNet agency’s decision shall be madeknown to the applying provider within nine-ty-five (95) calendar days after the applica-tion was received by the agency. A denial ofenrollment shall be made known to an apply-ing provider giving the reason(s) for thedenial in writing. The written notice of denial

will be effective upon the date it is mailed bythe single state agency to the address enteredon the application by the provider.

(D) In the event that the applications can-not be fully investigated by the single stateagency within ninety (90) days of receipt, theMO HealthNet agency, upon written notice tothe applying provider, may extend the timefor conducting the investigation for a periodnot to exceed one hundred twenty (120) cal-endar days from the date of receipt of theapplications by the MO HealthNet agency.The MO HealthNet agency must send thenotice of delay to the applying provider with-in sixty (60) calendar days from the time theapplication in question was received.

(3) The single state agency, at its discretion,may deny or limit an applying provider’senrollment and participation in the MOHealthNet program for any one (1) of the fol-lowing reasons:

(A) A false representation or omission ofany material fact or information required orrequested by the single state agency pursuantto an applying provider making application toenroll. This shall include material facts oromissions about previous Medicaid participa-tion in Missouri or any other state of theUnited States;

(B) Previous or current involuntary surren-der, removal, termination, suspension, ineli-gibility, or otherwise involuntary disqualifi-cation of the applying provider’s Medicaidparticipation in Missouri or any other state ofthe United States;

(C) Previous or current involuntary surren-der, removal, termination, suspension, orotherwise involuntary disqualification fromparticipation in Medicare;

(D) Previous or current involuntary surren-der, removal, termination, suspension, ineli-gibility, or otherwise involuntary disqualifi-cation from participation in anothergovernmental or private medical insuranceprogram. This includes, but is not limited to,programs such as Workers’ Compensationand Special Health Needs. For the purposesof subsections (3)(B)–(D), involuntary sur-render, removal, termination, suspension,ineligibility, or other involuntary disqualifica-tion shall include withdrawal from medicalassistance or medical insurance program par-ticipation arising from or as a result of anyadverse action by a government agency,licensing authority, or criminal prosecutionauthority of Missouri or any other state or thefederal government including Medicare;

(E) Regardless of changes in control orownership, the existence of any amount duethe single state agency which is the result ofan overpayment under the MO HealthNet

CODE OF STATE REGULATIONS 3ROBIN CARNAHAN (11/30/10)Secretary of State

Chapter 3—Conditions of Provider Participation, Reimbursementand Procedure of General Applicability 13 CSR 70-3

program of which the applying provider orformer owner, regardless of when the ser-vices were rendered, has had notice. Anyamount due which is the subject of a plan ofrestitution shall not be considered in applyingthis section unless the applying provider is indefault of the plan of restitution in which caseenrollment may be denied or limited;

(F) Previous or current conviction of anycrime relating to the applying provider’s pro-fessional, business, or past participation inMedicaid, Medicare, or any other public orprivate medical insurance program;

(G) Any civil or criminal fraud against theMO HealthNet program or any other publicor private medical insurance program;

(H) Any termination, removal, suspension,revocation, denial or consented surrender, orother involuntary disqualification of anylicense, permit, certificate, or registrationrelated to the applying provider’s business orprofession in Missouri or any other state ofthe United States. Any such license, permit,certificate, or registration which has beendenied or lost by the provider for reasons notrelated to matters of professional competencein the practice of the applying provider’s pro-fession, upon proof of reinstatement, shallnot be considered by the agency in its deci-sion to enroll the applying providers unlessthe conduct is harmful or dangerous to themental or physical health of a patient;

(I) Any false representation or omission ofa material fact in making application for anylicense, permit, certificate, or registrationrelated to the applying provider’s professionor business in Missouri or any other state ofthe United States;

(J) Any previous failure to correct defi-ciencies in provider operation after receivingwritten notice of the deficiencies from thesingle state agency;

(K) Any previous violation of any regula-tion or statute relating to the applyingprovider’s participation in the MO HealthNetprogram;

(L) Failure to supply further information tothe single state agency after receiving a writ-ten request for further information pursuantto a provider enrollment application or appli-cation for provider direct deposit;

(M) Failure to affix a proper signature to aprovider enrollment application, applicationfor provider direct deposit, or any otherenrollment forms. Submission of any applica-tion bearing a signature that conceals theinvolvement in the provider’s operation of aperson who would otherwise be ineligible forMedicaid participation shall be grounds fordenial of enrollment by the single state agen-cy. Otherwise, the single state agency shallgive the applying provider an opportunity to

provide a proper signature and, after that,consider the application as if the proper sig-nature was originally affixed;

(N) A previous or current conviction or aplea of guilty to a misdemeanor or felonycharge, including any suspended impositionof sentence, any suspended execution of sen-tence, or any period of probation or parolerelating to:

1. Endangering the welfare of a child;2. Abusing or neglecting a resident,

patient, or client;3. Misappropriating funds or property

belonging to a resident, patient, or client; or4. Falsifying documentation verifying

delivery of services to a personal care assis-tance services consumer;

(O) Placement on the “Family Care SafetyRegistry” as mandated by sections 210.900–210.936, RSMo;

(P) Placement on the “Missouri SexOffender Registry” as mandated by sections589.400–589.425 and 43.650, RSMo; or

(Q) Failure to complete an application forprovider direct deposit as required by 13 CSR70-3.140.

(4) After investigation and review of theapplying provider’s provider enrollmentapplication and application for provider directdeposit and consideration of all the informa-tion, facts, and circumstances relevant to theapplications, including, but not limited to, areview of the applying provider’s affiliates,the single state agency, at its discretion, in thebest interest of the MO HealthNet program,will make one (1) of the following determina-tions:

(A) Enroll the applying provider in anopen-ended provider agreement;

(B) Deny or limit the application of anapplying provider based on the abuse, fraud,or deficiencies of an affiliate, provided thateach decision to deny or limit is based on acase-by-case evaluation, taking into consider-ation all relevant facts and circumstancesknown to the single state agency. The pro-gram abuse, fraud, regulatory violation, ordeficiencies of a past or present affiliate of anapplying provider may be imputed to theapplying provider where the conduct of a pastor present affiliate was accomplished with theknowledge or approval of the applyingprovider; or

(C) Deny or limit the applying provider’senrollment for one (1) or more of the reasonsin subsections (3)(A)–(Q).

(5) Denial of enrollment shall preclude anyperson from submitting claims for payment,either personally or through claims submittedby any clinic, group, corporation, affiliate,

partner, or any other association to the singlestate agency or its fiscal agents for any ser-vices or supplies delivered under the MOHealthNet program whose enrollment as aMO HealthNet provider has been denied.Any claims submitted by a nonproviderthrough any clinic, group, corporation, affil-iate, partner, or any other association andpaid shall constitute overpayments.

(6) No clinic, group, corporation, partner-ship, affiliate, or other association may sub-mit claims for payment to the single stateagency or its fiscal agent for any services orsupplies provided by a person within eachassociation who has been denied enrollmentin the MO HealthNet program. Any claimsfor payment submitted and paid under thesecircumstances shall constitute overpayments.

(7) The provider shall advise the single stateagency, in writing, on enrollment forms spec-ified by the single state agency, of anychanges affecting the provider’s enrollmentrecords within ninety (90) days of the change,with the exception of change of ownership orcontrol of any provider which must be report-ed within thirty (30) days. The ProviderEnrollment Unit within the division isresponsible for determining whether a currentMO HealthNet provider record shall beupdated or a new MO HealthNet providerrecord is created. A new MO HealthNetprovider record is not created for anychanges, including, but not limited to, changeof ownership, change of operator, tax identi-fication change, merger, bankruptcy, namechange, address change, payment addresschange, Medicare number change, NationalProvider Identifier (NPI) change, or facili-ties/offices that have been closed andreopened at the same or different locations.This includes replacement facilities, whetherthey are at the same location or a differentlocation, and whether the Medicare numberis retained or if a new Medicare number isissued. If a new provider record is created inerror due to change information being with-held at the time of application, the new MOHealthNet provider record shall be madeinactive, the existing provider record will bemade active, the existing provider recordshall be updated, and the provider may besubject to sanction. The division shall issuepayments to the entity identified in the cur-rent MO HealthNet provider enrollmentapplication. Regardless of changes in controlor ownership, the division shall recover fromthe entity identified in the currentMO HealthNet provider enrollment applica-tion liabilities, sanctions, and penalties per-taining to the MO HealthNet program,

4 CODE OF STATE REGULATIONS (11/30/10) ROBIN CARNAHAN

Secretary of State

13 CSR 70-3—DEPARTMENT OF SOCIAL SERVICES Division 70—MO HealthNet Division

regardless of when the services were ren-dered.

(8) MO HealthNet provider identifiers arecontingent upon the applying provider receiv-ing a favorable determination of compliancewith Civil Rights requirements from theOffice of Civil Rights (OCR). If OCRapproval is not obtained and maintained, anyreimbursement received shall be recouped.

(9) The provider is responsible for all ser-vices provided and all claims filed usingher/his MO HealthNet provider identifierregardless to whom the reimbursement ispaid and regardless of whom in her/hisemploy or services produced or submitted theMO HealthNet claim, or both. The provideris responsible for submitting proper diagnosiscodes, procedure codes, and billing codes.When the length of time actually spent pro-viding a service (begin and end time) isrequired to be documented, the provider isresponsible for documenting such length oftime by documenting the starting clock timeand the end clock time, except for services asspecified pursuant to 13 CSR 70-91.010(4)(A), Personal Care Program,regardless to whom the reimbursement ispaid and regardless of whom in the provider’semploy or services produced or submitted theMO HealthNet claim.

(10) MO HealthNet provider identifiers shallnot be released to any non-governmental enti-ty, except the enrolled provider, by theMO HealthNet Division or its agents.

(11) MO HealthNet reimbursement shall notbe made for any services performed by anindividual not enrolled as a MO HealthNetprovider, except for those services performedby the employee of the enrolled provider whois acting within their scope of practice andunder the direct supervision of the enrolledprovider. For example, an enrolled psycholo-gy or therapy provider may only bill for ser-vices that they actually perform. Psychology,therapy, and psychiatric services reimbursedthrough the physician program do not allowbilling for supervised services.

(12) A provider that receives payment ormakes payment of five (5) million dollars ormore in a federal fiscal year under the MOHealthNet program must annually attest thatthe provider complies with the provisions ofsection 6032 of the federal Deficit ReductionAct of 2005. If a provider furnishes items orservices at more than a single location orunder more than one (1) contractual or otherpayment arrangement, the provisions apply to

that provider if the aggregate payments totalfive (5) million dollars or more. A providermeeting this dollar threshold and having morethan one (1) federal tax identification numbershall provide the single state agency writtennotification of each associated federal taxidentification number, each associatedprovider name, and each associated MOHealthNet provider identifier by September30 of each year. The provider’s annual attes-tation must be made by March 1 of each year.The provider must provide a copy of the attes-tation within thirty (30) days upon the requestof the single state agency. Any provider thatclaims an exemption from the provisions ofsection 6032 of the federal Deficit ReductionAct of 2005 must provide proof of suchexemption within thirty (30) days upon therequest of the single state agency.

AUTHORITY: sections 208.159, 208.164,and 210.924, RSMo 2000 and sections208.153 and 208.201, RSMo Supp. 2009.*This rule was previously filed as 13 CSR 40-81.165. Original rule filed June 14, 1982,effective Sept. 11, 1982. Amended: Filed July30, 2002, effective Feb. 28, 2003. Amended:Filed April 29, 2005, effective Oct. 30, 2005.Amended: Filed Nov. 1, 2005, effective June30, 2006. Amended: Filed March 30, 2007,effective Oct. 30, 2007. Amended: Filed June1, 2010, effective Dec. 30, 2010.

*Original authority: 208.153, RSMo 1967, amended

1967, 1973, 1989, 1990, 1991, 2007; 208.159, RSMo

1979; 208.164, RSMo 1982, amended 1995; 208.201,

RSMo 1987, amended 2007; and 210.924, RSMo 1999.

13 CSR 70-3.030 Sanctions for False orFraudulent Claims for MO HealthNet Ser-vices

PURPOSE: This rule establishes the basis onwhich certain claims for MO HealthNet ser-vices or merchandise will be determined to befalse or fraudulent and lists the sanctionswhich may be imposed and the method ofimposing those sanctions.

PUBLISHER’S NOTE: The secretary of statehas determined that the publication of theentire text of the material which is incorporat-ed by reference as a portion of this rule wouldbe unduly cumbersome or expensive. Thismaterial as incorporated by reference in thisrule shall be maintained by the agency at itsheadquarters and shall be made available tothe public for inspection and copying at nomore than the actual cost of reproduction.This note applies only to the reference materi-al. The entire text of the rule is printed here.

(1) Administration. (A) The MO HealthNet program shall be

administered by the Department of SocialServices, MO HealthNet Division. The ser-vices covered and not covered, the limitationsunder which services are covered, and themaximum allowable fees for all covered ser-vices shall be determined by the division andshall be included in the MO HealthNetprovider manuals, which are incorporated byreference and made a part of this rule as pub-lished by the Department of Social Services,MO HealthNet Division, 615 HowertonCourt, Jefferson City, MO 65109, at its web-site dss.mo.gov/mhd, October 1, 2017. Thisrule does not incorporate any subsequentamendments or additions.

(B) When a rule published in the MissouriCode of State Regulations relating to a specificprovider type or service incorporates by refer-ence a MO HealthNet provider manual whichcontains a later date of incorporation than 13CSR 70-3.030, the manual incorporated intothe more specific rule shall be applied in placeof the manual incorporated into 13 CSR 70-3.030.


(A) Adequate documentation means docu-mentation from which services rendered andthe amount of reimbursement received by aprovider can be readily discerned and verifiedwith reasonable certainty. “Adequate medicalrecords” are records which are of the type andin a form from which symptoms, conditions,diagnosis, treatments, prognosis, and the iden-tity of the patient to which these things relatecan be readily discerned and verified with rea-sonable certainty. All documentation must bemade available at the same site at which theservice was rendered. An adequate and com-plete patient record is a record which is legi-ble, which is made contemporaneously withthe delivery of the service, which addressesthe patient/client specifics, which include, at aminimum, individualized statements that sup-port the assessment or treatment encounter,and shall include documentation of the follow-ing information:

1. First name, last name, and eithermiddle initial or date of birth of the MOHealthNet participant;

2. An accurate, complete, and legibledescription of each service(s) provided;

3. Name, title, and signature of the MOHealthNet enrolled provider delivering theservice. Inpatient hospital services must havesigned and dated physician or psychologistorders within the patient’s medical record forthe admission and for services billed to MOHealthNet. For patients registered on hospital



records as outpatient, the patient’s medicalrecord must contain signed and dated physi-cian orders for services billed to MO Health-Net. Services provided by an individualunder the direction or supervision are notreimbursed by MO HealthNet. Services pro-vided by a person not enrolled with MOHealthNet are not reimbursed by MO Health-Net;

4. The name of the referring entity,when applicable;

5. The date of service (month/day/year);6. For those MO HealthNet programs

and services that are reimbursed according tothe amount of time spent in delivering or ren-dering a service(s) (except for services Amer-ican Medical Association Current ProceduralTerminology procedure codes 99291–99292and targeted case management servicesadministered through the Department ofMental Health and as specified under 13 CSR70-91.010 Personal Care Program (4)(A)) theactual begin and end time taken to deliver theservice (for example, 4:00–4:30 p.m.) mustbe documented;

7. The setting in which the service wasrendered;

8. The plan of treatment, evaluation(s),test(s), findings, results, and prescription(s)as necessary. Where a hospital acts as anindependent laboratory or independent radi-ology service for persons considered by thehospital as “nonhospital” patients, the hospi-tal must have a written request or requisitionslip ordering the tests or procedures;

9. The need for the service(s) in rela-tionship to the MO HealthNet participant’streatment plan;

10. The MO HealthNet participant’sprogress toward the goals stated in the treat-ment plan (progress notes);

11. Long-term care facilities shall beexempt from the seventy-two- (72-) hour doc-umentation requirements rules applying toparagraphs (2)(A)9. and (2)(A)10. However,applicable documentation should be con-tained and available in the entirety of themedical record;

12. For applicable programs, it is neces-sary to have adequate invoices, triptickets/reports, activity log sheets, employeerecords (excluding health records), and train-ing records of staff; and

13. For targeted case management ser-vices administered through the Department ofMental Health, documentation shall include:

A. First name, last name, and eithermiddle initial or date of birth of the MOHealthNet participant;

B. An accurate, complete, and legiblecase note of each service provided;

C. Name of the case manager provid-ing the service;

D. Date the service was provided(month/day/year);

E. Amount of time in minutes/hour(s)spent completing the activity;

F. Setting in which the service wasrendered;

G. Individual treatment plan or per-son centered plan with regular updates;

H. Progress notes;I. Discharge summaries when appli-

cable; andJ. Other relevant documents refer-

enced in the case note such as letters, forms,quarterly reports, and plans of care;

(B) Affiliates means persons having anovert, covert, or conspiratorial relationship sothat any one (1) of them directly or indirectlycontrols or has the power to control another;

(C) Closed-end provider agreement meansan agreement that is for a specified period oftime, not to exceed twelve (12) months, andthat must be renewed in order for theprovider to continue to participate in the MOHealthNet program;

(D) Contemporaneous means at the timethe service was performed or within five (5)business days, of the time the service wasprovided;

(E) Federal health care program means aprogram as defined in section 1128B(f) of theSocial Security Act;

(F) Fiscal agent means an organizationunder contract to the state MO HealthNetagency for providing any services in theadministration of the MO HealthNet program;

(G) MO HealthNet agency or the agencymeans the single state agency administeringor supervising the administration of a stateMedicaid plan;

(H) Open-end provider agreement meansan agreement that has no specific terminationdate and continues in force as long as it isagreeable to both parties;

(I) Participation means the ability andauthority to provide services or merchandiseto eligible MO HealthNet participants and toreceive payment from the MO HealthNet pro-gram for those services or merchandise;

(J) Person means any natural person, com-pany, firm, partnership, unincorporated asso-ciation, corporation, or other legal entity;

(K) Provider means an individual, firm,corporation, pharmacy, hospital, long-termcare facility, association, or institution whichhas a provider agreement to provide servicesto a participant pursuant to Chapter 208,RSMo;

(L) Record means any books, papers, jour-nals, charts, treatment histories, medical his-tories, tests and laboratory results, pho-

tographs, X rays, and any other recordings ofdata or information made by or caused to bemade by a provider relating in any way to ser-vices provided to MO HealthNet participantsand payments charged or received. MOHealthNet claim for payment information,appointment books, financial ledgers, finan-cial journals, or any other kind of patientcharge without corresponding adequate med-ical records do not constitute adequate docu-mentation;

(M) Supervision means to direct anemployee of the provider in the performanceof a covered and allowable service such asunder the MO HealthNet dental and nursemidwife programs or a covered and allowablenonpsychiatric service under the MO Health-Net physician program. In order to direct theperformance of such service, the providermust be in the office where the service isbeing provided and must be immediatelyavailable to give directions in person to theemployee actually rendering the service andthe adequately documented service must becosigned by the enrolled billing provider;

(N) Suspension from participation meansan exclusion from participation for a speci-fied period of time;

(O) Suspension of payments means place-ment of payments due a provider in an escrowaccount;

(P) Termination from participation meansthe ending of participation in the MO Health-Net program; and

(Q) Withholding of payments means areduction or adjustment of the amounts paid toa provider on pending and subsequently sub-mitted bills for purposes of offsetting overpay-ments previously made to the provider.

(3) Program Violations.(A) Sanctions may be imposed by the MO

HealthNet agency against a provider for anyone (1) or more of the following reasons:

1. Presenting, or causing to be present-ed, for payment any false or fraudulent claimfor services or merchandise in the course ofbusiness related to MO HealthNet;

2. Submitting, or causing to be submit-ted, false information for the purpose ofobtaining greater compensation than that towhich the provider is entitled under applicableMO HealthNet program policies or rules,including, but not limited to, the billing orcoding of services which results in paymentsin excess of the fee schedule for the serviceactually provided or billing or coding of ser-vices which results in payments in excess ofthe provider’s charges to the general public forthe same services or billing for higher level ofservice or increased number of units fromthose actually ordered or performed or both,


Secretary of State


or altering or falsifying medical records toobtain or verify a greater payment thanauthorized by a fee schedule or reimburse-ment plan;

3. Submitting, or causing to be submit-ted, false information for the purpose of meet-ing prior authorization requirements or for thepurpose of obtaining payments in order toavoid the effect of those changes;

4. Failing to make available, and disclos-ing to the MO HealthNet agency or its autho-rized agents, all records relating to servicesprovided to MO HealthNet participants orrecords relating to MO HealthNet payments,whether or not the records are commingledwith non-Title XIX (Medicaid) records. Allrecords must be kept a minimum of five (5)years from the date of service unless a morespecific provider regulation applies. The min-imum five- (5-) year retention of recordsrequirement continues to apply in the event ofa change of ownership or discontinuing enroll-ment in MO HealthNet. Services billed to theMO HealthNet agency that are not adequatelydocumented in the patient’s medical records orfor which there is no record that services wereperformed shall be considered a violation ofthis section. Copies of records must be provid-ed upon request of the MO HealthNet agencyor its authorized agents, regardless of themedia in which they are kept. Failure to makethese records available on a timely basis at thesame site at which the services were renderedor at the provider’s address of record with theMO HealthNet agency, or failure to providecopies as requested, or failure to keep andmake available adequate records which ade-quately document the services and paymentsshall constitute a violation of this section andshall be a reason for sanction. Failure to sendrecords, which have been requested via mail,within the specified time frame shall constitutea violation of this section and shall be a reasonfor sanction;

5. Failing to provide and maintain quality,necessary, and appropriate services, includingadequate staffing for long-term care facilityMO HealthNet participants, within acceptedmedical community standards as adjudged by abody of peers, as set forth in both federal andstate statutes or regulations. Failure shall bedocumented by repeat discrepancies. The dis-crepancies may be determined by a peer reviewcommittee, medical review teams, independentprofessional review teams, utilization reviewcommittees, or by Professional StandardsReview Organizations (PSRO). The medicalreview may be conducted by qualified peersemployed by the single state agency;

6. Engaging in conduct or performing anact deemed improper or abusive of theMO HealthNet program or continuing the

conduct following notification that the conductshould cease. This will include inappropriateor improper actions relating to the manage-ment of participants’ personal funds or otherfunds;

7. Breaching of the terms of the MOHealthNet provider agreement of any currentwritten and published policies and proceduresof the MO HealthNet program (Such policiesand procedures are contained in provider man-uals or bulletins which are incorporated byreference and made a part of this rule as pub-lished by the Department of Social Services,MO HealthNet Division, 615 HowertonCourt, Jefferson City, MO 65109, at its web-site www.dss.mo.gov/mhd, October 1, 2017.This rule does not incorporate any subsequentamendments or additions or fail to complywith the terms of the provider certification onthe MO HealthNet claim form;

8. Utilizing or abusing the MO Health-Net program as evidenced by a documentedpattern of inducing, furnishing, or otherwisecausing a participant to receive services ormerchandise not otherwise required orrequested by the participant, attending physi-cian, or appropriate utilization review team; adocumented pattern of performing and billingtests, examinations, patient visits, surgeries,drugs, or merchandise that exceed limits orfrequencies determined by the department forlike practitioners for which there is nodemonstrable need, or for which the providerhas created the need through ineffective ser-vices or merchandise previously rendered;

9. Rebating or accepting a fee or portionof a fee or charge for a MO HealthNet patientreferral; or collecting a portion of the servicefee from the participant, except this shall notapply to MO HealthNet services for whichparticipants are responsible for payment of acopayment or coinsurance in accordance with13 CSR 70-4.050 and 13 CSR 70-4.051;

10. Violating any provision of the StateMedical Assistance Act or any correspondingrule;

11. Submitting a false or fraudulentapplication for provider status which misrep-resents material facts. This shall include con-cealment or misrepresentation of materialfacts required on any provider agreements orquestionnaires submitted by affiliates whenthe provider knew, or should have known, thecontents of the submitted documents;

12. Violating any laws, regulations, orcode of ethics governing the conduct of occu-pations or professions or regulated industries.In addition to all other laws which wouldcommonly be understood to govern or regu-late the conduct of occupations, professions,or regulated industries, this provision shallinclude any violations of the civil or criminal

laws of the United States, of Missouri, or anyother state or territory, where the violation isreasonably related to the provider’s qualifica-tions, functions, or duties in any licensed orregulated profession or where an element ofthe violation is fraud, dishonesty, moralturpitude, or an act of violence;

13. Failing to meet standards requiredby state or federal law for participation (forexample, licensure);

14. Exclusion from the Medicare pro-gram or any other federal health care pro-gram;

15. Failing to accept MO HealthNetpayment as payment in full for covered ser-vices or collecting additional payment from aparticipant or responsible person, except thisshall not apply to MO HealthNet services forwhich participants are responsible for pay-ment of a copayment or coinsurance in accor-dance with 13 CSR 70-4.050 and 13 CSR 70-4.051;

16. Refusing to execute a new provideragreement when requested to do so by the sin-gle state agency in order to preserve the singlestate agency’s compliance with federal andstate requirements; or failure to execute anagreement within twenty (20) days for compli-ance purposes;

17. Failing to correct deficiencies inprovider operations within ten (10) days ordate specified after receiving written noticeof these deficiencies from the single stateagency or within the time frame providedfrom any other agency having licensing orcertification authority;

18. Being formally reprimanded or cen-sured by a board of licensure or an associationof the provider’s peers for unethical, unlawful,or unprofessional conduct; any termination,removal, suspension, revocation, denial, pro-bation, consented surrender, or other disqual-ification of all or part of any license, permit,certificate, or registration related to theprovider’s business or profession in Missourior any other state or territory of the UnitedStates;

19. Being suspended or terminated fromparticipation in another governmental medicalprogram such as Workers’ Compensation,Crippled Children’s Services, RehabilitationServices, Title XX Social Service BlockGrant, or Medicare;

20. Using fraudulent billing practicesarising from billings to third parties for costsof services or merchandise or for negligentpractice resulting in death or injury or sub-standard care to persons including, but notlimited to, the provider’s patients;

21. Failing to repay or make arrange-ments for the repayment of identified over-payments or otherwise erroneous payments



prior to the allowed forty-five (45) dayswhich the provider has to refund the request-ed amount;

22. Billing the MO HealthNet programmore than once for the same service when thebillings were not caused by the single stateagency or its agents;

23. Billing the state MO HealthNet pro-gram for services not provided prior to thedate of billing (prebilling), except in the caseof prepaid health plans or pharmacy claimssubmitted by point-of-service technology;whether or not the prebilling causes loss orharm to the MO HealthNet program;

24. Failing to reverse or credit back tothe medical assistance program (MO Health-Net) within thirty (30) days any pharmacyclaims submitted to the agency that representproducts or services not received by the par-ticipant; for example, prescriptions that werereturned to stock because they were notpicked up;

25. Conducting any action resulting in areduction or depletion of a long-term carefacility MO HealthNet participant’s personalfunds or reserve account, unless specificallyauthorized in writing by the participant, rela-tive, or responsible person;

26. Submitting claims for services notpersonally rendered by the individuallyenrolled provider, except for the provisionsspecified in the MO HealthNet dental, physi-cian, or nurse midwife programs where suchclaims may be submitted only if the individu-ally enrolled provider directly supervised theperson who actually performed the serviceand the person was employed by the enrolledprovider at the time the service was rendered.All claims for psychiatric, psychological coun-seling, speech therapy, physical therapy, andoccupational therapy services may only bebilled by the individually enrolled providerwho actually performs the service, as supervi-sion is noncovered for these services. Ser-vices performed by a nonenrolled person dueto MO HealthNet sanction, whether or not theperson was under supervision of the enrolledprovider, is a noncovered service;

27. Making any payment to any personin return for referring an individual to theprovider for the delivery of any goods or ser-vices for which payment may be made inwhole or in part under MO HealthNet. Solic-iting or receiving any payment from any per-son in return for referring an individual toanother supplier of goods or services regard-less of whether the supplier is a MO Health-Net provider for the delivery of any goods orservices for which payment may be made inwhole or in part under MO HealthNet is alsoprohibited. Payment includes, without limita-tion, any kickback, bribe, or rebate made,

either directly or indirectly, in cash or in-kind;

28. Billing for services through anagent, which were upgraded from those actu-ally ordered, performed; or billing or codingservices, either directly or through an agent,in a manner that services are paid for as sep-arate procedures when, in fact, the serviceswere performed concurrently or sequentiallyand should have been billed or coded as inte-gral components of a total service as pre-scribed in MO HealthNet policy for paymentin a total payment less than the aggregate ofthe improperly separated services; or billinga higher level of service than is documentedin the patient/client record; or unbundlingprocedure codes;

29. Conducting civil or criminal fraudagainst the MO HealthNet program or anyother state Medicaid (medical assistance) pro-gram, or any criminal fraud related to the con-duct of the provider’s profession or business;

30. Having sanctions or any otheradverse action invoked by another state Med-icaid program;

31. Failing to take reasonable measuresto review claims for payment for accuracy,duplication, or other errors caused or com-mitted by employees when the failure allowsmaterial errors in billing to occur. Thisincludes failure to review remittance advicestatements provided which results in pay-ments which do not correspond with the actu-al services rendered;

32. Submitting improper or false claimsto the state or its fiscal agent by an agent oremployee of the provider;

33. For providers other than long-termcare facilities, failing to retain in legible formfor at least five (5) years from the date of ser-vice, worksheets, financial records, appoint-ment books, appointment calendars (for thoseproviders who schedule patient/client appoint-ments), adequate documentation of the ser-vice, and other documents and records verify-ing data transmitted to a billing intermediary,whether the intermediary is owned by theprovider or not. For long-term care providers,failing to retain in legible form, for at leastseven (7) years from the date of service, work-sheets, financial records, adequate documenta-tion for the service(s), and other documentsand records verifying data transmitted to abilling intermediary, whether the intermedi-ary is owned by the provider or not. The doc-umentation must be maintained so as to pro-tect it from damage or loss by fire, water,computer failure, theft, or any other cause;

34. Removing or coercing from the pos-session or control of a participant any item ofdurable medical equipment which hasreached MO HealthNet-defined purchase

price through MO HealthNet rental paymentsor otherwise become the property of the par-ticipant without paying fair market value tothe participant;

35. Failing to timely submit civil rightscompliance data or information or failure totimely take corrective action for civil rightscompliance deficiencies within thirty (30)days after notification of these deficiencies orfailure to cooperate or supply informationrequired or requested by civil rights compli-ance officers of the single state agency;

36. Billing the MO HealthNet programfor services rendered to a participant in along-term care facility when the residentresided in a portion of the facility which wasnot MO HealthNet-certified or properlylicensed or was placed in a nonlicensed orMO HealthNet-noncertified bed;

37. Failure to comply with the provi-sions of the Missouri Department of SocialServices, MO HealthNet Division Title XIXParticipation Agreement with the providerrelating to health care services;

38. Failure to maintain documentationwhich is to be made contemporaneously tothe date of service;

39. Failure to maintain records for ser-vices provided and all billing done underhis/her provider number regardless to whomthe reimbursement is paid and regardless ofwhom in his/her employ or service producedor submitted the MO HealthNet claim orboth;

40. Failure to submit proper diagnosiscodes, procedure codes, billing codes regard-less to whom the reimbursement is paid andregardless of whom in his/her employ or ser-vice produced or submitted the MO Health-Net claim;

41. Failure to submit and document, asdefined in subsection (2)(A) the length of time(begin and end clock time) actually spent pro-viding a service, except for services as speci-fied under 13 CSR 70-91.010(4)(A) PersonalCare Program, regardless to whom the reim-bursement is paid and regardless of whom inhis/her employ or service produced or submit-ted the MO HealthNet claim or both;

42. Billing for the same service as anoth-er provider when the service is performed orattended by more than one (1) enrolledprovider. MO HealthNet will reimburse onlyone (1) provider for the exact same service;

43. Failing to make an annual attestationof compliance with the provisions of Sec-tion 6032 of the federal Deficit Reduction Actof 2005 by March 1 of each year, or failing toprovide a requested copy of an attestation, orfailing to provide written notification of hav-ing more than one (1) federal tax identifica-tion number by September 30 of each year, or


Secretary of State


failing to provide requested proof of aclaimed exemption from the provisions ofsection 6032 of the federal Deficit ReductionAct of 2005; and

44. Failing to advise the single stateagency, in writing, on enrollment forms spec-ified by the single state agency, of anychanges affecting the provider’s enrollmentrecords within ninety (90) days of the change,with the exception of change of ownership orcontrol of any provider which must be report-ed within thirty (30) days.

(4) Any one (1) or more of the followingsanctions may be invoked against providersfor any one (1) or more of the program vio-lations specified in section (3) of this rule:

(A) Failure to respond to notice of overpay-ments or notice of deficiencies in provideroperations within the specified forty-five- (45-)day time limit shall be considered cause towithhold future provider payments until thesituation in question is resolved;

(B) Termination from participation in theMO HealthNet program for a period of notless than sixty (60) days nor more than ten(10) years;

(C) Suspension of participation in the MOHealthNet program for a specified period oftime;

(D) Suspension or withholding of pay-ments to a provider;

(E) Referral to peer review committeesincluding PSROs or utilization review com-mittees;

(F) Recoupment from future provider pay-ments;

(G) Transfer to a closed-end provider agree-ment not to exceed twelve (12) months or theshortening of an already existing closed-endprovider agreement;

(H) Attendance at provider education ses-sions;

(I) Prior authorization of services;(J) One hundred percent (100%) review of

the provider’s claims prior to payment;(K) Referral to the state licensing board for

investigation;(L) Referral to appropriate federal or state

legal agency for investigation, prosecution, orboth, under applicable federal and state laws;

(M) Retroactive denial of payments; and(N) Denial of payment for any new admis-

sion to a skilled nursing facility (SNF), inter-mediate care facility (ICF), or ICF/individu-als with intellectual disabilities (IID) that nolonger meets the applicable conditions of par-ticipation (for SNFs) or standards (for ICFsand ICF/IIDs) if the facility’s deficiencies donot pose immediate jeopardy to patients’health and safety. Imposition of this sanction

must be in accordance with all applicable fed-eral statutes and regulations.

(5) Imposition of a Sanction.(A) The decision as to the sanction to be

imposed shall be at the discretion of the MOHealthNet agency. The following factors shallbe considered in determining the sanction(s)to be imposed:

1. Seriousness of the offense(s)—Thestate agency shall consider the seriousness ofthe offense(s) including, but not limited to,whether or not an overpayment (that is, finan-cial harm) occurred to the program, whethersubstandard services were rendered to MOHealthNet participants, or circumstanceswere such that the provider’s behavior couldhave caused or contributed to inadequate ordangerous medical care for any patient(s), ora combination of these. Violation of pharma-cy laws or rules, practices potentially danger-ous to patients, and fraud are to be consid-ered particularly serious;

2. Extent of violations—The state MOHealthNet agency shall consider the extent ofthe violations as measured by, but not limitedto, the number of patients involved, the num-ber of MO HealthNet claims involved, thenumber of dollars identified in any overpay-ment, and the length of time over which theviolations occurred. The MO HealthNet agen-cy may calculate an overpayment or imposesanctions under this rule by reviewing recordspertaining to all or part of a provider’s MOHealthNet claims. When records are examinedpertaining to part of a provider’s MO Health-Net claims, no random selection process inchoosing the claims for review as set forth in13 CSR 70-3.130 need be utilized by the MOHealthNet agency. But, if the random selectionprocess is not used, the MO HealthNet agencymay not construe violations found in the par-tial review to be an indication that the extentof the violations in any unreviewed claimswould exist to the same or greater extent;

3. History of prior violations—The stateagency shall consider whether or not theprovider has been given notice of prior viola-tions of this rule or other program policies. Ifthe provider has received notice and has failedto correct the deficiencies or has resumed thedeficient performance, a history shall be givensubstantial weight supporting the agency’sdecision to invoke sanctions. If the historyincludes a prior imposition of sanction, theagency should not apply a lesser sanction inthe second case, even if the subsequent viola-tions are of a different nature;

4. Prior imposition of sanctions—TheMO HealthNet agency shall consider moresevere sanctions in cases where a providerhas been subject to sanctions by the MO

HealthNet program, any other governmentalmedical program, Medicare, or exclusion byany private medical insurance carriers formisconduct in billing or professional prac-tice. Restricted or limited participation incompromise after being notified or a moresevere sanction should be considered as aprior imposition of a sanction for the purposeof this subsection;

5. Prior provision of provider educa-tion—In cases where sanctions are being con-sidered for billing deficiencies only, the MOHealthNet agency may mitigate its sanction ifit determines that prior provider education wasnot provided. In cases where sanctions arebeing considered for billing deficiencies onlyand prior provider education has been given,prior provider education followed by a repeti-tion of the same billing deficiencies shallweigh heavily in support of the medical agen-cy’s decision to invoke severe sanctions; and

6. Actions taken or recommended bypeer review groups, licensing boards, or Pro-fessional Review Organizations (PRO) or uti-lization review committees—Actions or rec-ommendations by a provider’s peers shall beconsidered as serious if they involve a deter-mination that the provider has kept or allowedto be kept, substandard medical records, neg-ligently or carelessly performed treatment orservices, or, in the case of licensing boards,placed the provider under restrictions or onprobation.

(B) Where a provider has been convictedof defrauding any Medicaid program, hasbeen previously sanctioned due to programabuse, has been terminated from the Medi-care program, the MO HealthNet agencyshall terminate the provider from participa-tion in the MO HealthNet program.

(C) When a sanction involving the collec-tion, recoupment, or withholding of MOHealthNet payments from a provider isimposed on a provider, it shall become effec-tive ten (10) days from the date of mailing ordelivery of said notice, whichever occursfirst. When any other sanction is imposed ona provider it shall become effective thirty(30) days from the date of mailing or deliveryof a decision of the Department of Social Ser-vices or its designated division, whicheveroccurs first. If, in the judgment of the singlestate agency, the surrounding facts and cir-cumstances clearly show that serious abuseor harm may result from delaying the imposi-tion of a sanction, any sanction may be madeeffective three (3) days after mailing of thenotice to the provider or immediately uponreceipt of notice by the provider, whicheveroccurs first.

(D) A sanction may be applied to allknown affiliates of a provider, provided that



each decision to include an affiliate is madeon a case-by-case basis after giving dueregard to all relevant facts and circumstances.The violation, failure, or inadequacy of per-formance may be imputed to an affiliate whenthe affiliate knew or should have known ofthe provider’s actions.

(E) Suspension or termination of anyprovider shall preclude the provider fromparticipation in the MO HealthNet program,either personally or through claims submittedby any clinic, group, corporation, or otherassociation to the single state agency or itsfiscal agents for any services or supplies pro-vided under the MO HealthNet programexcept for those services or supplies providedprior to the suspension or termination.

(F) No clinic, group, corporation, or otherassociation which is a provider of servicesshall submit claims for payment to the singlestate agency or its fiscal agents for any ser-vices or supplies provided by, or under thesupervision of, a person within the organiza-tion who has been suspended or terminatedfrom participation in the MO HealthNet pro-gram except for those services or supplies pro-vided prior to the suspension or termination.

(G) When the provisions of the previouslymentioned are violated by a provider of ser-vices which is a clinic, group, corporation, orother association, the single state agency maysuspend or terminate the organization, theindividual person, or both, within theorganization who knew or should have knownof the violation.

(H) When a provider has been sanctioned,the single state agency shall notify, as appro-priate, the applicable professional society,board of registration or licensure, federal andstate agencies of the finding made and thesanctions imposed.

(I) Where a provider’s participation in theMO HealthNet program has been suspendedor terminated, the single state agency shallnotify the county offices of the suspensionsor terminations.

(J) Except where termination has beenimposed, a provider who has been sanctionedmay be required to participate in a providereducation program as a condition of contin-ued participation. Provider education pro-grams may include:

1. Telephone and written instructions;2. Provider manuals and workshops;3. Instruction in claim form completion;4. Instruction on the use and format of

provider manuals;5. Instruction on the use of procedure

codes;6. Key provisions of the MO HealthNet

program;

7. Instruction on reimbursement rates;and

8. Instruction on how to inquire aboutcoding or billing problems.

(K) Providers that have been suspendedfrom the MO HealthNet program under sub-sections (4)(B) and (C) may be re-enrolled inthe MO HealthNet program upon expirationof the period of suspension from the programafter making satisfactory assurances of futurecompliance. Providers that have been termi-nated from the MO HealthNet program undersubsection (4)(B) may be re-enrolled in theprogram at the sole discretion of the singlestate agency and only after providing satisfac-tory evidence that the past cause for termina-tion has ceased and that future participation iswarranted.

(6) Amounts Due the Department of SocialServices From a Provider.

(A) If there exists an amount due theDepartment of Social Services from aprovider, the single state agency shall notifythe provider or the provider’s representativeof the amount of the overpayment. The noticeshall be mailed or delivered to the address onthe provider’s enrollment record. If theamount due is not sooner paid to the Depart-ment of Social Services by or on behalf of theprovider, the single state agency may takeappropriate action to collect the overpaymentforty-five (45) days from the date of mailingor delivery of said notice, whichever occursfirst. The single state agency may recover theoverpayment by withholding from currentMO HealthNet reimbursement. The with-holding may be taken from one (1) or morepayments until the funds withheld in theaggregate equal the amount due as stated inthe notice.

(B) When a provider receives notice of anoverpayment and the amount due is in excessof one thousand dollars ($1,000), theprovider, within fourteen (14) days of thenotice being mailed or delivered to theprovider, whichever occurs first, may submitto the single state agency a plan for repay-ment of forty percent (40%) of the overpay-ment amount and request that the plan beadopted and adhered to by the single stateagency in collecting the overpayment. Norepayment plans will be considered for thefirst sixty percent (60%) of the overpaymentamount. If this repayment plan is timelyreceived from a provider, the single stateagency shall consider the proposal, togetherwith all the facts and circumstances of thecase and reject, accept, or offer to accept amodified version of the provider’s plan forrepayment. The single state agency shall noti-fy the provider of its decision within ten (10)

days after the proposal is received. If no planfor repayment is agreed upon within thirty(30) days from the date of mailing or deliveryof a decision of the notice of the overpaymentto the provider, whichever occurs first, theMO HealthNet agency may take appropriateaction to collect the balance of the amountdue.

(C) If a plan agreed to and implementedunder provisions of subsection (6)(B) forrepayment of amounts due the Department ofSocial Services from a provider is breached,discontinued, or otherwise violated by aprovider, the single state agency, immediatelyupon the next payment to the provider, maybegin to withhold payments or portions ofpayments until the entire amount due hasbeen collected.

(D) Repayment or an agreement to repayamounts due the Department of Social Ser-vices by a provider shall not prevent theimposition of any sanction by the single stateagency upon the provider.

(E) The single state agency may collectprovider overpayments from any otherenrolled provider when the other enrolledprovider has received payment on behalf of theprovider who incurred the overpayment (suchas when a provider has directed payment toanother enrolled provider). The single stateagency may also collect provider overpay-ments from any enrolled provider with thesame federal employer identification number(EIN) as the provider who incurred the over-payment. The state agency shall notify theother enrolled provider(s) forty-five (45) daysprior to initiating the overpayment action. Thenotice shall be mailed to the address on theprovider’s(s’) enrollment record. If theamount due is in excess of one thousand dol-lars ($1,000), the other enrolled provider,within fourteen (14) days of mailing of thenotice, may submit to the single state agency aplan for repayment of forty percent (40%) ofthe overpayment amount and request that theplan be adopted and adhered to by the singlestate agency in collecting the overpayment. Norepayment plan will be considered for the firstsixty percent (60%) of the overpaymentamount. If this repayment plan is timelyreceived from the other enrolled provider, thesingle state agency shall consider the proposal,together with all the facts and circumstancesof the case and reject, accept, or offer toaccept a modified version of the other enrolledprovider’s plan for repayment. The single stateagency shall notify the other enrolled providerof its decision within ten (10) days after theproposal is received. If no plan for repaymentis agreed upon within thirty (30) days after theother enrolled provider receives notice of theoverpayment, the Medicaid agency may take


Secretary of State


appropriate action to collect the balance of theamount due.

AUTHORITY: sections 208.153, 208.201, and660.017, RSMo 2016.* This rule was previous-ly filed as 13 CSR 40-81.160. Original rulefiled Sept. 22, 1979, effective Feb. 11, 1980.Amended: Filed Nov. 25, 1981, effectiveMarch 11, 1982. Emergency amendment filedApril 14, 1982, effective April 24, 1982,expired July 10, 1982. Amended: Filed April14, 1982, effective July 11, 1982. Amended:Filed April 16, 1985, effective Sept. 1, 1985.Emergency amendment filed Dec. 5, 1986,effective Dec. 15, 1986, expired April 13,1987. Amended: Filed Dec. 16, 1986, effec-tive April 11, 1987. Amended: Filed Jan. 7,1987, effective April 26, 1987. Emergencyamendment filed April 15, 1988, effectiveApril 25, 1988, expired Aug. 22, 1988.Amended: Filed June 2, 1988, effective Aug.25, 1988. Amended: Filed Aug. 2, 1990,effective Feb. 14, 1991. Emergency amendmentfiled Dec. 17, 1993, effective Jan. 1, 1994,expired April 30, 1994. Emergency amend-ment filed April 15, 1994, effective April 30,1994, expired Aug. 13, 1994. Amended: FiledFeb. 16, 1994, effective Aug. 28, 1994.Amended: Filed May 16, 2005, effective Nov.30, 2005. Amended: Filed July 3, 2006, effec-tive Dec. 30, 2006. Amended: Filed Nov. 15,2006, effective May 30, 2007. Amended: FiledMarch 30, 2007, effective Sept. 30, 2007.Amended: Filed Aug. 31, 2007, effectiveMarch 30, 2008. Amended: Filed Aug. 17,2009, effective Feb. 28, 2010. Amended: FiledSept. 16, 2013, effective April 30, 2014.Amended: Filed Aug. 15, 2014, effective Feb.28, 2015. Amended: Filed Oct. 15, 2015,effective April 30, 2016. Amended: Filed Oct.3, 2016, effective May 30, 2017. Amended:Filed Sept. 22, 2017, effective May 30, 2018.

*Original authority: 208.153, RSMo 1967, amended1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.201,RSMo 1987, amended 2007; and 660.017, RSMo 1993,amended 1995.

13 CSR 70-3.040 Duty of Medicaid Partic-ipating Hospitals and Other Vendors toAssist in Recovering Third-Party Payments

PURPOSE: This rule places a certain duty onMedicaid participating hospitals and othervendors to assist the Division of Family Ser-vices in making Medicaid third-party liabilityrecoveries.

(1) All Medicaid participating hospitals orother vendors who have received reimburse-ment under Medicaid (Title XIX), or havemade claim or anticipate making a claim forreimbursement, and who shall receive arequest from an attorney or insurance carrierfor medical or other information pertaining to

the Medicaid recipient for whom reimburse-ment has been received or claim made shallinform the attorney or insurance carrier thatthe Division of Family Services has the dutyunder section 208.153, RSMo to seek reim-bursement from any source contractually orlegally obligated to be primarily responsibleto pay any moneys to or on behalf of theMedicaid recipient.

AUTHORITY: section 208.153, RSMo Supp.1991.* This rule was previously filed as 13CSR 40-81.090. Original rule filed May 20,1977, effective Sept. 11, 1977.

*Original authority: 208.153, RSMo 1967, amended1967, 1973, 1989, 1990, 1991.

13 CSR 70-3.050 Obtaining InformationFrom Providers of Medical Services

PURPOSE: This rule provides the basis forexamination of the records of any providerwho expects to receive payment from the Divi-sion of Family Services and for maintainingthe confidentiality of any of those records.

PUBLISHER’S NOTE: The secretary of statehas determined that the publication of theentire text of the material which is incorpo-rated by reference as a portion of this rulewould be unduly cumbersome or expensive.Therefore, the material which is so incorpo-rated is on file with the agency who filed thisrule, and with the Office of the Secretary ofState. Any interested person may view thismaterial at either agency’s headquarters orthe same will be made available at the Officeof the Secretary of State at a cost not toexceed actual cost of copy reproduction. Theentire text of the rule is printed here. Thisnote refers only to the incorporated by refer-ence material.

(1) Public Law 89-97, 1965 Amendment tothe Social Security Act (42 U.S.C.A. Section301), sections 201.151 and 208.153, RSMo,and other pertinent sections of Chapter 208,RSMo require Missouri to provide certainmedical services to eligible individuals andfurther provide that these services may beobtained from any provider who has enteredinto an agreement for provision of medicalservices with the Missouri Division of Fami-ly Services. Therefore, to aid the Division ofFamily Services in determining the properand correct payment for those services, theacceptance of these medical services and ben-efits by any applicant or recipient of publicassistance benefits constitutes authorizationfor the Division of Family Services, or itsduly authorized representative, to examine allrecords pertaining to medical services provid-

ed the applicant or recipient in order thatproper payment for the services may be madeto the provider of services.

(2) Section 208.155, RSMo, regarding theconfidentiality of all information concerningapplicants for or recipients of medical ser-vices shall be confidential, shall be strictlyadhered to.

AUTHORITY: section 207.020, RSMo Supp.1993.* This rule was previously filed as 13CSR 40-81.060. Original rule filed Sept. 29,1975, effective Oct. 9, 1975.

*Original authority: 207.020, RSMo 1945, amended 1961,1965, 1977, 1981, 1982, 1986, 1993.

13 CSR 70-3.060 Medicaid Program Pay-ment of Claims for Medicare Part B Ser-vices (Rescinded August 11, 1988)

AUTHORITY: sections 208.153, RSMo 1986and 208.201, RSMo Supp. 1987. Originalrule filed March 2, 1988, effective May 12,1988. Emergency rescission filed April 29,1988, effective May 9, 1988. Rescinded:Filed May 17, 1988, effective Aug. 11, 1988.

13 CSR 70-3.100 Filing of Claims, MOHealthNet Program

PURPOSE: This rule establishes the generalprovisions for submission or resubmission ofclaims and adjustments of claims to MOHealthNet.

PUBLISHER’S NOTE: The secretary of statehas determined that the publication of theentire text of the material which is incorpo-rated by reference as a portion of this rulewould be unduly cumbersome or expensive.This material as incorporated by reference inthis rule shall be maintained by the agency atits headquarters and shall be made availableto the public for inspection and copying at nomore than the actual cost of reproduction.This note applies only to the reference mate-rial. The entire text of the rule is printedhere.

(1) Claim forms used for filing MO Health-Net services as appropriate to the provider ofservices are—

(A) Nursing Home Claim—electronicclaim submission or individualized providersoftware when authorized by the state’s fiscalagent;

(B) Pharmacy Claim—MO-8803, Revision11/00 or POS, on-line claim format—NCPDP current version or electronic claimsubmission;



(C) Outpatient Hospital Claim—UB-04CMS-1450 or electronic claim submission;

(D) Professional Services Claim—CMS-1500, Revision 12/90, or electronic claimsubmission;

(E) Dental Claim—American Dental Asso-ciation (ADA) 2002, 2004 revision, DentalForm or electronic claim submission; or

(F) Inpatient Hospital Claim—UB-04CMS-1450 or electronic claim submission.

(2) Specific claims filing instructions aremodified as necessary for efficient and effec-tive administration of the program as requiredby federal or state law or regulation. Refer-ence the appropriate MO HealthNet providermanual, provider bulletins, and claim filinginstructions for specific claim filing instruc-tions information, which are incorporated byreference and made a part of this rule as pub-lished by the Department of Social Services,MO HealthNet Division, 615 HowertonCourt, Jefferson City, MO 65109, at its web-site at www.dss.mo.gov/mhd, September 15,2009. This rule does not incorporate any sub-sequent amendments or additions.

(3) Time Limit for Original Claim Filing.Claims from participating providers thatrequest MO HealthNet reimbursement mustbe filed by the provider and received by thestate agency within twelve (12) months fromthe date of service. The counting of thetwelve (12)-month time limit begins with thedate of service and ends with the date ofreceipt.

(A) Claims that have been initially filedwith Medicare within the Medicare timelyfiling requirement and which require separatefiling of an electronic claim with MO Health-Net will meet timely filing requirements bybeing submitted by the provider and receivedby the state agency within twelve (12) monthsof the date of service or six (6) months fromthe date on the Medicare provider’s notice ofthe allowed claim. Claims denied by Medi-care must be filed by the provider andreceived by the state agency within twelve(12) months from the date of service. Thecounting of the twelve (12)-month time limitbegins with the date of service and ends withthe date of receipt. Medicare/Medicaidcrossover claims must be submitted throughan electronic media. Claims that have beeninitially filed with Medicare and whichrequire separate filing of an electronic claimwith MO HealthNet must include the Medi-care internal control number or the Medicareclaim identification number found on theMedicare provider’s notice. Paper billingsfor Medicare/Medicaid crossover claims will

not be processed. Paper billings (claims) willnot be returned to the provider. Paper billingswill not be retained by the MO HealthNetDivision or its contractors.

(B) Third-Party Resources.1. Claims for participants who have a

third-party resource that is primary to MOHealthNet must be submitted to the third-party resource for adjudication unless other-wise specified by the MO HealthNet Divi-sion. Documentation specified by the MOHealthNet Division which indicates the third-party resource’s adjudication of the claimmust be attached to the claim filed for MOHealthNet reimbursement. If the MO Health-Net Division waives the requirement that thethird-party resource’s adjudication must beattached to the claim, documentation indicat-ing the third-party resource’s adjudication ofthe claim must be kept in the provider’srecords and made available to the division atits request. The claim must meet the MOHealthNet timely filing requirement by beingfiled by the provider and received by the stateagency within twelve (12) months from thedate of service.

2. The twelve (12)-month initial filingrule may be extended if a third-party payer,after making a payment to a provider, beingsatisfied that the payment is correct, laterreverses the payment determination, some-time after the twelve (12) months from thedate of service has elapsed, and requests theprovider return the payment. Because a third-party resource was clearly available to coverthe full amount of liability, and this wasknown to the provider, the provider may nothave initially filed a claim with the MOHealthNet state agency. Under this set of cir-cumstances, the provider may file a claimwith the MO HealthNet agency later thantwelve (12) months from the date of services.The provider must submit this type of claimto the Third Party Liability Unit at PostOffice Box 6500, Jefferson City, MO 65102-6500 for special handling. The MO Health-Net state agency may accept and pay this spe-cific type of claim without regard to thetwelve (12)-month timely filing rule; howev-er, all claims must be filed for MO HealthNetreimbursement within twenty-four (24)months from the date of service in order to bepaid.

(4) Time Limit for Resubmission of a ClaimAfter Twelve (12) Months From the Date ofService.

(A) Claims which have been originallysubmitted and received within twelve (12)months from the date of service and deniedor returned to the provider may be resubmit-

ted within twenty-four (24) months of thedate of service. Those claims must be filed bythe provider and received by the state agencywithin twenty-four (24) months from the dateof service. The counting of the twenty-four(24)-month time limit begins with the date ofservice and ends with the date of receipt.

(B) Documentation specified by the MOHealthNet Division in MO HealthNetprovider manuals which indicates the claimwas originally received timely must beattached to the resubmission or entered on theclaim form (electronic or paper).

(C) Claims will not be paid when filed bythe provider and received by the state agencybeyond twenty-four (24) months from thedate of service.

(5) Denial. Claims that are not submitted in atimely manner and as described in sections(1) and (2) of this rule will be denied. Exceptthat at any time in accordance with a courtorder, the agency may make payments tocarry out hearing decision, corrective action,or court order to others in the same situationas those directly affected by it. The agencymay make payment at any time when a claimwas denied due to state agency error or delay,as determined by the state agency. In orderfor payment to be made, the state agencymust be informed of any claims denied due tostate agency error or delay within six (6)months from the date of the remittance adviceon which the error occurred; or within six (6)months of the date of completion or determi-nation in the case of a delay; or twelve (12)months from the date of service, whichever islonger.

(6) Time Limit for Filing an Adjustment.Adjustments to a paid claim must be filedwithin twenty-four (24) months from the dateof the remittance advice on which paymentwas made. If an adjustment processed withinthe twenty-four (24) months from the date ofthe remittance advice limitation necessitatesfiling a corrected claim, the timely filinglimit for resubmitting the corrected claim islimited to ninety (90) days from the date ofthe remittance advice indicating recoupment,or twelve (12) months from the date of ser-vice, whichever is longer.

(7) Definitions.(A) Claim A—claim is each individual line

item of service on a claim form, for which acharge is billed by a provider, for all claimform types except inpatient hospital. An inpa-tient hospital service claim is all the billedcharges contained on one (1) inpatient claimdocument.

(B) Date of payment/denial—The date of


Secretary of State


payment or denial of a claim is the date onthe remittance advice at the top center of eachpage under the words remittance advice.

(C) Date of receipt—The date of receipt ofa claim is the date the claim is received by thestate agency. For a claim which is processed,this date appears as a Julian date in the inter-nal control number (ICN). For a claim whichis returned to the provider, this date appearson the Return to Provider form letter.

(D) Date of service—The date of servicewhich is used as the beginning point fordetermining the timely filing limit applies tothe various claim types as follows:

1. Nursing home—The through date orending date of service for each line item foreach participant listed on the claim;

2. Pharmacy—The date dispensed foreach line item for each individual participantlisted on the paper claim form, or on elec-tronically submitted claims through point ofservice (POS) or the Internet;

3. Outpatient hospital—The ending dateof service for each individual line item on theclaim;

4. Professional services (CMS-1500)—The ending date of service for each individualline item on the claim;

5. Dental—The date service was per-formed for each individual line item on theclaim;

6. Inpatient hospital—The through dateof service in the area indicating the claimedperiod of service; and

7. For service which involves the pro-viding of dentures, hearing aids, eyeglasses,or items of durable medical equipment; forexample, artificial larynx, braces, hospitalbeds, wheelchairs, the date of service will bethe date of delivery or placement of thedevice or item.

(E) Internal control number (ICN)—Thefiscal agent prints a thirteen (13)-digit num-ber on each document it processes throughthe Medicaid Management Information Sys-tem (MMIS). The year of receipt is indicatedby the third and fourth digits and the Juliandate appears as the fifth, sixth, and seventhdigits. In an example ICN, 490600152006,06 is the year 2006 and 001 is the Julian datefor January 1.

(F) Medicare internal control number—The number assigned to a Medicare claim bythe Medicare provider which is used for iden-tification purposes. The Medicare internalcontrol number is also referred to as theMedicare claim identification number.

(G) Julian date—In a Julian system, thedays of a year are numbered consecutivelyfrom 001 (January 1) to 365 (December 31)or 366 in a leap year. For example, in 1984,a leap year, June 15 is the 167th day of that

year, thus, 167 is the Julian date for June 15,1984.

(H) Twelve (12)-month time limit—Thisunit is defined as three hundred sixty-six(366) days.

(I) Twenty-four (24)-month time limit—This unit is defined as seven hundred thirty-one (731) days.

AUTHORITY: sections 208.153 and 208.201,RSMo Supp. 2008.* This rule was previouslyfiled as 13 CSR 40-81.070 and 13 CSR 40-81.071. Original rule filed June 2, 1976,effective Oct. 11, 1976. Emergency rescissionfiled July 18, 1979, effective July 31, 1979,expired Nov. 10, 1979. Emergency rule filedJuly 18, 1979, effective Aug. 1, 1979, expiredNov. 10, 1979. Rescinded and readopted:Filed July 18, 1979, effective Nov. 11, 1979.Rescinded and readopted: Filed Sept. 12,1984, effective Jan. 12, 1985. Amended:Filed April 21, 1992, effective Jan. 15, 1993.Amended: Filed June 3, 1993, effective Dec.9, 1993. Amended: Filed Sept. 23, 1993,effective May 9, 1994. Amended: Filed Sept.28, 2001, effective March 30, 2002. Amend-ed: Filed June 15, 2006, effective Dec. 30,2006. Amended: Filed Jan. 2, 2008, effectiveJune 30, 2008. Amended: Filed July 31,2008, effective Jan. 30, 2009. Amended:Filed Aug. 17, 2009, effective Feb. 28, 2010.

*Original authority: 208.153, RSMo 1967, amended1967, 1973, 1989, 1990, 1991, 2007 and 208.201, RSMo1987, amended 2007.

13 CSR 70-3.105 Timely Payment of MOHealthNet Claims

PURPOSE: This rule advises MO HealthNetproviders of the time frames in which they canexpect payment for the service(s) they provideto MO HealthNet participants. This ruleimplements Section 1902(a)(37) of the federalSocial Security Act.

PUBLISHER’S NOTE: The secretary of statehas determined that the publication of theentire text of the material which is incorpo-rated by reference as a portion of this rulewould be unduly cumbersome or expensive.Therefore, the material which is so incorpo-rated is on file with the agency who filed thisrule, and with the Office of the Secretary ofState. Any interested person may view thismaterial at either agency’s headquarters orthe same will be made available at the Officeof the Secretary of State at a cost not toexceed actual cost of copy reproduction. Theentire text of the rule is printed here. Thisnote refers only to the incorporated by refer-ence material.

(1) As used in this rule, unless the contextclearly indicates otherwise, the followingterms shall mean:

(A) Claim A—bill submitted by a providerto the MO HealthNet Division for MOHealthNet reimbursement for a procedure, aset of procedures, or a service rendered a MOHealthNet participant for a given diagnosis ora set of related diagnoses;

(B) Clean claim—A claim that can be pro-cessed without obtaining additional informa-tion from the provider of the service or froma third party. It includes a claim with errorsoriginating in the state’s claim system. It doesnot include a claim from a provider who isunder investigation for fraud or abuse, or aclaim under review for medical necessity;

(C) Date of payment—The date of thecheck or other form of payment;

(D) Date of receipt—The date the MOHealthNet Division receives the claim, asindicated by its date stamp on the claim;

(E) Nonpractitioner claim—Claims for thefollowing services: inpatient hospital, state-operated mental health facility, outpatienthospital, inpatient psychiatric facility forindividuals age twenty-one (21) and under,intermediate care facility for the mentallyretarded (ICF/MR), home health services(personal care home and community-basedservices), family planning (rendered by ahospital—inpatient or outpatient), steriliza-tion (rendered by a hospital—inpatient or out-patient), nursing facility; and durable medicalequipment; and

(F) Practitioner claim—Claims for the fol-lowing services: physician, dental, clinic,family planning (rendered by a physician,clinic or other practitioner), laboratory andX-ray services, prescribed drugs, early andperiodic screening, rural health clinic, steril-ization services (rendered by a physician,clinic or other practitioner), and other (chiro-practors, podiatrists, psychologists, registeredor licensed practical nurses providing privateduty nursing services, optometrists, physicaltherapists, occupational therapists, speechpathologists, audiologists and Christian Sci-ence practitioners).

(2) In accordance with Title 42 of the Code ofFederal Regulations part 447 section 45, theMO HealthNet Division, each fiscal year,will process and pay within thirty (30) days ofthe date of receipt, ninety percent (90%) ofall clean claims from practitioners who are inindividual or group practice, or who practicein shared health facilities and nonpractition-ers.

(3) The MO HealthNet Division, each fiscalyear, will process and pay within ninety (90)



days of the date of receipt, ninety-nine per-cent (99%) of all clean claims from practi-tioners who are in individual or group prac-tice, or who practice in shared healthfacilities and nonpractitioners.

(4) The MO HealthNet Division must pay allother claims within twelve (12) months of thedate of receipt. The time limitation does notapply to—

(A) Retroactive adjustments; (B) Claims submitted by providers who are

under investigation for fraud or abuse; and (C) Claims submitted to both Medicare

and Medicaid.

(5) The MO HealthNet Division may makepayments at any time in accordance with acourt order, to carry out hearing decisions oragency corrective actions taken to resolve adispute, or to extend the benefits of a hearingdecision, corrective action, or court order toothers in the same situation as those directlyaffected by it.

AUTHORITY: section 208.201, RSMo Supp.2007.* Original rule filed Dec. 11, 1991,effective June 25, 1992. Amended: Filed July31, 2008, effective Jan. 30, 2009.

*Original authority: 208.201, RSMo 1987, amended 2007.

13 CSR 70-3.110 Second Opinion Require-ment Before Nonemergency Elective Surgi-cal Operations(Rescinded June 30, 2011)

AUTHORITY: section 207.020, RSMo Supp.1993. This rule was previously filed as 13CSR 40-81.052. Emergency rule filed Sept.18, 1981, effective Sept. 28, 1981, expiredJan. 13, 1982. Original rule filed Sept. 18,1981, effective Jan. 14, 1982. Rescinded:Filed Dec. 1, 2010, effective June 30, 2011.

13 CSR 70-3.120 Limitations on Paymentof Out-of-State Nonemergency MedicalServices

PURPOSE: This rule establishes a regulatorybasis for implementation of prior authoriza-tion on all out-of-state nonemergency MOHealthNet-covered services.

PUBLISHER’S NOTE: The secretary of statehas determined that the publication of theentire text of the material which is incorpo-rated by reference as a portion of this rulewould be unduly cumbersome orexpensive. This material as incorporated byreference in this rule shall be maintained by

the agency at its headquarters and shall bemade available to the public for inspectionand copying at no more than the actual costof reproduction. This note applies only to thereference material. The entire text of the ruleis printed here.

(1) All nonemergency, MO HealthNet-cov-ered services, except for those servicesexempted in section (6) of this rule, which areto be performed or furnished out-of-state foreligible MO HealthNet participants and forwhich MO HealthNet is to be billed, must beprior authorized in accordance with policiesand procedures established by the MOHealthNet Division before the services areprovided.

(2) Nonemergency services, for the purposeof the prior authorization requirement, arethose services which do not meet the defini-tion of emergency. Emergency services aredefined as those services provided in a hospi-tal, clinic, office, or other facility that isequipped to furnish the required care, aftersudden onset of a medical condition manifest-ing itself by acute symptoms of sufficientseverity (including severe pain) that theabsence of immediate medical attention couldreasonably be expected to result in a) placingthe patient’s health in serious jeopardy, b)serious impairment to bodily functions, or c)serious dysfunction of any bodily organ orpart.

(3) Out-of-state is defined as not within thephysical boundaries of Missouri nor withinthe boundaries of any state which physicallyborders on the Missouri boundaries. Border-state providers of services (those providerslocated in Arkansas, Illinois, Iowa, Kansas,Kentucky, Nebraska, Oklahoma, Tennessee)will be considered as being on the sameMO HealthNet participation basis asproviders of services located within Missourifor purposes of administration of this rule.

(4) The out-of-state provider of services mustmeet the requirements for participation in theMO HealthNet program and have a state-approved participation agreement in effect inorder to receive reimbursement for any cov-ered service, emergency or nonemergency.

(5) The patient’s attending physician isresponsible for obtaining prior authorizationof the services s/he believes to be medicallynecessary.

(A) Failure to obtain prior authorizationfor the services shall result in no payment bythe MO HealthNet program.

(B) All prior authorization requests mustbe submitted in accordance with policies and

procedures established by the MO HealthNetDivision as stated in the respective MOHealthNet Provider Manual and provider bul-letins which are incorporated by referenceand made a part of this rule as published bythe Department of Social Services,MO HealthNet Division, 615 HowertonCourt, Jefferson City, MO 65109, at its web-site at www.dss.mo.gov/mhd, June 15, 2009.This rule does not incorporate any subse-quent amendments or additions.

(C) Prior authorization by the MO Health-Net agency shall approve the medical neces-sity of the covered services to be performedonly. It shall not guarantee payment as theparticipant must be eligible on the date theservice was provided.

(D) Prior authorization expires one hun-dred eighty (180) days from the date a specif-ic service was approved by the state.

(E) All requests for prior authorizationmust be submitted to the Participant ServicesUnit of the MO HealthNet Division. Thephysician who is referring the patient for thenonemergency services must call or write theMO HealthNet Division for authorization.

(F) Telephone prior authorizations may begranted.

(6) The following are exempt from therequirement for prior authorization of none-mergency MO HealthNet-covered servicesfor out-of-state providers:

(A) All services provided individuals hav-ing both Medicare and MO HealthNet cover-age for which Medicare does provide cover-age and is the primary payer (crossoverclaims);

(B) All border state providers as defined insection (3) of this rule;

(C) All foster care children living outsideMissouri. Nonemergency services which rou-tinely require prior authorization will contin-ue to require prior authorization by out-of-state providers even though the service wasprovided to a foster care child. Foster carechildren are identified on the MO HealthNetID card with a Type of Assistance (TOA)indicator of “D” or “Z”; and

(D) All independent laboratory and emer-gency ambulance services.

(7) All other policies and procedures applica-ble to the MO HealthNet program will be ineffect for services provided by out-of-stateproviders.

AUTHORITY: sections 208.153 and 208.201,RSMo Supp. 2008.* This rule was previouslyfiled as 13 CSR 40-81.190. Emergency rulefiled Sept. 18, 1981, effective Sept. 28, 1981,expired Jan. 13, 1982. Original rule filedSept. 18, 1981, effective Jan. 14, 1982.


Secretary of State


Amended: Filed Oct. 21, 1994, effective June30, 1995. Amended: Filed May 14, 2009,effective Nov. 30, 2009.


13 CSR 70-3.130 Computation of ProviderOverpayment by Statistical Sampling

PURPOSE: This rule establishes the methodwhere the billing forms or claims for paymentsubmitted by Medicaid providers will beexamined to determine compliance with TitleXIX (Medicaid) Program requirements andproper payment, and sets forth the statisticalmethodology to be employed and the mannerin which providers may challenge the results.


(A) Adequate records means records fromwhich services rendered and the amount ofreimbursement received for services by aprovider can be readily discerned and veri-fied with reasonable certainty. Adequatemedical records are records which are of thetype and in a form required of good medicalpractice;

(B) Amount due means an amount ofmoney owed to the Medicaid agency by aprovider resulting from a finally determinedoverpayment;

(C) Claim for payment or claim means adocument or electronically transmitted datasubmitted to the Medicaid agency for the pur-pose of obtaining payment by the Title XIXMedicaid Program. A claim for paymentmeans any one (1) document regardless ofhow many services, dates of service or recip-ients to which it pertains. In the case of elec-tronically transmitted claims for payment, aclaim for payment means all services for eachrecipient for which reimbursement is soughtin the transmitted information;

(D) Medicaid agency or the agency meansthe single state agency administering orsupervising the administration of the stateMedicaid plan;

(E) Overpayment means an amount ofmoney paid to a provider by the Medicaidagency to which s/he was not entitled by rea-son of improper billing, error, fraud, abuse,lack of verification, or insufficient medicalnecessity;

(F) Participation means the ability andauthority to provide services or merchandiseto eligible Medicaid recipients and to receivepayment from the Medicaid program for ser-vices or merchandise;

(G) Provider means any person, partner-

ship, corporation, not-for-profit corporation,professional corporation, or other businessentity that enters into a contract or provideragreement with the Department of Social Ser-vices for the purpose of providing services toeligible persons and obtaining from thedepartment or its divisions reimbursement forservices;

(H) Records means any books, papers,journals, charts, treatment histories, medicalhistories, test and laboratory results, pho-tographs, X rays, and any other recordings ofdata or information made by or caused to bemade by a provider relating in any way to ser-vices provided to Medicaid recipients andpayments charged or received for services.Medicaid claim for payment information doesnot constitute adequate records. A providermust retain all records for five (5) years;

(I) Review group means all claims for pay-ment or all claims relating to a specific ser-vice or a specific item or merchandise sub-mitted by a provider between two (2) certaindates. To be valid, the review group begin-ning and ending dates must be establishedbefore the statistical sample is selected. If thedates are changed, a new statistical samplemust be identified;

(J) Selected at random means the processwhere claims in a review group are assignedconsecutive numbers and after the assigna-tion, twenty-five percent (25%) of thosenumbers identified as the statistical sample byuse of a random numbers table or computer-generated random numbers;

(K) Statistical sample means twenty-fivepercent (25%) of a review group of claims forpayment submitted by a provider. The samplemust be selected at random to be valid; and

(L) Supervision means the service was per-formed while the provider was physically pre-sent during the service or the provider was onthe premises and readily available to givedirection to the person actually performingthe service.

(2) When the Medicaid agency determinesthat claims for payment submitted by aprovider shall be reviewed, the followingactions will be taken:

(A) A Review Group Selected. All claimsfor which the provider was not paid or forwhich a particular service or item of mer-chandise under review was not paid will beremoved from the review group before a sta-tistical sample is identified. The agency shallnot use statistical sampling to determine over-payment where the review group consists offewer than one hundred (100) claims for pay-ment;

(B) A Statistical Sample Selected From theReview Group.

1. When the review group selected bythe state agency exceeds five hundred (500)claims, the agency, at its discretion, mayrequest that the provider whose claims areunder review waive examination of a portionof the claims in a statistical sample. If arequest results in a waiver, the state agencywill not review claims in the randomly select-ed statistical sample in which the total aggre-gate amount paid for the claim document isless than a fixed amount specified in thewaiver request. A waiver will not reduce thenumber of claims in the review group andcalculations of underpayments or overpay-ments shall be made as if all claims in therandomly selected statistical sample had beenreviewed.

2. At the sole discretion of the stateagency, any request for waiver of a full statis-tical sample review may offer the provider thefurther option that it may elect to have thestatistical sample selected from the reviewgroup by the following statistical samplingformula:

Sample Size=96

1+(96÷Review Group Size)

The request for waiver shall contain the for-mula with the calculations completed for thesize of the review group selected for theprovider in question.

3. When a statistical sample has beenselected by formula, the number of claims inthe review group remains the same in calcu-lating total overpayments or underpayments.A statistical sample selected by formulareplaces the twenty-five percent (25%) statis-tical sample in calculating total overpaymentsor underpayments.

4. The state agency has the sole discre-tion both to request a waiver and whether tooffer in this request an election to theprovider to use a sample selected by statisti-cal sampling formula. If a waiver is request-ed, the provider has the sole discretionwhether to have the full twenty-five percent(25%) statistical sample reviewed or to waiveexamination of a portion of claims in a statis-tical sample. If the provider elects the waiver,only claims paid above a fixed amount will bereviewed or, if a statistical sampling formulaoption has been offered by the state agency,the provider has the sole discretion to electthe statistical sampling formula.

5. Once a provider has waived a full sta-tistical sample review or has elected to have asample selected by statistical sampling for-mula, the provider’s decision may not berevoked or rescinded by the provider; and



(C) Each claim or each portion of a claimrelating to a particular service or item of mer-chandise reviewed. The review process mayinclude any one (1) or more of the following:

1. Determination of medical necessityby a qualified consultant or employee of theagency. The reimbursement received by theprovider for services or merchandise deter-mined to be medically unnecessary shall con-stitute an overpayment. Medically unneces-sary includes services that are inappropriateor excessive for the diagnosis tested;

2. Determination of proper billing codesas required under program benefit limita-tions. The reimbursement received by theprovider for services or merchandise throughthe use of improper billing codes or billingcodes in excess of program benefit limitationsshall constitute an overpayment;

3. Determination that services or mer-chandise were delivered by the provider incompliance with the requirements of 13 CSR70-3.030(3)(A). The reimbursement receivedby the provider for services or merchandisedelivered in violation of any provision of 13CSR 70-3.030(3)(A) shall constitute an over-payment;

4. Determination that delivery of ser-vices or merchandise appearing on thereviewed claims is verified by adequaterecords kept by the provider. Reimbursementreceived by the provider for services or mer-chandise not verified by adequate recordsshall constitute an overpayment;

5. Determination that services or mer-chandise delivered by the provider were per-formed or delivered by the provider for ser-vices performed or merchandise delivered byanother or without proper supervision shallconstitute an overpayment;

6. Determination that services per-formed or merchandise delivered by theprovider are verified by statements of the eli-gible recipients of the services or merchan-dise. Reimbursement received for services ormerchandise not verified by the recipientsshall constitute an overpayment; and

7. Determination that information sub-mitted by the provider accompanying theclaims for payment was adequate. Thisincludes, but is not limited to, physicianexamination certifications, medical necessityforms, and test results. Reimbursementreceived by the provider for services or mer-chandise not accompanied by adequate infor-mation of this type shall constitute an over-payment.

(3) When a review of a provider’s claims bystatistical sampling has been completed, atotal overpayment shall be computed by total-ing all overpayments for the statistical sample

and subtracting all underpayments found inthe sample to obtain a total overpayment.This total is then divided by the number ofclaims contained in the statistical sample toobtain an average overpayment for the sam-ple. The total overpayment for the review willthen be determined by multiplying the aver-age sample overpayment by the number ofclaims in the review group. If there exists anet underpayment for the sample, then theaverage underpayment shall be computed inthe same manner and the provider notified ofthe results.

(4) When a total overpayment has been com-puted by statistical sampling, the Medicaidagency may proceed to recover the fullamount of the overpayment from the provideras an amount due. Recovery of the overpay-ment shall be accomplished according to theprovisions of 13 CSR 70-3.030(6), exceptthat in cases where the amount due was com-puted by statistical sample, the notice inform-ing the provider of the amount due requiredby 13 CSR 70-3.030(6)(A) and (B) shall alsocontain the following information:

(A) The dates encompassed by the reviewgroup;

(B) The number of claims in the reviewgroup and, if applicable, what particular ser-vice or item or merchandise pertained to thereview group;

(C) The number of claims in the statisticalsample; and

(D) A generally summarized description ofthe reasons for the overpayment determina-tions with all claims in the statistical sampleidentified as to which overpayment descrip-tion applies to each.

AUTHORITY: section 208.165, RSMo 2000and sections 208.153 and 208.201, RSMoSupp. 2010.* This rule was previously filed as13 CSR 40-81.161. Original rule filed April14, 1983, effective Oct. 13, 1983. Amended:Filed Sept. 17, 1986, effective Dec. 11, 1986.Emergency amendment filed Feb. 4, 1987,effective Feb. 14, 1987, expired April 25,1987. Amended: Filed Feb. 4, 1987, effectiveJune 11, 1987. Amended: Filed July 30, 2010,effective Feb. 28, 2011.

*Original authority: 208.153, RSMo 1967, amended1967, 1973, 1989, 1990, 1991, 2007; 208.165, RSMo1982; and 208.201, RSMo 1987, amended 2007.

13 CSR 70-3.140 Direct Deposit ofProvider Reimbursement

PURPOSE: This rule describes the proce-dures for the direct deposit of MO HealthNetprovider payments. This requirement is being

implemented due to the reduction and consol-idation of Department of Social Services’mail room staff with the Office of Administra-tion; handling, cost for postage, printing, andmailing paper checks; and will eliminate thecost of returned or lost checks.

(1) Effective October 1, 2010, theMO HealthNet Division will require enrolledproviders to have their MO HealthNet checksautomatically deposited to an authorized bankaccount.

(2) MO HealthNet providers must completethe Application for Provider Direct DepositForm MO 886-3089 available on theMO HealthNet Division website atwww.dss.mo.gov/mhd, unless otherwiseagreed upon by the Department of Social Ser-vices.

(A) The completed application authorizesthe Office of Administration to deposit MOHealthNet payments into an authorizedchecking or savings account.

(B) A provider’s account may only be deb-ited when an error has occurred resulting inan erroneous payment to the provider.

(C) Direct deposit will begin following: 1. Submission of a properly completed

application form to the Department of SocialServices, MO HealthNet Division;

2. The successful processing of a testtransaction through the banking system; and

3. Authorization to make payment usingthe direct deposit option by the MO Health-Net Division.

(D) The state will conduct direct depositthrough the automated clearing house system,utilizing an originating depository financialinstitution. The rules of the National Auto-mated Clearing House Association and itsmember local Automated Clearing HouseAssociations shall apply, as limited or modi-fied by law.

(3) All direct deposit applications must besigned with an original signature by theprovider enrolled in the MO HealthNet pro-gram when that provider is an individual.Applications on behalf of groups or business-es (except those described in this rule) mustbe signed with an original signature by theindividual (officer) with fiscal responsibilityfor the group or business. Signature stampsor other facsimiles will not be accepted.

(4) The MO HealthNet Division will termi-nate or suspend the direct deposit option foradministrative or legal actions, including, butnot limited to, ownership change, duly exe-cuted liens or levies, legal judgments, noticeof bankruptcy, administrative sanctions for


Secretary of State


the purpose of ensuring program compliance,death of a provider, and closure or abandon-ment of an account.

AUTHORITY: section 208.201, RSMo Supp.2009.* Original rule filed Oct. 4, 1993,effective June 6, 1994. Amended: Filed June1, 2010, effective Dec. 30, 2010.


13 CSR 70-3.150 Authorization To ReceivePayment for Medicaid Services

PURPOSE: This rule establishes who mayreceive payment for services furnished to arecipient of medical assistance by a providerwho is subject to either the Federal Reim-bursement Allowance (FRA) or the NursingFacility Reimbursement Allowance (NFRA).This rule is necessary to comply with theterms and conditions required by the HealthCare Financing Administration for approvalof Missouri’s 1115 Demonstration Waiver.

(1) Authorization To Receive Payment. Pay-ment for any services covered by the Mis-souri Medicaid program to a recipient eligi-ble for medical assistance by an enrolledMedicaid provider who is subject to eitherthe Federal Reimbursement Allowance (FRA)or the Nursing Facility ReimbursementAllowance (NFRA) shall be—

(A) By direct deposit to the provider’saccount at a bank or other financial institu-tion;

(B) To a person or entity affiliated with theenrolled provider; or

(C) To a business agent, or to a govern-ment agency or a recipient specified by acourt order, as permitted under federal regu-lations at 42 Code of Federal Regulations sec-tion 447.10(e) and (f).

(2) Two (2) or more unaffiliated providersmay not by agreement or other joint actiondesignate a common business agent or otherrecipient of their payments under the Mis-souri Medicaid program.

(3) Authorizations to receive payment that donot meet the foregoing requirements of sec-tion (1) of this rule shall be void upon theeffective date of this rule.

AUTHORITY: sections 208.158 and 208.201,RSMo 1994.* Original rule filed July 15,1998, effective Jan. 30, 1999.

*Original authority: 208.158, RSMo 1967 and 208.201,RSMo 1987.

13 CSR 70-3.160 Electronic Submission ofMO HealthNet Claims and ElectronicRemittance Advices

PURPOSE: This rule implements the require-ment that claims for reimbursement by theMO HealthNet program be submitted elec-tronically and remittance advices be retrievedelectronically.

(1) “Electronic claim” means a claim that issubmitted via electronic media.

(2) Electronic submission of MO HealthNetclaims for services rendered under the MOHealthNet program is required. A MOHealthNet claim may be paid only if submit-ted as an electronic claim for processing bythe Medicaid Management Information Sys-tem.

(A) To utilize the Internet for electronicclaim submissions, the provider must applyonline via the Application for MO HealthNetInternet Access Account link.

(B) Each user is required to complete thisonline application to obtain a user ID andpassword.

(C) The enrolled MO HealthNet providershall be solely responsible for the accuracyand authenticity of said electronic mediaclaims submitted, whether submitted directlyor by an agent.

(D) The enrolled MO HealthNet providershall agree that services described on theelectronic media claim are true, accurate, andcomplete.

(E) The enrolled MO HealthNet providercertifies that services described on the elec-tronic media claim are personally rendered bythe provider.

(3) State-required supporting documentation(paper attachments) must be maintained atthe place of service for auditing purposes.

(A) The failure of the enrolled MO Health-Net provider to keep or furnish, or both, suchinformation shall constitute grounds for thedisallowance and recoupment of all applica-ble charges or payments.

(B) The enrolled MO HealthNet providershall be responsible for refund of any pay-ments that result from claims being paid inap-propriately or inaccurately.

(C) The records shall be maintained forfive (5) years, unless the records are the sub-ject of an audit or litigation. Records that arethe subject of an audit or litigation shall bemaintained until the conclusion of the auditor litigation.

(4) Medical record documentation shall sup-port the medical necessity of the service

being provided as well as the frequency of theservice. The provider shall establish andmaintain a record containing the signature ofeach participant of service furnished by theMO HealthNet enrolled provider or, whenapplicable, the signature of a responsible per-son made on behalf of the participant. Clini-cal laboratories, radiologists, and patholo-gists are exempt from the requirement that aMO HealthNet enrolled provider establishand maintain a record containing the signa-ture of each participant of service. A physi-cian’s order shall be documented in the med-ical record. Clinical laboratories,radiologists, and pathologists shall maintain arecord of the ordering physician for a MOHealthNet service for which they requestreimbursement.



(C) The records shall be maintained forfive (5) years, unless the records are the sub-ject of an audit or litigation. Records that arethe subject of an audit or litigation shall bemaintained until the conclusion of the auditor litigation.

(5) The provider shall keep such records,including original source documents, as arenecessary to disclose fully the nature andextent of services provided to participantsunder the MO HealthNet program and to fur-nish information regarding any payment ofclaims for providing such services as the MOHealthNet Division, or its designee, mayrequest. The enrolled MO HealthNetprovider agrees that the service was medical-ly necessary for the treatment of the condi-tion as indicated by the diagnosis and shallmaintain records, including source docu-ments, to verify such.



(C) The records shall be maintained forfive (5) years, unless the records are the sub-ject of an audit or litigation. Records that arethe subject of an audit or litigation shall be



maintained until the conclusion of the auditor litigation.

(6) The enrolled MO HealthNet providermust identify and bill third party insuranceand Medicare coverage prior to billing MOHealthNet.

(7) Sufficient security procedures must be inplace to ensure that all transmissions of doc-uments are authorized and protect participantspecific data from improper access.

(8) The provider is responsible for assuringthat electronic billing software purchasedfrom any vendor or used by a billing agentcomplies with billing requirements of theMO HealthNet program and shall be respon-sible for modifications necessary to meetelectronic billing standards.

(9) The enrolled MO HealthNet provideragrees to accept as payment in full theamount paid by MO HealthNet for the elec-tronic media claims submitted for payment.

(10) The submission of an electronic mediaclaim is a claim for MO HealthNet payment.

(A) Any person who, with intent todefraud or deceive, makes, causes to bemade, or assists in the preparation of anyfalse statement, misrepresentation, or omis-sion of a material fact in any claim or appli-cation for any claim, regardless of amount,knowing the same to be false, is subject tocivil or criminal sanctions, or both, under allapplicable state and federal statutes.

(11) “Electronic remittance advice” means aremittance that is retrieved via electronicmedia.

(12) The enrolled MO HealthNet provideragrees to retrieve his/her remittance advicevia electronic media.

(A) To utilize the Internet for electronicremittance advice retrieval, the provider mustapply online via the Application for MOHealthNet Internet Access Account link.

(B) Each user is required to complete thisonline application to obtain a user ID andpassword.

(C) Sufficient security procedures must bein place to ensure that all transmissions ofdocuments are authorized and protect partic-ipant specific data from improper access.

AUTHORITY: sections 208.153 and 208.201,RSMo Supp. 2009.* Original rule filed April29, 2005, effective Nov. 30, 2005. Amended:Filed June 1, 2010, effective Dec. 30, 2010.


13 CSR 70-3.170 Medicaid Managed CareOrganization Reimbursement Allowance

PURPOSE: This rule establishes the formulafor determining the Medicaid Managed CareOrganizations’ Reimbursement Allowanceeach Medicaid Managed Care Organizationis required to pay for the privilege of engag-ing in the business of providing health benefitservices in this state as required by sections208.431 to 208.437, RSMo.

(1) Medicaid Managed Care OrganizationReimbursement Allowance (MCORA) shallbe assessed as described in this section.

(A) Definitions.1. Medicaid Managed Care Organiza-

tion (MCO). A health benefit plan, asdefined in section 376.1350, RSMo, with acontract under 42 U.S.C. section 1396b(m)to provide health benefit services to MOHealthNet managed care program eligibilitygroups.

2. Department. Department of SocialServices.

3. Director. Director of the Departmentof Social Services.

4. Division. MO HealthNet Division.5. Health annual statement. The Nation-

al Association of Insurance Commissioners(NAIC) annual financial statement filed withthe Missouri Department of Insurance,Financial Institutions and Professional Regis-tration.

6. Effective July 1, 2005 through June30, 2006, Total Revenues. Total Revenuesreported for Title XIX—Medicaid on theNAIC annual statement schedule “Analysis ofOperations by Lines of Business.” ColumnNo. 8, Line 7.

7. Engaging in the business of providinghealth benefit services. Accepting paymentfor health benefit services.

8. Effective July 1, 2006, Total Rev-enues. Total capitated payments a Medicaidmanaged care organization receives from thedivision for providing, or arranging for theprovision of, health care services to its mem-bers or enrollees.

(B) Beginning July 1, 2005, each MedicaidMCO in this state shall, in addition to allother fees and taxes now required or paid,pay a Medicaid Managed Care OrganizationReimbursement Allowance (MCORA) for theprivilege of engaging in the business of pro-viding health benefit services in this state.Collection of the MCORA shall begin uponCenters for Medicare and Medicaid Services

(CMS) approval of the changes in Medicaidcapitation rates that are effective July 1,2005.

1. Effective July 1, 2005 through June30, 2006, the Medicaid MCORA owed forexisting Medicaid MCOs shall be calculatedby multiplying the Medicaid MCORA taxrate by the Total Revenues, as defined above.The most recent available NAIC HealthAnnual Statement shall be used. The Medi-caid MCORA shall be divided by and collect-ed over the number of months for which eachMedicaid MCORA is effective. The Medi-caid MCORA rates, effective dates, andapplicable NAIC Health Annual Statementsare set forth in section (2).

A. Exceptions.(I) If an existing Medicaid MCO’s

applicable NAIC Health Annual Statement,as set forth in section (2), does not representa full calendar year worth of revenue due tothe Medicaid MCO entering the Medicaidmarket during the calendar year, the TotalRevenues used to determine the MCORAshall be the partial year Total Revenuesreported on the NAIC Health Annual State-ments schedule titled Analysis of Operationsby Lines of Business annualized.

(II) If an existing Medicaid MCOdid not have Total Revenues reported on theapplicable NAIC Health Annual Statementdue to the Medicaid MCO not entering theMedicaid market until after the calendar year,the Total Revenue used to determine the Med-icaid MCORA shall be the MC+ regionalweighted average per member per month netcapitation rate in effect during the same cal-endar year multiplied by the MedicaidMCO’s estimated annualized member monthsbased on the most recent complete month.

2. Effective July 1, 2006, the MedicaidMCORA owed for existing Medicaid MCOsshall be calculated by multiplying the Medi-caid MCORA tax rate by the prior monthTotal Revenue, as defined above.

A. Exceptions.(I) For the month of July 2006, the

Medicaid MCORA owed for existing Medi-caid MCOs shall be calculated by multiplyingthe Medicaid MCORA tax rate by the currentmonth Total Revenue, as defined above.

(C) Effective July 1, 2005 through June30, 2006, the Department of Social Servicesshall prepare a confirmation schedule of theinformation from each Medicaid MCO’sNAIC Health Annual Statement Analysis ofOperations by Lines of Business. EffectiveJuly 1, 2006, the Department of Social Ser-vices shall prepare a confirmation schedule ofthe Medicaid MCORA calculation. TheDepartment of Social Services shall provideeach Medicaid MCO with this schedule.


Secretary of State


1. Effective July 1, 2005 through June30, 2006, the schedule shall include:

A. Medicaid MCO name;B. Medicaid MCO provider number;C. Calendar year from the NAIC

Health Annual Statement; andD. Total Revenues reported on the

Analysis of Operations by Lines of Businessschedule.

2. Effective July 1, 2006, the scheduleshall include:

A. Medicaid MCO name;B. Medicaid MCO provider number;

andC. Medicaid MCORA tax rate.

3. Each Medicaid MCO required to paythe Medicaid MCORA shall review the infor-mation in the schedule referenced in para-graph (1)(C)1. of this regulation and if neces-sary, provide the department with correctinformation. If the information supplied bythe department is incorrect, the MedicaidMCO, within fifteen (15) calendar days ofreceiving the confirmation schedule, mustnotify the division and explain the correc-tions. If the division does not receive correct-ed information within fifteen (15) calendardays, it will be assumed to be correct, unlessthe Medicaid MCO files a protest in accor-dance with subsection (1)(E) of this regula-tion.

(D) Payment of the Medicaid MCORA.1. Offset. Each Medicaid MCO may

request that their Medicaid MCORA be offsetagainst any Missouri Medicaid payment dueto that MCO. A statement authorizing theoffset must be on file with the division beforeany offset may be made relative to the Medi-caid MCORA by the MCO. Assessmentsshall be allocated and deducted over theapplicable service period. Any balance dueafter the offset shall be remitted by the Med-icaid MCO to the department. The remit-tance shall be made payable to the director ofthe Department of Revenue and deposited inthe state treasury to the credit of the Medi-caid MCORA Fund. If the remittance is notreceived before the next MO HealthNet pay-ment cycle, the division shall offset the bal-ance due from that check.

2. Check. If no offset has been autho-rized by the Medicaid MCO, the division willbegin collecting the Medicaid MCORA onthe first day of each month. The MedicaidMCORA shall be remitted by the MedicaidMCO to the department. The remittance shallbe made payable to the director of the Depart-ment of Revenue and deposited in the statetreasury to the credit of the MedicaidMCORA Fund.

3. Failure to pay the Medicaid MCORA.If a Medicaid MCO fails to pay its Medicaid

MCORA within thirty (30) days of notice, theMedicaid MCORA shall be delinquent. Forany delinquent Medicaid MCORA, thedepartment may compel the payment of suchreimbursement allowance in the circuit courthaving jurisdiction in the county where themain offices of the Medicaid MCO is locat-ed. In addition, the director of the Depart-ment of Social Services or the director’sdesignee may cancel or refuse to issue,extend, or reinstate a MO HealthNet contractagreement to any Medicaid MCO that fails topay such delinquent reimbursement allowancerequired unless under appeal. Furthermore,except as otherwise noted, failure to pay adelinquent reimbursement allowance imposedshall be grounds for denial, suspension, orrevocation of a license granted by the Depart-ment of Insurance, Financial Institutions andProfessional Registration. The director of theDepartment of Insurance, Financial Institu-tions and Professional Registration may deny,suspend, or revoke the license of the Medi-caid MCO with a contract under 42 U.S.C.section 1396b(m) that fails to pay a MCO’sdelinquent reimbursement allowance unlessunder appeal.

(E) Each Medicaid MCO, upon receivingwritten notice of the final determination of itsMedicaid MCORA, may file a protest withthe director of the department setting forththe grounds on which the protest is based,within thirty (30) days from the date ofreceipt of written notice from the department.The director of the department shall reconsid-er the determination and, if the MedicaidMCO so requested, the director or the direc-tor’s designee shall grant the Medicaid MCOa hearing to be held within forty-five (45)days after the protest is filed, unless extendedby agreement between the Medicaid MCOand the director. The director shall issue afinal decision within forty-five (45) days ofthe completion of the hearing. After a finaldecision by the director, a Medicaid MCO’sappeal of the director’s final decision shall beto the Administrative Hearing Commission inaccordance with sections 208.156, RSMoand 621.055, RSMo.

(2) Medicaid MCORA Rates for SFY 2006.The Medicaid MCORA rates for SFY 2006determined by the division, as set forth in(1)(B) above, are as follows:

(A) The Medicaid MCORA will be fiveand ninety-nine hundredths percent (5.99%)of the Total Revenues reported by each Med-icaid MCO on the calendar year 2004 NAICHealth Annual Statement Analysis of Opera-tions by Lines of Business, for the six (6)-month period of July 2005 through December2005, and five percent (5.00%) of the Total

Revenues reported by each Medicaid MCOon the calendar year 2004 NAIC HealthAnnual Statement Analysis of Operations byLines of Business for the six (6)-month peri-od of January 2006 through June 2006. TheMedicaid MCORA will be collected overtwelve (12) months (July 2005 through June2006). No Medicaid MCORA shall be col-lected by the Department of Social Services ifthe federal Center for Medicare and Medi-caid Services (CMS) determines that suchreimbursement allowance is not authorizedunder Title XIX of the Social Security Act.If CMS approval of the reimbursementallowance occurs after July 2005, the totalMedicaid MCORA for SFY 2006 will be col-lected over the number of months remainingin the fiscal year.


(A) The Medicaid MCORA will be fiveand ninety-nine hundredths percent (5.99%)of the prior month Total Revenue received byeach Medicaid MCO. The MedicaidMCORA will be collected each month forSFY 2007 (July 2006 through June 2007).No Medicaid MCORA shall be collected bythe Department of Social Services if the fed-eral Centers for Medicare and Medicaid Ser-vices (CMS) determines that such reimburse-ment allowance is not authorized under TitleXIX of the Social Security Act.


(A) The Medicaid MCORA will be fiveand ninety-nine hundredths percent (5.99%)of the prior month Total Revenues receivedby each Medicaid MCO for each month ofthe six (6)-month period of July 2007 throughDecember 2007, and five and forty-nine hun-dredths percent (5.49%) of the prior monthTotal Revenues received by each MedicaidMCO for each month of the six (6)-monthperiod of January 2008 through June 2008.The Medicaid MCORA will be collectedeach month for SFY 2008 (July 2007 throughJune 2008). No Medicaid MCORA shall becollected by the Department of Social Ser-vices if the federal Centers for Medicare andMedicaid Services (CMS) determines thatsuch reimbursement allowance is not autho-rized under Title XIX of the Social SecurityAct.

(5) Medicaid MCORA Rates for SFY 2009.The Medicaid MCORA rates for SFY 2009



determined by the division, as set forth in(1)(B) above, are as follows:

(A) The Medicaid MCORA will be fiveand forty-nine hundredths percent (5.49%) ofthe prior month Total Revenue received byeach Medicaid MCO. The MedicaidMCORA will be collected each month forSFY 2009 (July 2008 through June 2009). NoMedicaid MCORA shall be collected by theDepartment of Social Services if the federalCenters for Medicare and Medicaid Services(CMS) determines that such reimbursementallowance is not authorized under Title XIXof the Social Security Act.

(6) Medicaid MCORA Rates for SFY 2010.The Medicaid MCORA rates for SFY 2010determined by the division, as set forth insubsection (1)(B) above, are as follows:

(A) The Medicaid MCORA will be fiveand forty-nine hundredths percent (5.49%) ofthe prior month Total Revenue received byeach Medicaid MCO for the three (3)-monthperiod of July 1, 2009, through September30, 2009. The Medicaid MCORA will becollected for the three (3)-month period ofJuly 1, 2009, through September 30, 2009.No Medicaid MCORA shall be collected bythe Department of Social Services if the fed-eral Centers for Medicare and Medicaid Ser-vices (CMS) determines that such reimburse-ment allowance is not authorized under TitleXIX of the Social Security Act.

AUTHORITY: sections 208.201, 208.431, and208.435, RSMo Supp. 2008.* Original rulefiled June 1, 2005, effective Dec. 30, 2005.Emergency amendment filed May 5, 2006,effective May 15, 2006, expired Nov. 10,2006. Emergency amendment filed June 15,2006, effective July 1, 2006, expired Dec. 28,2006. Amended: Filed June 15, 2006, effec-tive Dec. 30, 2006. Emergency amendmentfiled June 20, 2007, effective July 1, 2007,expired Dec. 27, 2007. Amended: Filed June20, 2007, effective Jan. 30, 2008. Emergencyamendment filed June 18, 2008, effective July1, 2008, expired Dec. 28, 2008. Amended:Filed March 17, 2008, effective Sept. 30,2008. Emergency amendment filed June 19,2009, effective July 1, 2009, expired Sept.30, 2009. Amended: Filed July 1, 2009,effective Jan. 30, 2010.

*Original authority: 208.201, RSMo 1987, amended 2007;208.431, RSMo 2005; and 208.435, RSMo 2005.

13 CSR 70-3.180 Medical Pre-CertificationProcess

PURPOSE: This rule establishes the medicalpre-certification process of the MO HealthNet

Program for certain covered diagnostic andancillary procedures and services prior toprovision of the procedure or service as acondition of reimbursement. This rule shallonly apply to those diagnostic and ancillaryprocedures or services that are listed in theprovider manuals, provider bulletins, or clin-ical edits criteria which are incorporated byreference and made a part of this rule. Themedical pre-certification process serves as autilization management tool, allowing pay-ment for services that are medically neces-sary, appropriate, and cost-effective withoutcompromising the quality of care provided toMO HealthNet participants.


(1) Providers are required to seek pre-certifi-cation for certain specified services listed inthe provider manuals, provider bulletins, orclinical edits criteria before delivery of theservices. This rule shall apply to diagnosticand ancillary procedures and services listed inthe provider manuals, provider bulletins, orclinical edits criteria when ordered by ahealthcare provider unless provided in an inpa-tient hospital or emergency room setting. Thispre-certification process shall not include pri-mary services performed directly by theprovider. In addition to services and proce-dures that are available through the traditionalmedical assistance program, expanded ser-vices are available to children twenty (20)years of age and under through the HealthyChildren and Youth (HCY) Program. Someexpanded services also require pre-certifica-tion. Certain services require pre-certificationonly when provided in a specific place orwhen they exceed certain limits. These limi-tations are explained in detail in subsections13(3) and 14(4) of the applicable providermanuals, provider bulletins, or clinical editscriteria, which are incorporated by referenceand made a part of this rule as published bythe Department of Social Services, MOHealthNet Division, 615 Howerton Court, Jef-ferson City, MO 65109, at its website atwww.dss.mo.gov/mhd, April 1, 2009. Therule does not incorporate any subsequent

amendments or additions. This rule shallonly apply to those diagnostic and ancillaryprocedures or services that are listed in theprovider manuals, provider bulletins, or clin-ical edits criteria which are incorporated byreference and made a part of this rule.

(2) All requests for pre-certification must beinitiated by an enrolled medical assistanceprovider and approved by the MO HealthNetDivision. A covered service for which pre-certification is requested must meet medicalcriteria established by the MO HealthNetDivision’s medical consultants or medicaladvisory groups in order to be approved.

(3) An approved pre-certification requestdoes not guarantee payment. The providermust be enrolled and verify participant eligi-bility on the date of service.

(4) Approved services/procedures must beinitiated within six (6) months of the date thepre-certification approval is issued. Ser-vices/procedures initiated after the six (6)-month approval period will be void and pay-ment denied.

(5) The pre-certification for a specific serviceis time and patient status and/or diagnosissensitive. A denial at any given time shall notprejudice or impact the decision to grant afuture request for the same or similar service.

(6) Pre-certifications for exactly the same ser-vice may be granted to allow provision overan extended period of time and may be grant-ed for a term of not more than one (1) year.

(7) If a pre-certification request is denied, themedical assistance participant will receive aletter which outlines the reason for the denialand the procedure for appeal. The MOHealthNet participant must contact the Partic-ipant Services Unit within ninety (90) days ofthe date of the denial letter if they wish torequest a hearing. After ninety (90) days arequest to appeal the pre-certification deci-sion is denied.

AUTHORITY: sections 208.153 and 208.201,RSMo Supp. 2008.* Original rule filed July3, 2006, effective Feb. 28, 2007. Amended:Filed March 2, 2009, effective Aug. 30, 2009.

*Original authority: 208.153, RSMo 1967, amended1973, 1989, 1990, 1991, 2007 and 208.201, RSMo 1987,amended 2007.

13 CSR 70-3.190 Telehealth Services

PURPOSE: This rule establishes coverage ofthe Telehealth spoke site facility fee and to


Secretary of State


define services considered appropriate forthis form of interactive technology from a hubsite to a participant at a spoke site.


(1) Administration. (A) This rule is established pursuant to the

authority granted to the Missouri Departmentof Social Services, MO HealthNet Division,to promulgate rules governing the practice ofTelehealth in the MO HealthNet Program.

(B) Definitions. 1. Community Mental Health Center

(CMHC) means a legal entity through whichcomprehensive mental health services are pro-vided to individuals residing in a certain ser-vice area.

2. Consultation means a type of evalua-tion and management service as defined bythe most recent edition of the Current Proce-dural Terminology published annually by theAmerican Medical Association.

3. Consulting provider means a providerwho evaluates the patient and appropriatemedical data or images through a Telehealthmode of delivery, upon recommendation ofthe referring provider.

4. Comprehensive Substance Treatmentand Rehabilitation (CSTAR) means a MOHealthNet qualified and enrolled outpatientsubstance abuse treatment program. Cover-age is targeted to MO HealthNet-eligible par-ticipants who are assessed as requiring sub-stance abuse treatment.

5. Department means the Department ofSocial Services.

6. Distant site means a Telehealth sitewhere the health care provider providing theTelehealth service is physically located at thetime the Telehealth service is provided and isconsidered the place of service.

7. Division means the MO HealthNetDivision, within the Department of SocialServices.

8. GT modifier means a modifier thatidentifies a Telehealth service which isapproved by the Healthcare Common Proce-dure Coding System (HCPCS).

9. Health care provider means a:

A. Missouri licensed physician;B. Missouri licensed advanced regis-

tered nurse practitioner;C. Missouri licensed dentist or oral

surgeon;D. Missouri licensed psychologist or

provisional licensee;E. Missouri licensed pharmacist; orF. Missouri licensed speech, occupa-

tional, or physical therapist.10. MTN means the Missouri Telehealth

Network.11. Originating site means a Telehealth

site where the MO HealthNet participantreceiving the Telehealth service is located forthe encounter. The originating site mustensure immediate availability of clinical staffduring a Telehealth encounter in the event aparticipant requires assistance. An originat-ing site must be one (1) of the following loca-tions:

A. Office of a physician or health careprovider;

B. Hospital;C. Critical access hospital;D. Rural health clinic;E. Federally Qualified Health Center;F. Nursing home;G. Dialysis center;H. Missouri state habilitation center

or regional office;I. Community mental health center;J. Missouri state mental health facili-

ty; K. Missouri state facility; L. Missouri residential treatment

facility—licensed by and under contract withthe Children’s Division (CD) and has a con-tract with the CD. Facilities must have multi-ple campuses and have the ability to adhere totechnology requirements addressed in thisrule. Only Missouri licensed psychiatrists,licensed psychologists or provisionallylicensed psychologists, and advanced regis-tered nurse practitioners who are enrolledMO HealthNet providers may be consultingproviders at these locations; or

M. Comprehensive Substance Treat-ment and Rehabilitation (CSTAR) program.

12. Participant means an individual eli-gible for medical assistance benefits onbehalf of needy persons through MO Health-Net, under section 208.151, RSMo.

13. Presenting provider means aprovider who:

A. Introduces a patient to a consultingprovider for examination, observation, orconsideration of medical information; and

B. May assist in the Telehealthencounter.

14. Telepresenter means a person who isan employee of the originating site and is with

the patient during the time of the encounterwho aids in the examination by following theorders of the consulting clinician, includingthe manipulation of cameras and appropriateplacement of other peripheral devices used toconduct the patient examination.

15. Referring provider means a providerwho evaluates a patient, determines the needfor a consultation, and arranges the servicesof a consulting provider for the purpose ofdiagnosis or treatment.

16. Telehealth means the use of medicalinformation exchanged from one (1) site toanother via electronic communications toimprove the health status of a patient. Tele-health means the practice of health care deliv-ery, evaluation, diagnosis, consultation, ortreatment using the transfer of medical data,audio visual, or data communications that areperformed over two (2) or more locationsbetween providers who are physically sepa-rated from the patient or from each other.

17. Telehealth service means a medicalservice provided through advanced telecom-munications technology from a distant site toa participant at an originating site.

18. Two (2)-way interactive video meansa type of advanced telecommunications tech-nology that permits a real time service to takeplace between a participant and a presentingprovider or a Telepresenter at the originatingsite and a health care provider at the distantsite.

(2) Covered Services. (A) A Telehealth service shall be covered

only if it is medically necessary.(B) A Telehealth service shall require use

of two (2)-way interactive video and shall notinclude store and forward services. The par-ticipant must be able to see and interact withthe off-site provider at the time services areprovided via Telehealth.

(C) The distant site is the location wherethe physician or practitioner is physicallylocated at the time of the Telehealth service.Coverage of services rendered through Tele-health at the distant site is limited to:

1. Consultations made to confirm adiagnosis; or

2. Evaluation and management services;or

3. A diagnosis, therapeutic, or interpre-tive service; or

4. Individual psychiatric or substanceabuse assessment diagnostic interview exam-inations; or

5. Individual psychotherapy; or6. Pharmacologic management.

(D) The participant must be present for theencounter.



(3) Eligible Providers.(A) A health care provider utilizing Tele-

health at either a distant site or an originatingsite shall be enrolled as a MO HealthNetprovider pursuant to 13 CSR 70-3.020 andlicensed for practice in Missouri. A healthcare provider utilizing Telehealth must do soin a manner that is consistent with the provi-sions of all laws governing the practice of theprovider’s profession.

(B) A provider agrees to conform to MOHealthNet program policies and instructionsas specified in the provider manuals and bul-letins, which are incorporated by referenceand made a part of this rule as published bythe Department of Social Services, MOHealthNet Division, 615 Howerton Court,Jefferson City, MO 65109, at its websitewww.dss.mo.gov/mhd, April 1, 2009. Thisrule does not incorporate any subsequentamendments or additions.

(4) Prior Authorization and UtilizationReview. All services are subject to utilizationreview for medical necessity and programcompliance. Reviews can be performedbefore services are furnished, before paymentis made, or after payment is made.

(A) Prior Authorization. Certain proce-dures or services can require prior authoriza-tion from the MO HealthNet Division or itsauthorized agents. Services for which priorauthorization was obtained remain subject toutilization review at any point in the paymentprocess. A service provided through Tele-health is subject to the same prior authoriza-tion and utilization review requirement whichexist for the service when not providedthrough Telehealth.

(B) Eligibility Determination. Prior autho-rization of services does not guarantee anindividual is eligible for a MO HealthNet ser-vice. Providers must verify that an individualis eligible for a specific program at the timeservices are furnished and must determine ifthe participant has other health insurance.

(5) Reimbursement. (A) Reimbursement to the health care

provider delivering the medical service at thedistant site is made at the same amount as thecurrent fee schedule for the service providedwithout the use of a telecommunication sys-tem.

(B) The claim for service will use theappropriate procedure code for the coveredservices addressed in (2)(C) and the GT mod-ifier indicating interactive communicationwas used.

(C) The originating site is eligible toreceive a facility fee. Facility fees are notpayable to the distant site.

(D) Services provided by practitionersmust be within their scope(s) of practice andaccording to MO HealthNet policy.

(E) Reimbursement for services furnishedby interns or residents in hospitals withapproved teaching program or services fur-nished in other hospitals that participate inteaching programs is made through institu-tional reimbursement. The division cannotbe billed directly by interns or residents forTelehealth services.

(6) Documentation for the Encounter. Patientrecords at the distant and originating sites areto document the Telehealth encounter consis-tent with the service documentation describedin MO HealthNet provider manuals and bul-letins.

(A) A request for a Telehealth service froma referring provider and the medical necessityfor the Telehealth service shall be document-ed in the participant’s medical record.

(B) A health care provider shall keep acomplete medical record of a Telehealth ser-vice provided to a participant and followapplicable state and federal statutes and reg-ulations for medical record keeping and con-fidentiality in accordance with 13 CSR 70-3.030 and 13 CSR 70-98.015.

(C) Documentation of a Telehealth serviceby the health care provider shall be includedin the participant’s medical record main-tained at the participant’s location and shallinclude:

1. The diagnosis and treatment planresulting from the Telehealth service andprogress note by the health care provider;

2. The location of the distant site andoriginating site;

3. A copy of the signed informed con-sent form; and

4. Documentation supporting the medi-cal necessity of the Telehealth service.

(7) Confidentiality and Data Integrity. AllTelehealth activities must comply with therequirements of the Health Insurance Porta-bility and Accountability Act of 1996, asamended, and all other applicable state andfederal laws and regulations.

(A) A Telehealth service shall be per-formed on a private, dedicated telecommuni-cations line approved through the MissouriTelehealth Network (MTN). The telecommu-nications line must be secure and utilize amethod of encryption adequate to protect theconfidentiality and integrity of the Telehealthservice information. The Missouri TelehealthNetwork must also approve the equipmentthat will be used in Telehealth service.

(B) Both a distant site and an originatingsite shall use authentication and identification

to ensure the confidentiality of a Telehealthservice.

(C) A provider of a Telehealth service shallimplement confidentiality protocols thatinclude:

1. Identifying personnel who haveaccess to a Telehealth transmission; and

2. Preventing unauthorized access to aTelehealth transmission.

(D) A provider’s protocols and guidelinesshall be available for inspection by the depart-ment upon request.

(8) Informed Consent. (A) Before providing a Telehealth service

to a participant, a health care provider shalldocument written informed consent from theparticipant or the participant’s legal guardianand shall ensure that the following writteninformation is provided to the participant in aformat and manner that the participant is ableto understand:

1. The participant shall have the optionto refuse the Telehealth service at anytimewithout affecting the right to future care ortreatment and without risking the loss orwithdrawal of a MO HealthNet benefit towhich the participant is entitled;

2. The participant shall be informed ofalternatives to the Telehealth service that areavailable to the participant;

3. The participant shall have access tomedical information resulting from the Tele-health service as provided by law;

4. The dissemination, storage, or reten-tion of an identifiable participant image orother information from the Telehealth serviceshall not occur without the written informedconsent of the participant or the participant’slegally authorized representative;

5. The participant shall have the right tobe informed of the parties who will be pre-sent at the originating site and the distant siteduring the Telehealth service and shall havethe right to exclude anyone from either site;and

6. The participant shall have the right toobject to the videotaping or other recordingof a Telehealth service.

(B) A copy of the signed informed consentshall be retained in the participant’s medicalrecord and provided to the participant or theparticipant’s legally authorized representativeupon request.

(C) The requirement to obtain informedconsent before providing a service shall notapply to an emergency situation if the partic-ipant is unable to provide informed consentand the participant’s legally authorized repre-sentative is unavailable.

AUTHORITY: section 208.201, RSMo Supp.


Secretary of State


2008.* Original rule filed Jan. 2, 2008,effective Aug. 30, 2008. Amended: Filed Feb.17, 2009, effective Aug. 30, 2009.


13 CSR 70-3.200 Ambulance Service Re-imbursement Allowance

PURPOSE: This rule establishes the formulafor determining the Ambulance Service Reim-bursement Allowance each ground emergencyambulance service must pay, except for anyambulance service owned and operated by anentity owned or operated by the board ofcurators, as defined in Chapter 172, RSMo,or any department of the state, in addition toall other fees and taxes now required or paid,for the privilege of engaging in the businessof providing ground emergency ambulanceservices in Missouri.

(1) Ambulance Service ReimbursementAllowance shall be assessed as described inthis section.

(A) Definitions.1. Ambulance. Ambulance shall have

the same meaning as such term is defined insection 190.100, RSMo.

2. Department. Department of SocialServices.

3. Director. Director of the Departmentof Social Services.

4. Division. MO HealthNet Division.5. Gross receipts. Emergency ambulance

revenue from Medicare, Medicaid, insurance,and private payments received by an ambu-lance service licensed under section 190.109,RSMo (or by its predecessor in interest follow-ing a change of ownership). Revenue fromCPT Code A0427/A0425 ambulance service,advanced life support, emergency transport,level 1 (ALS1–emergency), and associatedground mileage; CPT Code A0429/A0425ambulance services, basic life support, emer-gency transport (BLS–emergency), and associ-ated ground mileage; and CPT CodeA0433/A0425 advanced life support, level 2(ALS2), and associated ground mileage.

6. Engaging in the business of providingambulance services. Accepting payment forambulance services as such term is defined insection 190.100, RSMo.

(B) Beginning October 1, 2013, each groundemergency ambulance services provider in thisstate, except for any ambulance service ownedand operated by an entity owned and operatedby the state of Missouri, including but not lim-ited to any hospital owned or operated by theboard of curators, as defined in Chapter 172,

RSMo, or any department of the state, shall,in addition to all other fees and taxes nowrequired or paid, pay an ambulance servicereimbursement allowance for the privilege ofengaging in the business of providing ambu-lance services as defined in section 190.100,RSMo. Gross receipts shall be obtained bythe division from a survey conducted six (6)months after calendar year end (i.e., calendaryear 2012 gross receipts will be obtainedthrough survey sent out by the state in 2013).Collection of the ambulance service reim-bursement allowance beginning October 1,2013, and thereafter each October 1, shall bebased on gross receipts collected in the priorcalendar year. (i.e. October 1, 2013 shall bebased on gross receipts collected in calendaryear 2012).

1. The ambulance service reimbursementallowance owed for currently licensed emer-gency ambulance providers as defined in sec-tion 190.100, RSMo, shall be calculated bymultiplying the ambulance service reimburse-ment allowance tax rate by the gross receipts,as defined above in paragraph (1)(A)5.

A. Exceptions.(I) For emergency ambulance pro-

viders without reported survey data, the grossreceipts used to determine the ambulance ser-vice reimbursement allowance shall be estimat-ed as follows:

(a) Emergency ambulance pro-viders shall be divided into quartiles based ontotal emergency ambulance transports;

(b) Gross receipts shall be indi-vidually summed and divided by the totalemergency ambulance transports in the quar-tile to yield an average gross receipt peremergency ambulance transport; and

(c) The number of emergencyambulance transports as reported to theDepartment of Health and Senior Services(Bureau of Emergency Medical Services(BEMS) data) as required by 19 CSR 30-40.375(3) for the emergency ambulanceprovider without reported survey data shall bemultiplied by the average gross receipts peremergency ambulance transport.

(C) The Department of Social Servicesshall provide each emergency ambulanceprovider with a final determination letter.The letter shall include emergency ambulanceprovider name, National Provider Identifier(NPI) number, total emergency ambulancegross receipts, ambulance service reimburse-ment allowance tax rate, and annual taxamount.

1. Each emergency ambulance providerrequired to pay the ambulance service reim-bursement allowance shall review the infor-

mation in the letter and, if necessary, providethe department with correct information. Ifthe information supplied by the department isincorrect, the emergency ambulance provider,within fifteen (15) calendar days of receivingthe confirmation schedule, must notify thedivision and explain the corrections. If thedivision does not receive corrected informa-tion within fifteen (15) calendar days, it willbe assumed to be correct, unless the emer-gency ambulance provider files a protest inaccordance with subsection (1)(E) of this reg-ulation.

(D) Payment of the Ambulance ServiceReimbursement Allowance.

1. Offset. Each emergency ambulanceprovider may request that its ambulance ser-vice reimbursement allowance be offsetagainst any Missouri Medicaid payment dueto that emergency ambulance provider. Astatement authorizing the offset must be onfile with the division before any offset may bemade relative to the ambulance service reim-bursement allowance by the emergency ambu-lance provider. Assessments shall be allocat-ed and deducted over the applicable serviceperiod. Any balance due after the offset shallbe remitted by the emergency ambulanceprovider to the department. The remittanceshall be made payable to the director of theDepartment of Revenue and deposited in thestate treasury to the credit of the ambulanceservice reimbursement allowance fund. If theremittance is not received before the next MOHealthNet payment cycle, the division shalloffset the balance due from that check.

2. Check. If no offset has been autho-rized by the emergency ambulance provider,the division will begin collecting the ambu-lance service reimbursement allowance on thefirst day of each month. The ambulance ser-vice reimbursement allowance shall be remit-ted by the emergency ambulance provider tothe department. The remittance shall be madepayable to the director of the Department ofRevenue and deposited in the state treasury tothe credit of the ambulance service reim-bursement allowance fund.

3. Failure to pay the ambulance servicereimbursement allowance. If an emergencyambulance provider fails to pay its ambulanceservice reimbursement allowance within thir-ty (30) days of notice, the ambulance servicereimbursement allowance shall be delinquent.For any delinquent ambulance service reim-bursement allowance, the department maycompel the payment of such reimbursementallowance in the circuit court having jurisdic-tion in the county where the main office ofthe emergency ambulance provider is located.

CODE OF STATE REGULATIONS 23JASON KANDER (3/31/14)Secretary of State


In addition, the director of the Department ofSocial Services or the director’s designeemay cancel or refuse to issue, extend, or rein-state an emergency ambulance provideragreement to any emergency ambulanceprovider that fails to pay such delinquentreimbursement allowance required unlessunder appeal.

(E) Each emergency ambulance provider,upon receiving written notice of the finaldetermination of its ambulance service reim-bursement allowance, may file a protest withthe director of the department setting forththe grounds on which the protest is based,within thirty (30) days from the date ofreceipt of written notice from the department.The director of the department shall reconsid-er the determination and, if the emergencyambulance provider so requested, the directoror the director’s designee shall grant theemergency ambulance provider a hearing tobe held within forty-five (45) days after theprotest is filed, unless extended by agreementbetween the emergency ambulance providerand the director. The director shall issue afinal decision within forty-five (45) days ofthe completion of the hearing. After a finaldecision by the director, an emergency ambu-lance provider’s appeal of the director’s finaldecision shall be to the Administrative Hear-ing Commission in accordance with sections208.156 and 621.055, RSMo.

(2) Ambulance Service ReimbursementAllowance Rate beginning October 1, 2013.The ambulance service reimbursementallowance rate beginning October 1, 2013determined by the division, as set forth insubsection (1)(B) above, is as follows:

(A) The ambulance service reimbursementallowance rate shall be three and seventy-fourhundredths percent (3.74%) of gross receiptsas determined in paragraph (1)(A)5. abovewith an aggregate annual adjustment, by theMO HealthNet Division, not to exceed onepercent (1.0%) based on the ambulance ser-vices total gross receipts. No ambulance ser-vice reimbursement allowance shall be col-lected by the Department of Social Services ifthe federal Centers for Medicare and Medi-caid Services (CMS) determines that suchreimbursement allowance is not authorizedunder Title XIX of the Social Security Act.

AUTHORITY: sections 190.836 and 208.201,RSMo Supp. 2013.* Original rule filed March19, 2010, effective Nov. 30, 2010. Amended:Filed Oct. 10, 2013, effective April 30, 2014.

*Original authority: 190.836, RSMo 2009 and 208.201,RSMo 1987, amended 2007.

13 CSR 70-3.210 Electronic Retention ofRecords

PURPOSE: This rule advises MO HealthNetproviders of the opportunity to store recordson an electronic medium to save resourceswhen storing records.

(1) Records required to be maintained by theDepartment of Social Services may be main-tained in an electronic medium. Recordsmeans any books, papers, journals, charts,treatment histories, medical histories, testsand laboratory results, photographs, X rays,and any other recordings of data or informa-tion made by or caused to be made by aprovider relating in any way to services pro-vided to MO HealthNet participants and pay-ments charged or received.

(2) Upon transfer of an original paper recordto an electronic medium, the enrolledprovider may destroy the original paperrecord after assuring that all information con-tained in the original record, including signa-tures, handwritten notations, or pictures, iscontained in the durable medium.

(3) If the provider does not retain the originalpaper record, or if there was no originalpaper record, a duplicate or back-up systemsufficient to permit reconstruction of theelectronic records shall be established at aseparate location.

(4) Nothing in this regulation shall be con-strued as requiring the utilization of any par-ticular method of record retention by anenrolled provider. Records may be retained inany form that can be made available forreview at the same site at which the servicewas provided or at the provider’s address ofrecord with the Department of Social Ser-vices. Copies of records must be providedupon request of the Department of Social Ser-vices, Department of Health and Senior Ser-vices, and/or Department of Mental Healthor its authorized agents, regardless of themedia in which they are kept. Failure to makethese records available at the same site atwhich the services were rendered or at theprovider’s address of record with the Depart-ment of Social Services, or failure to providecopies when and as requested, or failure tokeep and make available records which docu-ment the services and payments as required in13 CSR 70-3.030 shall constitute a violationof this section and shall be a reason for sanc-tion.

AUTHORITY: section 208.201, RSMo Supp.2010.* Original rule filed July 1, 2011, effec-tive Dec. 30, 2011.


13 CSR 70-3.220 Electronic Health RecordIncentive Program

PURPOSE: The Health Information Technol-ogy and Clinical Health Act (HITECH) offersincentive payments to encourage eligible pro-fessionals and hospitals to adopt certifiedElectronic Health Records (EHRs). This ruleestablishes the basis on which eligible hospi-tals and professionals participating in theMO HealthNet Program will be eligible toreceive payments when they successfullydemonstrate that they have adopted, imple-mented, or upgraded to certified EHR tech-nology in the first year and meaningfully usecertified electronic health record technologyin subsequent years.

(1) Definitions. Patient volume shall be cal-culated as outlined in 42 CFR 495.302–495.306.

(2) Eligible Providers. To qualify for Medi-caid incentive payments during the first year,eligible professionals and hospitals mustcomplete registration and attestation require-ments, meet volume thresholds for Medicaidpatients, and show that they have adopted,implemented, or upgraded to certified elec-tronic health record (EHR) technology. Insubsequent years, payments require demon-stration of meaningful use of certified EHRtechnology. To be deemed an “eligible pro-fessional or hospital” for the electronic healthrecord incentive program, a professional orhospital must satisfy the following criteria:

(A) The eligible professional or hospitalmust be currently enrolled as a MO Health-Net provider, either in the fee for service pro-gram or a managed care organization whichhas a contract with the state of Missouri;

(B) The provider must be one (1) of thefollowing:

1. An eligible professional, listed as—A. A physician;B. A dentist;C. A certified nurse midwife;D. A nurse practitioner; orE. A physician assistant practicing in

a federally-qualified health center or ruralhealth clinic when a physician assistant is theprimary provider, director, or owner of thesite;

2. An acute care hospital, defined as ahealth care facility where the average lengthof stay is twenty-five (25) days or fewer,which has a Centers for Medicare and Medi-caid Services (CMS) certification numberwith the last four digits in the series 0001–0879 or 1300–1399; or

3. A children’s hospital, defined as aseparately certified children’s hospital, either

24 CODE OF STATE REGULATIONS (3/31/14) JASON KANDER

Secretary of State


freestanding or a hospital-within-hospital,that predominately treats individuals undertwenty-one (21) years of age and has a CMScertification number with the last four digitsin the series 3300–3399;

(C) For the year for which the provider isapplying for an incentive payment—

1. An eligible professional must have atleast thirty percent (30%) of the profession-al’s patient volume covered by Medicaid,except that—

A. A pediatrician must have at leasttwenty percent (20%) Medicaid patient vol-ume;

B. A professional practicing at a fed-erally-qualified health center or rural healthclinic must have at least fifty percent (50%)of patient encounters in a federally-qualifiedhealth center or rural health clinic, with aminimum thirty percent (30%) patients whoare medically needy, defined as those fur-nished uncompensated care, or serviceseither at no cost or at a reduced cost based ona sliding scale or ability to pay, or patientscovered by the MO HealthNet program or thestate’s Children’s Health Insurance Program(CHIP); and

C. Professionals have the option tobase their volume on either—

(I) Their individual Medicaidpatient encounters as a percentage of theirtotal individual encounters; or

(II) The practice’s total Medicaidencounters as a percentage of the practice’stotal patient encounters;

2. An acute care hospital must have tenpercent (10%) Medicaid patient volume; and

3. A children’s hospital is presumed tomeet the Medicaid patient volume require-ment;

(D) Application and Agreement. Any eli-gible provider who wants to participate in theMissouri electronic health record incentiveprogram must declare the intent to participateby electronically registering with the Centersfor Medicare and Medicaid Services (CMS)using the Medicare and Medicaid electronichealth record incentive program registrationand attestation website. CMS will notify theDepartment of Social Services of an eligibleprovider’s registration for the Medicaidincentive payment program.

1. The department will maintain a web-site and secure portal with instructions forsubmitting documentation of patient volume,certified technology, and other informationrequired to apply for the Medicaid EHRincentive at the website, http://mo.arraincen-tive.com.

2. The applicant shall use the websiteto—

A. Attest to the applicant’s qualifica-

tions to receive the incentive payment; and B. Submit an electronic copy of a

signed attestation form.3. The department may request any

missing or additional information from theprovider. If missing or additional informationis required, the department will notify theprovider by electronic mail of the specificinformation needed. If the provider fails tosubmit the required information, the depart-ment will determine the registration incom-plete and application will remain in anincomplete status until the required informa-tion is submitted.

4. The department may request addition-al information from sources other than theprovider to validate the provider’s attestationsubmitted as a result of this rule;

(E) Record Retention. Providers mustretain records to support their eligibility forthe incentive payment for a minimum of six(6) years. The department will selectproviders for audit after issuance of an incen-tive payment. Incentive payment recipientsshall cooperate with the department by pro-viding proof of—

1. Eligibility for the incentive program;2. Medicaid patient volume thresholds;3. Purchase of certified electronic health

record technology; and4. Meaningful use of electronic health

record technology;(F) Patient Consent Form. Providers must

retain records to support the disclosure ofpatient health information to all treatingproviders; and

(G) Administrative Appeal. Any eligibleprovider or any provider that claims to be aneligible provider and who has been subject toadverse actions related to the electronichealth record incentive program may seekreview of the department’s action pursuant tosection 621.055, RSMo. Appealable issuesinclude:

1. Provider eligibility determination;2. Medicaid patient volume thresholds;3. Incentive payment amounts; or4. Demonstration of adopting, imple-

menting, upgrading, and meaningful use oftechnology.

(3) The department will make an incentivepayment to a provider as a result of this rulein accordance with the requirements of 42CFR 495.308–495.312. A provider who hasreceived an incentive payment as a result ofthis rule must continue to meet the eligibilitystandards for that payment through the entirepayment year. If the department finds that aprovider is deficient, the department maytake any of the following actions:

(A) Suspend an incentive payment until theprovider has removed the deficiency to the

satisfaction of the department;(B) Require full repayment of all or a por-

tion of an incentive payment; or(C) Terminate participation in the MO

HealthNet electronic health record incentiveprogram.

AUTHORITY: section 208.201, RSMo Supp.2010.* Original rule filed July 1, 2011, effec-tive Dec. 30, 2011.


13 CSR 70-3.230 Payment Policy forProvider Preventable Conditions

PURPOSE: This rule establishes the MOHealthNet payment policy for services provid-ed by acute care hospitals or ambulatory sur-gical centers that result in Provider Pre-ventable Conditions, errors in medical carethat are clearly identifiable, preventable, andserious in their consequences for patients.

(1) Definitions.(A) Provider Preventable Conditions (PPC).

An umbrella term for hospital and non-hospi-tal acquired conditions identified by the statefor nonpayment to ensure the high quality ofMedicaid services. PPCs include two (2) dis-tinct categories, Health Care-Acquired Con-ditions (HCAC) and Other Provider-Pre-ventable Conditions (OPPC).

(B) Health Care-Acquired Conditions(HCAC). Apply to conditions that occurredduring a Medicaid inpatient hospital stay.HCACs are defined as the full list of Medi-care Hospital Acquired Conditions, with theexception of Deep Vein Thrombosis/Pul-monary Embolism following total kneereplacement or hip replacement in pediatricand obstetric patients, as the minimumrequirements for states’ PPC nonpaymentprogram.

(C) Other Provider-Preventable Conditions(OPPC). This includes the list of SeriousReportable Events in Healthcare as publishedby the National Quality Forum. These condi-tions apply broadly to Medicaid inpatient andoutpatient health care settings where theseevents may occur.

(D) Adverse event. A discrete, auditable,and clearly defined occurrence as identifiedby the National Quality Forum in its list ofserious adverse events in health care, as ofDecember 15, 2008 (and as further definedby the criteria and implementation guidanceof Table 1 of the National Quality Forum’spublication “Serious Reportable Events inHealthcare: 2006 Update” which is avail-able at http://www.qualityforum.org/publi-cations/reports/sre_2006.asp), or an event



identified by the Centers for Medicare andMedicaid Services, as of December 15,2008, that leads to a negative consequence ofcare resulting in an unintended injury or ill-ness which was preventable.

(E) Preventable. An event that reasonablycould have been anticipated and avoided bythe establishment and implementation ofappropriate policies, procedures, and proto-cols by a hospital or by staff conformance toestablished hospital policies, procedures, andprotocols.

(F) Serious. An adverse event that resultsin death or loss of a body part, disability, orloss of bodily function lasting more thanseven (7) days or, for a hospital patient, theloss of bodily function is still present at thetime of discharge from a hospital.

(G) Healthcare facility. For purposes of theregulation shall mean a hospital or ambulato-ry surgical center.

(2) Payment to hospitals enrolled as MOHealthNet providers for care related only tothe treatment of the consequences of a HCACwill be denied or recovered by the MO Health-Net Division when the HCAC is determinedto have occurred during an inpatient hospitalstay.

(A) HCAC conditions include:1. Foreign object retained after surgery;2. Air embolism;3. Blood incompatibility;4. Stage III and IV pressure ulcers;5. Falls and trauma—

A. Fractures;B. Dislocations;C. Intracranial Injuries;D. Crushing Injuries;E. Burns; orF. Electric Shock;

6. Catheter-associated Urinary TractInfection;

7. Vascular catheter-associated infec-tion;

8. Manifestations of poor glycemic con-trol—

A. Diabetic Ketoacidosis;B. Nonketotic Hyperosmolar coma;C. Hypoglycemic coma;D. Secondary diabetes with ketoaci-

dosis; orE. Secondary diabetes with hyperos-

molarity;9. Surgical site infection following:

A. Coronary Artery Bypass Graft(CABG)—Mediastinitis;

B. Bariatric surgery—(I) Laparoscopic gastric Bypass;(II) Gastroenterostomy; or(III) Laparoscopic gastric restric-

tive surgery; or

C. Orthopedic procedures—(I) Spine;(II) Neck;(III) Shoulder; or(IV) Elbow; and

10. Deep Vein Thrombosis (DVT)/Pul-monary Embolism (PE) excluding those inpediatric and obstetric patients following:

A. Total knee replacement; orB. Hip replacement.

(B) Hospitals enrolled as MO HealthNetproviders shall include the “Present onAdmission” (POA) indicator on the CMS1450 UB-04 or electronic equivalent whensubmitting inpatient claims for paymentbeginning July 1, 2010. The POA indicator isto be used according to the Official CodingGuidelines for Coding and Reporting and theCMS guidelines. The POA indicator willprompt review of inpatient hospital claimswith an HCAC diagnosis code when appro-priate according to the CMS guidelines.

(C) HCACs are based on Medicare inpa-tient prospective payment system rules effec-tive October 1, 2010 (FY 2011), published inthe Federal Register, 75:157 (Aug. 16,2010), pp. 50084–50085, with the inclusionof present on admission (POA) indicators asprovided by the final regulation published inthe Federal Register, 76:108 (June 6, 2011),pp. 32816–32838. Unlike Medicare, all MOHealthNet enrolled hospitals must report theabove mentioned HCACs on claims submittedto MO HealthNet for consideration of pay-ment.

(3) Payment to hospitals or ambulatory surgi-cal centers enrolled as MO HealthNetproviders for care related only to the treat-ment of the consequences of an OtherProvider-Preventable Condition such as aserious adverse event will be denied or recov-ered by the MO HealthNet Division when theserious adverse event is determined to—

(A) Be preventable;(B) Be within the control of the hospital or

ambulatory surgical center;(C) Have occurred during an inpatient hos-

pital admission, outpatient hospital care, orcare in an ambulatory surgical center;

(D) Have resulted in serious harm; and(E) Be included on the National Quality

Forum list of Serious Reportable Events as ofDecember 15, 2008, non-payable by Medi-care as of December 15, 2008. The NationalQuality Forum list of serious reportableevents as of December 15, 2008, includes:

1. Surgery performed on the wrongbody part;

2. Surgery performed on the wrongpatient;

3. Wrong surgical procedure on apatient;

4. Foreign object left in a patient aftersurgery or other procedure;

5. Intraoperative or immediately post-operative death in a normal health patient;

6. Patient death or serious disabilityassociated with the use of contaminateddrugs, devices, or biologics provided by thehealthcare facility;

7. Patient death or serious disabilityassociated with the use or function of adevice in patient care in which the device isused or functions other than as intended;

8. Patient death or serious disabilityassociated with intravascular air embolismthat occurs while being cared for in a health-care facility;

9. Infant discharged to the wrong per-son;

10. Patient death or serious disabilityassociated with patient elopement (disappear-ance) for more than four (4) hours;

11. Patient suicide or attempted suicideresulting in serious disability, while beingcared for in a healthcare facility;

12. Patient death or serious disabilityassociated with a medication error (errorinvolving the wrong drug, wrong dose,wrong patient, wrong time, wrong rate,wrong preparation, or wrong route of admin-istration);

13. Patient death or serious disabilityassociated with a hemolytic reaction due tothe administration of ABO-incompatibleblood or blood products;

14. Maternal death or serious disabilityassociated with labor or delivery on a low-risk pregnancy while being cared for in ahealthcare facility;

15. Patient death or serious disabilityassociated with hypoglycemia, the onset ofwhich occurs while the patient is being caredfor in a healthcare facility;

16. Death or serious disability (Ker-nicterus) associated with failure to identifyand treat hyperbilirubinemia in neonates;

17. Stage III or IV pressure ulcersacquired after admission to a healthcare facil-ity;

18. Patient death or serious disabilitydue to spinal manipulative therapy;

19. Patient death or serious disabilityassociated with an electric shock while beingcared for in a healthcare facility;

20. Any incident in which a line desig-nated for oxygen or other gas to be deliveredto a patient contains the wrong gas or is con-taminated by toxic substances;

21. Patient death or serious disabilityassociated with a burn incurred from any


Secretary of State


source while being cared for in a healthcarefacility;

22. Patient death associated with a fallwhile being cared for in a healthcare facility;

23. Patient death or serious disabilityassociated with the use of restraints orbedrails while being cared for in a healthcarefacility;

24. Any instance of care ordered by orprovided by someone impersonating a physi-cian, nurse, pharmacist, or other licensedhealthcare provider;

25. Abduction of a patient of any age; or26. Sexual assault on a patient within or

on the grounds of a healthcare facility; (F) Other Provider-Preventable Conditions

(OPPC) or serious adverse events are to bebilled as follows:

1. Medical claims using the CMS 1500claim form, must be billed with the surgicalprocedure code and modifier which indicatesthe type of serious adverse event: modifierPA (wrong body part), PB (wrong patient), orPC (wrong surgery), AND/OR at least one(1) of the diagnosis codes indicating wrongsurgery, wrong patient, or wrong body partmust be present as one of the first four (4)diagnosis codes on the claim;

2. Outpatient hospital claims using theCMS 1450 UB-04 claim form or its electron-ic equivalent must be billed with at least one(1) of the diagnosis codes indicating wrongsurgery, wrong patient, or wrong body partwithin the first five (5) diagnosis codes listedon the claim; and

3. Inpatient hospital claims, using theCMS 1450 UB-04 claim form or its electron-ic equivalent must be billed with a type of bill0110.

A. If there are covered services orprocedures provided during the same stay asthe serious adverse event service, then thefacility must submit two (2) claims; one (1)claim with covered services unrelated to theOPPC event and the other claim for any andall services related to the OPPC event.

B. The Type of Bill 0110 claim mustalso contain one (1) of the diagnosis codesindicating wrong surgery, wrong patient, orwrong body part within the first five (5) diag-nosis codes listed on the claim.

(4) A MO HealthNet participant shall not beliable for payment for an item or servicerelated to an OPPC or HCAC or the treat-ment of consequences of an OPPC or HCACthat would have been otherwise payable bythe MO HealthNet Division.

(5) The review process for Provider Prevent-able Conditions (PPC) will include a reviewof the claim and, if applicable, any informa-

tion provided during the inpatient certifica-tion review to determine if the length of staywas extended by the PPC. Medical recordswill be requested from the provider as neededto complete the review. Providers will berequired to submit the medical records to theMO HealthNet Division within thirty (30)days of receipt of the request for records.Medical records will be reviewed by clinical-ly appropriate medical professionals withinthe MO HealthNet Division or its contractedmedical consultants to assess the quality ofmedical care provided and the circumstancessurrounding that care. MO HealthNet pay-ment denials or recoupments will be calculat-ed by the MO HealthNet Division based onthe facts of each OPPC or HCAC. The calcu-lation of the denial of payment or recoupmentwill be reviewed by the MO HealthNet Divi-sion Medical Director and the MO HealthNetDivision Director after consideration of thereview findings provided by the clinical staffwho completed the review. The final decisionof the division regarding the denial of pay-ment or recoupment shall be subject toreview by the Administrative Hearing Com-mission pursuant to the provisions of section208.156, RSMo. Such payment limitationshall only apply to the hospital or ambulatorysurgical center where the OPPC or HCACoccurred and shall not apply to care providedby other hospitals should the patient subse-quently be transferred or admitted to anotherhospital for needed care.

(6) A MO HealthNet participant shall not beliable for payment, and must not be billed,for any item or service related to a PPC.

AUTHORITY: sections 208.153 and 208.201,RSMo Supp. 2011.* Material in this rule orig-inally filed as 13 CSR 70-15.200. Originalrule filed Nov. 30, 2011, effective June 30,2012.


13 CSR 70-3.240 MO HealthNet PrimaryCare Health Homes

PURPOSE: This rule establishes the MOHealthNet Primary Care Health Home pro-gram for MO HealthNet participants withchronic conditions.

(1) Definitions. (A) EMR—Electronic Medical Records,

also referred to as Electronic Health Records(EHR).

(B) Health Home—A primary care practice

or site that provides comprehensive primaryphysical and behavioral health care to MHDpatients with chronic physical and/or behav-ioral health conditions, using a partnership orteam approach between the Health Homepractice’s/site’s health care staff and patientsin order to achieve improved primary careand to avoid preventable hospitalization oremergency department use for conditionstreatable by the Health Home.

(C) Meaningful Use Stage One—TheAmerican Recovery and Reinvestment Act(ARRA) of 2009 created the Electronic HealthRecords (EHR) incentive payments programto provide Medicare or Medicaid incentivepayments to eligible professionals in primarycare practices. Meaningful use means that theeligible professionals or providers documentthat they are using certified EHR technologyin ways that can be measured significantly inquality and in quantity. Stage one of meaning-ful use means the eligible professionals meettwenty (20) out of twenty-five (25) meaningfuluse objectives as specified by the Centers forMedicare and Medicaid Services (CMS).

(D) MHD—MO HealthNet Division,Department of Social Services.

(E) NCQA—National Committee of Quali-ty Assurance, an entity chosen by MHD tocertify that a primary care practice hasobtained a level of Health Home recognitionafter the practice achieves specified HealthHome standards.

(F) Needy Individuals—Patients whoseprimary care services are either reimbursedby MHD or the Children’s Health InsuranceProgram (CHIP), or are provided as uncom-pensated care by the primary care practice, orare furnished at no cost or at reduced cost topatients without insurance.

(G) Patient Panel—The list of patients forwhom each provider at the practice siteserves as the primary care provider.

(H) CMS—Centers for Medicare and Med-icaid Services.

(I) The Joint Commission—An entity cho-sen by MHD to certify that a primary carepractice has obtained a level of Health Homerecognition after the practice achieves speci-fied Health Home standards.

(2) A primary care practice site shall meetthe following requirements at the time of thesite’s application to be considered for selec-tion as a Health Home site by MHD and forparticipation in a Health Home learning col-laborative:



(A) It must have substantial Medicaid uti-lization in its patient population, with needyindividuals comprising no less than twenty-five percent (25%) of its patient population;

(B) It must demonstrate that it has strongengaged leadership committed to, and capableof, leading the practice site through a continu-ing Health Home transformation process andsustaining transformed practice processes;

(C) It must have patient panels assigned toeach primary care clinician;

(D) It must actively utilize MHD’s com-prehensive electronic health record for carecoordination and prescription monitoring forMHD participants;

(E) It must utilize an interoperable patientregistry to input annual metabolic screeningresults, track and measure care of individu-als, automate care reminders, and produceexception reports for care planning;

(F) It must meet the minimum accessrequirements of third-next-available appoint-ment within thirty (30) days and same-dayurgent care;

(G) It must have completed EMR imple-mentation and have been using EMR at stageone of meaningful use for at least six (6)months prior to the beginning of HealthHome services; and

(H) It must comply with established timeframes for Health Home applications, inquirysubmission, learning collaborative atten-dance, and any reporting deadlines.

(3) Health Home Responsibilities AfterSelection.

(A) Health Home practice sites will have aphysician champion to provide physician lead-ership and encourage practice transformationto the Health Home model. Health Homepractice sites shall form a health team com-prised of, at a minimum, a primary care physi-cian (i.e., family practice, internal medicine,or pediatrics) or nurse practitioner, a behav-ioral health consultant, and a nurse clinicalcare manager. The team will be supported asneeded by the care coordinator, Health HomeDirector, and the practice administrator oroffice manager. Other team members mayinclude, for example, dietitians, nutritionists,pharmacists, or social workers.

(B) Practice sites selected to be MHDHealth Homes shall participate in HealthHome webinars, care team forums, and othertraining opportunities. A Health Home willparticipate in topical work groups as request-ed by MHD.

(C) Health Homes shall convene practiceteam meetings at regular intervals to assistwith the practice’s transformation into aHealth Home and to support continual HealthHome evolution.

(D) A Health Home shall create and main-tain a patient registry using EHR software, astand-alone registry, or a third-party datarepository and measures reporting system.The patient registry is the system used toobtain information critical to the managementof the health of a primary care practice’spatient population, including dates of ser-vices, types of services, and laboratory valuesneeded to track chronic conditions. TheHealth Home’s patient registry will be usedfor—

1. Patient tracking;2. Patient risk stratification;3. Analysis of patient population health

status and individual patient needs; and4. Reporting as specified by MHD.

(E) Primary care practice sites must trans-form how they operate in order to becomeHealth Homes. Transformation involves mas-tery of thirteen (13) Health Home core com-petencies to be taught through the learningcollaborative. The thirteen (13) core compe-tencies are—

1. Patient/family/peer/advocate/care-giver-centeredness or a whole-patient orien-tation to care;

2. Multi-disciplinary team-based ap-proach to care;

3. Personal patient/primary care clini-cian relationships;

4. Planned visits and follow-up care;5. Population-based tracking and analy-

sis with patient-specific reminders;6. Care coordination across settings,

including referral and transition management;7. Integrated clinical care management

services focused on high-risk patients includ-ing medication management, such as medica-tion histories, medication care plans, andmedication reconciliation;

8. Patient and family education;9. Self-management support by mem-

bers of the practice team;10. Involvement of the patient in goal

setting, action planning, problem solving, andfollow-up;

11. Evidence-based care delivery,including stepped care protocols;

12. Integration of quality improvementstrategies and techniques; and

13. Enhanced access.(F) By the eighteenth month following the

receipt of the first MHD Health Home pay-ment, a practice site participating in theHealth Home program shall demonstrate toMHD that the practice site has either—

1. Submitted to the National Committeeof Quality Assurance (NCQA) an applicationfor Health Home status and has obtainedNCQA recognition of Health Home status ofat least Level 1 under the most recent NCQA

standard; or2. Applied to The Joint Commission for

certification as a Primary Care MedicalHome.

(G) A Health Home shall submit to MHDor its designee the following information, asfurther specified by MHD or its designee,within the specified time frames:

1. Monthly narrative practice reportsthat describe the Health Home’s efforts andprogress toward implementing Health Homepractices;

2. Monthly clinical quality indicatorreports utilizing clinical data obtained fromthe Health Home’s patient registry or third-party data repository; and

3. Other reports as specified by MHD.(H) Practices selected to participate in the

Health Home program must provide evidenceof Health Home practice transformation onan ongoing basis using measures and stan-dards established by MHD. Evidence ofHealth Home transformation includes:

1. Development of fundamental HealthHome functionality at six (6) months and attwelve (12) months of entering the HealthHome program, based on an assessment pro-cess to be applied by MHD or its designee;

2. Significant improvement on clinicalindicators specified by and reported to MHDor its designee; and

3. Development of quality improvementplans to address gaps and opportunities forimprovement identified during and after theHealth Home application process.

(I) A Health Home must notify MHDwithin five (5) working days of the followingchanges:

1. Changes in the employment or con-tracting of Health Home team members, orchanges in the percentage of full-time equiv-alent work time devoted to the Health Homeby any Health Home team member; or

2. If the Health Home experiences sub-stantive changes in practice ownership orcomposition, including:

A. Acquisition by another practice;B. Acquisition of another practice; orC. Merger with another practice.

(J) Health Homes shall participate in eval-uations determined necessary by CMS and/orMHD. Participation in evaluations mayrequire responding to surveys and requestsfor interviews of Health Home practice staffand patients. Health Homes shall provide allrequested information to an evaluator in atimely fashion.

(K) Within three (3) months of selection tobe a Health Home, a practice site will devel-op processes with area hospitals to shareinformation on Health Home participantsadmitted to inpatient departments or seen in


Secretary of State


the emergency department.(L) In order to provide Health Home ser-

vices to a participant with substance use dis-order and who is eligible for Health Homeservices in accordance with subparagraph(4)(A)2.A., a Primary Care Health Homepractice must have at least one (1) performingprovider who qualifies and applies for a waiv-er under the Drug Addiction Treatment Act of2000 (DATA 2000) to provide medication-assisted treatment.

(4) Health Home Patient Requirements.(A) To become a MO HealthNet Health

Home patient, an individual—1. Must be an MHD participant or a

participant enrolled in an MHD managedcare health plan; and

2. Must have at least—A. Two (2) of the following chronic

conditions:(I) Asthma;(II) Diabetes;(III) Cardiovascular disease;(IV) A developmental disability; (V) Be overweight, as evidenced by

having a body mass index (BMI) of at leasttwenty-five (25) for adults, or being at orabove the eighty-fifth (85th) percentile on thestandard pediatric growth chart for children;

(VI) Depression;(VII) Anxiety; or(VIII) Substance use disorder; or

B. One (1) chronic health conditionand be at risk for a second chronic healthcondition as defined by MHD. In addition tobeing a chronic health condition, diabetesshall be a condition that places a patient atrisk for a second chronic condition. Smokingor regular tobacco use shall be considered at-risk behavior leading to a second chronichealth condition; or

C. One (1) of the following stand-alone chronic conditions:

(I) Uncontrolled pediatric asthmaas defined by MO HealthNet; or

(II) Obesity, as evidenced by havinga BMI over thirty (30) for adults, or beingabove the ninety-fifth (95th) percentile on thestandard pediatric growth chart for children.

(B) A list of participants eligible for HealthHome services and identified by MHD asexisting users of services at Health Homepractices will be provided monthly to eachHealth Home based on qualifying chronichealth conditions. Health Home organizationswill determine enrollees from the lists provid-ed by MHD as well as practice patients iden-tified through the Health Homes’ EMR sys-tems.

(C) After being enrolled in Health Homes,participants will be granted the option at any

time to change their Health Homes if desired.Participants will be given the opportunity toopt out of receiving services from theirHealth Home providers.

(5) Required Health Home Services.(A) All Health Homes shall provide clini-

cal care management services for enrolledpatients, including those who are at high riskfor future hospital inpatient admissions orhospital emergency department use.

1. Essential clinical care managementservices include:

A. Identification of high-risk patientsand use of patient information to determinethe level of participation in clinical care man-agement services;

B. Assessment of preliminary serviceneeds;

C. Individual treatment plan develop-ment for each patient, including patient goals,preferences, and optimal clinical outcomes;

D. Intensive monitoring, follow-up,and clinical management of high-riskpatients;

E. Assignment of health team rolesand responsibilities by the clinical care man-ager;

F. Monitoring of individual and popu-lation health status and service use to deter-mine adherence to, or variance from, treat-ment guidelines;

G. Development of treatment guide-lines for health teams to follow across risklevels or health conditions; and

H. Development and dissemination ofreports that indicate progress toward meetingdesired outcomes for client satisfaction,health status, service delivery, and costs.

2. Clinical care management activitiesgenerally include frequent patient contact,clinical assessment, medication review andreconciliation, communication with treatingclinicians, and medication adjustment by pro-tocol.

3. A Health Home shall employ or con-tract with at least one (1) licensed nurse asthe Health Home clinical care managerresponsible for providing clinical care man-agement services. The clinical care managershall function as a member of the HealthHome practice team whenever patients of thepractice team are receiving clinical care man-agement services.

4. Health Homes shall ensure and docu-ment that funding for clinical care manage-ment services is used exclusively to provideclinical care management services.

5. Recognized Health Homes may col-laborate in the provision of clinical care man-agement services.

(B) Health Homes shall provide health pro-

motion services for their patients. Health pro-motion services include:

1. Providing health education specific toa patient’s chronic conditions;

2. Emphasizing patient self-direction,planning, and skill development so patientscan help manage and monitor their chronichealth conditions;

3. Providing support for improvingsocial networks; and

4. Providing health-promoting lifestyleinterventions, including but not limited to:

A. Substance abuse prevention;B. Smoking prevention and cessation;C. Nutritional counseling;D. Obesity prevention and reduction;

andE. Physical exercise activities.

(C) All Health Homes shall provide com-prehensive care coordination services neces-sary to implement individual treatment plans,reduce hospital inpatient admissions, andinterrupt patterns of frequent hospital emer-gency department use.

1. Care coordination requires that amember of the Health Home team assistpatients in the development, revision, andimplementation of their individual treatmentplans.

2. Care coordination also includesappropriate linkages, referrals, and follow-ups to needed services and supports.

3. Health Homes that specialize in pri-mary physical health care shall obtain the ser-vices of a licensed behavioral health profes-sional to assist with care coordinationservices.

4. Other essential care coordinationactivities include:

A. Appointment scheduling;B. Arranging transportation for medi-

cally-necessary services;C. Monitoring referrals and follow-

ups;D. Providing comprehensive transi-

tional care by collaborating with physicians,nurses, social workers, discharge planners,pharmacists, and other health care profes-sionals to continue implementation ofpatients’ treatment plans;

E. For patients with developmentaldisabilities (DD), coordinating with DD casemanagers for services more directly related tohabilitation and other DD-related services;

F. Referring Health Home patients tosocial and community resources for assis-tance in areas such as legal services, housing,and disability benefits; and

G. Providing individual and familysupport services by working with patients andtheir families to increase their abilities tomanage the patients’ care and live safely in



the community.

(6) Hospitals and participating Health Homesites shall communicate transitional careplanning for Health Home participants,including inpatient discharge planning, suchthat effective patient-centered, quality-drivenprovider coordination is ensured.

(7) Health Home Payment Components.(A) General.

1. All Health Home payments to a prac-tice site are contingent on the site meeting theHealth Home requirements set forth in thisrule. Failure to meet these requirements isgrounds for revocation of a site’s HealthHome status and termination of paymentsspecified within this rule.

2. MO HealthNet Health Home reim-bursement will be in addition to a provider’sexisting MHD reimbursement for servicesand procedures and will not change existingreimbursement for a provider’s non-HealthHome services and procedures.

3. No Health Home payments will bemade to an MHD Health Home until the cal-endar month immediately following theHealth Home’s first learning collaborativesession.

4. Should experience reveal to MHD thatelements of the Health Home paymentmethodology will not function, or are notfunctioning, as MHD intended, MHDreserves the right to make changes to the pay-ment methodology after consultation with rec-ognized Health Homes and receipt of requiredfederal approvals.

(B) MHD Health Homes shall receive per-member-per-month (PMPM) payments toreimburse Health Home sites for costsincurred for patient clinical care managementservices, comprehensive care coordinationservices, health promotion services, andHealth Home administrative and reportingcosts.

1. A Health Home’s PMPM reimburse-ment will be determined from the number ofpatients that choose, or are assigned to, theHealth Home site.

2. A current month’s PMPM paymentsto a Health Home site will be based on—

A. The number of Health Home-eligi-ble patients receiving Health Home servicesat the Health Home in the month consideredfor payment;

B. The number of Health Home-eligi-ble patients in subparagraph (7)(B)2.A. whoare assigned to the Health Home at the begin-ning of the month considered for payment;and

C. The number of Health Home-eligi-ble patients in subparagraphs (7)(B)2.A. and

(7)(B)2.B. who are Medicaid-eligible at theend of the month considered for payment.

3. During the first year of participationin the Health Home program, a Health Homewill receive PMPM payments only for MHDor MHD managed care participants—

A. With two (2) or more of the fol-lowing chronic conditions:

(I) Asthma;(II) Diabetes;(III) Cardiovascular disease,

including hypertension;(IV) Overweight (BMI > 25); or(V) Developmental disabilities; or

B. With one (1) of the conditions insubparagraph (7)(C)3.A. and be at risk for asecond chronic condition because of diabetesor tobacco use.

4. In order to generate a PMPM pay-ment to a Health Home, a patient assigned tothe Health Home must have received at leastone (1) non-Health Home service based onpaid Medicaid fee for service or managedcare claims.

5. In order to receive PMPM payments,a Health Home must demonstrate to MHDthat the Health Home has hired, or has con-tracted with, a clinical care manager to pro-vide services at the Health Home site.

(8) Health Home Corrective Action Plans.(A) Health Homes shall undergo an assess-

ment process to be applied by MHD or itsdesignee at six (6) months and at twelve (12)months of entering the Primary Care HealthHome program. If the assessment shows thata Health Home practice site fails to meet theHealth Home requirements as set forth in sec-tion (3) of this rule, or fails to provide therequired Health Home services as set forth insection (5) of this rule, the Health Homepractice site shall participate in a correctiveaction plan to address any such failures dis-closed as a result of the assessment process.The corrective action plan will last for six (6)months and may be extended or renewed atMHD’s discretion. At the end of the correc-tive action plan period, the Health Homepractice site will be reassessed to determineits compliance with the requirements of thisrule.

(B) The Health Home practice site will bereassessed at the end of the corrective actionplan period, including any extensions andrenewals granted by MHD. If the reassess-ment shows that the Health Home still fails tomeet Health Home requirements or providerequired Health Home services, MHD shallterminate the Health Home practice site fromthe Primary Care Health Home program.

AUTHORITY: section 208.201, RSMo 2016.*

Original rule filed Dec. 15, 2011, effectiveJuly 30, 2012. Amended: Filed Sept. 29,2016, effective June 30, 2017.


13 CSR 70-3.250 Payment Policy for EarlyElective Delivery

PURPOSE: This rule establishes the MOHealthNet payment policy for early electivedelivery provided in any setting. The goal ofthis payment policy is to improve health out-comes for both the mother and child.

PUBLISHER’S NOTE: The secretary of statehas determined that the publication of theentire text of the material which is incorporat-ed by reference as a portion of this rule wouldbe unduly cumbersome or expensive. Thismaterial as incorporated by reference in thisrule shall be maintained by the agency at itsheadquarters and shall be made available tothe public for inspection and copying at nomore than the actual cost of reproduction.This note applies only to the reference materi-al. The entire text of the rule is printed here.

(1) The following definition(s) will be used inadministering this rule:

(A) Early Elective Delivery—a delivery byinduction of labor without medical necessityfollowed by vaginal or Caesarean section deliv-ery or a delivery by Cesarean section beforethirty-nine (39) weeks gestation without medi-cal necessity.

(2) Early elective deliveries, or deliveriesbefore thirty-nine (39) weeks gestation with-out a medical indication, shall not be reim-bursed by the MO HealthNet Division(MHD). Those delivery-related services shallbe denied or recouped by MHD. Non-pay-ment includes services billed by the deliver-ing physicians/provider and the deliveringinstitution.

(3) Services determined to be caused byEarly Elective Delivery—

(A) All services provided during the deliv-ery-related stay at the delivering institutionfor maternal care related to an early electivedelivery shall not be reimbursed by MHD.Non-payment or recoupment includes obstet-ric and institutional or facility charges; and

(B) Non-routine newborn services provid-ed for newborns during the initial delivery-related stay at the delivering institution forconditions resulting from an early electivedelivery and that are identified within seven-ty-two (72) hours of delivery may be subjectto review and recoupment. Non-payment or


Secretary of State


recoupment includes facility or institutionalcharges.

(4) Payment for delivery prior to thirty-nine(39) weeks shall only be made if delivery ismedically indicated.

(A) Services must be consistent with accept-ed health care practice standards and guide-lines. MHD, through consultants, includingexpertise in obstetrics and pediatrics/neonatol-ogy, shall audit deliveries prior to thirty-nine(39) weeks gestational age that are billed toMHD for medical necessity and review thosethat would potentially be denied due to ques-tions regarding medical necessity and non-routine services provided for newborns duringthe initial delivery related stay. Documentationmust adequately demonstrate sufficient evi-dence of medical necessity to justify deliveryprior to thirty-nine (39) weeks. Evidence shallinclude information of substantial nature aboutthe pregnancy-complicating condition which isdirectly associated with the need for deliveryprior to thirty-nine (39) weeks. Delivery willbe considered medically necessary if withoutdelivery, the mother or child would beadversely affected (significant and immediateimpact on the normal function of the body, ill-ness, infection, mortality).

(B) Delivery must be demonstrated to be—1. Of clear clinical benefit and required

for reasons other than convenience of thepatient, family, or medical provider;

2. Appropriate for the pregnancy-com-plicating condition in question; and

3. Conform to the standards of generallyaccepted obstetrics practice as supported byapplicable medical and scientific literature andas included in the MO HealthNet providermanuals and bulletins, which are incorporatedby reference and made part of this rule as pub-lished by the Department of Social Services,MO HealthNet Division, 615 HowertonCourt, Jefferson City, MO 65109, at its web-site www.dss.mo.gov/mhd, dated April 15,2013.

(C) The determination of services causedby Early Elective Delivery shall be a finaldecision of the MO HealthNet Division.

(5) If a newborn or mother or both are trans-ferred to another hospital for higher levelcare following standard medical practice, thereceiving hospital shall not be subject to thisearly elective delivery policy. The hospitalreceiving the transfer shall be reimbursed fol-lowing MHD reimbursement rules.

AUTHORITY: section 208.201, RSMo Supp.2013.* Original rule filed March 12, 2014,effective Sept. 30, 2014.


13 CSR 70-3.260 Payment Policy for Asth-ma Education and In-Home Environmen-tal Assessments

PURPOSE: This rule establishes the MOHealthNet payment policy for asthma educa-tion and in-home environmental assessments.To improve the health of MO HealthNet’sparticipants with asthma and to reduce MOHealthNet’s costs associated with partici-pants with uncontrolled asthma, MO Health-Net will implement a statewide asthma educa-tion and home assessment program focusingon youth participants who are most at risk ofhaving uncontrolled asthma.

(1) The following definition(s) will be used inadministering this rule:

(A) Asthma Education-direct training ofthe patient and family by qualified asthmaeducation provider in areas including, but notlimited to, avoiding triggers, medication com-pliance, proper use of inhalers, and use ofdurable medical equipment;

(B) In-Home Environmental Assessment-thorough and detailed analysis of the homeenvironment by a qualified environmentalassessment provider evaluating for asthmatriggers including, but not limited to, rodentexcrement, mites, animal dander, insects,dust, mold with recommendations for reme-dial actions;

(C) Uncontrolled Asthma-those with a pri-mary diagnosis of asthma with one (1) ormore asthma-related hospitalization in atwelve- (12-) month period, two (2) asthma-related emergency department visits in atwelve- (12-) month period, or three (3) ormore urgent care visits in a twelve- (12-)month period, and over use of rescue inhalersand/or under use of inhaled corticosteroids;

(D) Qualified Academic University-BasedCenters.

1. The academic university-based centerresponsible for tracking asthma educatorsmust meet the following criteria:

A. Serve as a contractor for the Cen-ters for Disease Control (CDC) National Asth-ma Control Program (NACP) funded by Mis-souri Asthma Prevention and Control Program(MAPCP);

B. Maintain a comprehensive databasethat contains information on individualstrained receiving Expert Panel Report 3 (EPR-3) compliant asthma training;

C. Staff providing the training must bea Certified Asthma Educator as recognized bythe National Association of Asthma Educa-tors; and

D. Provide training that focuses oneducational/behavioral objectives in four (4)key areas—

(I) Inhaled corticosteroid adher-ence;

(II) Inhaled technique;(III) Environmental trigger reduc-

tion; and(IV) Regular check-ups with con-

trol measures. 2. The academic university-based center

responsible for tracking asthma in-homeenvironmental assessors must meet the fol-lowing criteria:

A. Serve as the contractor for theCDC NACP funded MAPCP;

B. Provide a vital linkage betweenhealth care providers and public healthresources through a Central Access Point(CAP);

C. Maintain a comprehensive databasethat contains information on individualstrained specific to Home EnvironmentalAssessments (HEAs) for asthma trigger iden-tification and reduction in the home setting;and

D. Track quality indicators and col-lect required outcomes data;

(E) Qualified providers (asthma educationand environmental assessment)-a professionalwith appropriate training, as defined in sec-tion (4) of this regulation, in asthma educa-tion or environmental/home assessment, asevidenced by a national and/or state certifica-tion from an accepted program; and

(F) Youth participants-any individualyounger than the age of twenty-one (21).

(2) Definition and Description of MedicalServices.

(A) Asthma education—1. Asthma education non-physician,

(thirty- (30-) minute sessions, twice peryear); or

2. Preventive medicine counseling, indi-vidual, (fifteen- (15-) minute sessions four(4) times per year); or

3. Preventive medicine counseling, indi-vidual, (thirty- (30-) minute sessions twiceper year); or

4. Self-Management Education usingstandardized effective curriculum, individu-ally, either incident to a clinical encounter oras preventative service, (ninety- (90-) minutesession once per year).

(B) Asthma Environmental Assessment:Asthma environmental assessments mayinclude, but are not limited to, a thoroughassessment of the home including home his-tory and ownership, building occupant behav-iors and job history, home cleaning tech-niques, laundry processes, pets and pestshistories, kitchen processes, structure defi-ciencies, ventilation and moisture conditions,conducting and recording basic air sampling



procedures, and examination of the externalenvironment of the home to identify and sup-port the reduction of disease causing agentsleading to medical complications of asthma.In-home assessments for asthma triggers donot include remediation of issues identified inthe home.

1. Asthma environmental assessmentnon-physician, two (2) assessments per year.

(3) Recipient Criteria. In order to qualify for,and receive, asthma education and/or in-home environmental assessments, the partic-ipant must have a primary diagnosis of asth-ma and meet the MO HealthNet Division’s(MHD) definition of a youth participant withuncontrolled asthma or at risk for an asthmat-ic attack. MHD will include the followingcriteria in defining participant eligibility:

(A) Age;(B) Inpatient hospital stays;(C) Emergency room and urgent care visits;(D) Overuse of rescue inhalers; and(E) Under use of inhaled corticosteroids.

(4) Qualified Provider Criteria. A qualifiedprovider must meet the minimum educationand certification requirements to qualify as aprovider of asthma education and/or in-homeenvironmental assessments set forth in thissubsection.

(A) Asthma Education— 1. Asthma educators must have the cre-

dentials set forth in this subsection:A. Shall be certified by a national

program or a state program. Eligibility crite-ria for admission into the certification pro-grams are determined by the administrator ofthe program;

B. Asthma educators must have one (1)of the following certifications in good stand-ing:

(I) Current and active NationalAsthma Educator Certification (AEC); or

(a) Thirty-five (35) CEU everyfive (5) years; or

(b) Retake AEC asthma educatorexam within the timeframes set forth by theAEC;

(II) State certification. The providermust have a current certificate from a Mis-souri state training program provided by anaccredited institute of higher education, suchas a university, that provides a training pro-gram utilizing asthma education curriculumincorporating similar guidelines to nationalcertification programs. It is preferable that thecurriculum is also accredited. Upon success-ful completion of the training program a cer-tificate must be provided. A certificate meansthat the student has successfully completedthe training program and is competent to pro-vide asthma education services;

(a) Program may contain a mixof didactics with practicum work in the field;and

(b) The graduates are required tomaintain the same number of CEUs as thenational program—

I. Thirty-five (35) CEUsevery five (5) years; or

II. Retake certification examevery seven (7) years;

2. Mentor program. A mentee is some-one who is working towards a certificate.Once certified, the asthma educator canbecome a mentor for individuals that areseeking their national certification. Mentors,who must be an enrolled Medicaid provider,can have a maximum of three (3) mentees ata time. Mentors have the capability of billingMHD for their services, while mentees can-not. Services provided by a mentee under thesupervision of the mentor can be billed toMHD by the mentor. The asthma educationactivities and interventions of the menteeshall be performed pursuant to the mentor’sorder, control, and full professional responsi-bility. The mentor shall maintain a continuingrelationship with the mentee and shall meetwith the mentee at a minimum of one (1)hour per month face-to-face. The mentorshall review all patient care, evaluate thequality of care delivered, and terminate anymentee relationship that fails to conform tothe standard of care. Individuals that qualifyfor a mentorship are individuals not certifiedas asthma educators and seeking eithernational or state certification. These individ-uals can be mentored for a maximum time-frame of eighteen (18) months to obtain onethousand (1,000) hours of service. Once theone thousand (1,000) hours are obtained, thementee must attempt to obtain the NationalAEC or the state certification. In the eventthe mentee fails the National AEC test or thestate certification process, the mentee may nolonger provide asthma education services toenrolled MO HealthNet participants.

(B) In-Home Environmental Assessorsmust have the credentials set forth in this sub-section:

1. Shall be certified by a national pro-gram or a state program. Eligibility criteriafor admission into the certification programsare determined by the administrator of theprogram;

2. An In-Home Environmental Assessormust have one (1) of the following certifica-tions in good standing:

A. National Certification; or(I) National Environmental Health

Association (NEHA) Healthy Home Special-ist; or

(II) Building Performance Institute

(BPI) Healthy Home Evaluator Micro-Cre-dential;

B. State Certification. The providermust have a current certificate from a Mis-souri state training program provided by anaccredited institute of higher education, suchas a university, that provides a training pro-gram utilizing curriculum incorporating sim-ilar guidelines to national certification pro-grams. It is preferable that the curriculum isalso accredited. Upon successful completionof the training program a certificate must beprovided. A certificate means that the studenthas successfully completed the training pro-gram and is competent to provide in-homeenvironmental assessment.

(5) Process for Enrollment in Asthma Educa-tion and In-Home Environmental Assess-ments.

(A) A physician’s referral as part of a nor-mal office visit for evaluation and manage-ment is necessary for both asthma educationand in-home environmental assessment. Thephysician must prescribe the service in theparticipant’s plan of care for services to beconsidered.

(B) As part of the referral, a physiciandetermines and specifies the level and type ofasthma education and in-home environmentalassessment based on available history and inconsultation with asthma educators and in-home environmental assessors, as needed.

(C) The physician must seek prior autho-rization from MHD.

(6) Qualifying Academic University-BasedCenters function to track and ensure currentcertification of asthma education providersand asthma environmental assessors by pro-viding MHD with the following services:

(A) The qualified academic university-based centers must maintain a website withan up-to-date provider list for physicians andtheir offices to utilize to consult asthma edu-cators and asthma in-home environmentalassessors to provide services to participantsonce a prior authorization has been approved.

1. The qualified academic university-based center responsible for tracking asthmain-home environmental assessors must main-tain an up-to-date list of all certified in-homeenvironmental assessors in the state; and

2. The qualified academic university-based center responsible for tracking asthmaeducators must maintain an up-to-date list ofall trained asthma educators in the state;

(B) An up-to-date provider list must alsobe available to providers on the Departmentof Social Services’ websitehttps://dssapp.dss.mo.gov/providerlist/sprovider.asp.


Secretary of State


(7) Model/Algorithm for identifying the eligi-ble population. The youth participant musthave a primary diagnosis of asthma and—

(A) One (1) or more inpatient stays relatedto asthma; or

(B) Two (2) or more emergency depart-ment visits related to asthma; or

(C) Three (3) or more urgent care visitsrelated to asthma; or

(D) One (1) emergency department visit orone (1) urgent care visit related to asthmawith a high rate of short-acting beta-agonistinhaler fills and/or low rates of inhaled corti-costeroid refills; or

(E) Responsible provider prescribes ser-vices in the plan of care.

(8) Authorization Limits.(A) All services will require a prior autho-

rization.(B) Annual limit of asthma education visits

will be dependent on the codes used, butshall not exceed one (1) hour per year withthe exception of one (1) ninety- (90-) minuteself-management session and two (2) in-homeenvironmental assessments that are allowedannually. Any additional asthma educationand environmental in-home assessments willneed to go through the prior authorizationprocess and be deemed medically necessary.

(9) Reimbursement Methodology for AsthmaEducation and Asthma Environmental Assess-ments.

(A) MHD shall provide reimbursement forasthma education and in-home environmentalassessments to enrolled asthma educators andenvironmental assessors who are currentlycertified and in good standing with the state.

(B) Reimbursement for services is made ona fee-for-services basis. The maximum allow-able fee for a unit of service has been deter-mined by MHD to be a reasonable fee, con-sistent with efficiency, economy, and qualityof care. Payment for covered services is thelower of the provider’s actual billed charge(should be the provider’s usual and custom-ary charge to the general public for the ser-vice), or the maximum allowable per unit ofservice. Reimbursement shall only be madefor services authorized by MHD or itsdesignee.

(C) Except as otherwise noted in the plan,state developed fee schedule rates are thesame for both public and private providers ofasthma education and asthma environmentalassessments. The agency’s fee schedule ispublished athttp://www.dss.mo.gov/mhd/providers/index.htm and are effective for services providedon or after the effective date of the state planamendment.

AUTHORITY: section 208.201, RSMo 2016.*Original rule filed June 23, 2016, effectiveJan. 30, 2017.




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