PROVIDER ENROLLMENT PROGRAM REQUIREMENTS

Listed below are the program names, provider types, program requirements, and required attachments for each provider type.

All providers using a federal tax ID number must attach a copy of a document PREPRINTED by IRS showing the tax ID number and legal name. Examples of acceptable forms are: CP 575 or 147C letter; or letter from IRS with the Federal Tax Identification Number and legal name. A W-9 is not acceptable.

Acupuncture (72)

MO HealthNet Division (MHD) is implementing statewide complementary and alternative therapy services for chronic pain, effective for dates of service on or after April 01, 2019, for participants 21 years of age and older who have evidence of chronic pain. Eligible participants will receive complementary and/or alternative therapy services as deemed medically necessary.

Specialty AQ – Acupuncture Acupuncture services will require a Smart prior authorization (PA) for participants 21 years of age and older.
For participants to be eligible for complementary and alternative therapy services the individual must meet the following criteria:

Be currently enrolled in MO HealthNet, and

Be 21 years of age or older, and

Have chronic pain , and

Have diagnosis within the chronic pain list provided in the MO HealthNet Provider’s Manual for this program.

Applied Behavior Analysis (ABA) Qualified Psychologist (49)

Must be enrolled with MO HealthNet as a psychologist. Must submit documentation of ABA in scope of education, training, and competence in order to add ABA specialty. If not already enrolled as psychologist, complete a Psychologist enrollment application and submit a copy of the permanent license, Medicare number if enrolled with Medicare, and the ABA documentation. Provider will be enrolled as a Psychologist (49) and be assigned a specialty code of “LP”.

Adult Day Care (29)

Required documentation must be submitted with the completed enrollment application. Out of state providers cannot enroll. Each licensed Adult Day Care provider must enroll and bill separately.

Adult Day Care providers must be currently licensed and maintain licensure as an Adult Day Care through the Department of Health and Senior Services.

Applicants must submit the enrollment documents found at:
https://mmac.mo.gov/providers/provider-enrollment/home-and-community-based-services/adult-day-care-waiver-services/

Aged & Disabled Waiver Homemaker/Chore and Respite (28)

Required documentation must be submitted with the completed enrollment application. Out of state (non-bordering) providers cannot enroll. Must maintain a Social Services Block Grant (SSBG) contract. Each provider must enroll and bill separately.

Institutional Respite

Must submit a copy of the nursing home facility license.

Adult Day Basic

Must submit a copy of current license as a social-type program through Department of Health and Senior Services.

Ambulance - Ground (80)

Required documentation must be submitted with the enrollment application. Missouri applicants must submit a copy of the Ground Ambulance Service license issued by the Department of Health & Senior Services, out of state applicants must submit a copy of the Ground Ambulance Service license issued by their state agency, and Medicare number. Each ambulance provider must enroll and bill separately.

Out of State Applicants

Missouri Medicaid considers enrollment of an out of state provider if at least one of the following conditions is met:

· *Emergency services are defined as those services provided in a hospital, clinic, office or other facility that is equipped to furnish the required care, after sudden onset of medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in (a) placing the patient health in serious jeopardy; (b) serious impairment to bodily functions; or a serious dysfunction of any body organ or part.

· Services were provided to a MEDICARE/MO HEALTHNET PARTICIPANT with Medicare as primary payor;

· Provider of service is located in a BORDERING STATE OF MISSOURI**

· Services were provided to a FOSTER CARE CHILD not residing in Missouri**

· Services were provided by an INDEPENDENT LAB

· Services were PRIOR AUTHORIZED by the Missouri State consultant

**Services which routinely require prior authorization or have other limitations continue to require prior authorization and are subject to established limitation, policies and procedures applicable to the MO HEALTHNET programs.

If your claim DOES NOT meet one of the specific conditions listed above, the participant is responsible for the charges, and you DO NOT need to enroll as a MO HealthNet provider. If you determine your claim(s) meets one of the specific conditions listed above, you must request a paper application. All services must meet timely filing requirements. ENROLLMENT DOES NOT GUARANTEE PAYMENT.

It is your responsibility to verify the participant eligibility for dates of service provided. If the participant is enrolled with a Missouri Managed Care Health Plan, you must contact the Managed Care Health Plan concerning services provided, MO HealthNet is not responsible for those services. It is not necessary that you enroll with MO HealthNet unless you have provided services to participants who ARE NOT enrolled with a Managed Care Health Plan.

Air Ambulance (80)

Above Out of State rules also apply. Submit a copy of the Helicopter Service license and a copy of the FAA Air Carrier Certificate to operate a helicopter service. Separate enrollment records are created for Air and Ground Ambulances. Each air ambulance provider must enroll and bill separately.

Ambulatory Surgery Center (ASC) (50)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll. Individual practitioners practicing at the ASC must enroll individually. The ASC and individual applications cannot be faxed as one transmission; each application and its required attachments must be faxed separately. Each ASC provider must enroll and bill separately.

Must be licensed by the Department of Health & Senior Services and Medicare certified as an ASC. Must submit a copy of the license.

Assistant Behavior Analyst (73)

Must submit a copy of the current permanent license. A specialty code of “LA” will be assigned.

Effective April 1, 2023, MO HealthNet created a new specialty code for Provisionally Licensed Assistant Behavior Analyst and that code is “AB”. These providers can enroll and begin providing ABA services in the community and those that are included in a MO HealthNet participant’s individualized education program (IEP). ABA services included in an IEP must be billed by the school (96 provider type). ABA services that are not included in a participant’s IEP are not covered in place of service school (03).

A provisional licensee must only provide services allowed under the provisional licensure. A provisional licensee may not operate as an independent practitioner, receive direct payment from MHD or own their own business in the practice of ABA.

Provisional licensed individuals must complete the payment information on the enrollment application with either the supervisor or employer’s name and the tax ID number assigned to the payee.

Provisional licensees must submit a copy of their permanent license to the Missouri Medicaid Audit and Compliance Provider Enrollment Unit upon receipt of license to be maintained as an MHD provider.

Audiologist/Hearing Instrument Specialist (33)

Required documentation must be submitted with the original signed agreement. Each provider must enroll separately.

Must have a current permanent license and submit a copy of the license and Medicare number if enrolled with Medicare. If licensed as both an Audiologist and Hearing Instrument Specialist, submit a copy of both licenses.

Autism Clinic (50)

To be assigned a specialty code of “AC”, the clinic must have at least two MO HealthNet enrolled Licensed Behavior Analysts on staff.

Behavior Analyst (73)

Must submit a copy of the current permanent license. A specialty code of “LB” will be assigned.

Effective April 1, 2023, MO HealthNet created a new specialty code for Provisional Licensed Behavior Analyst and that code is “BA”. These providers can enroll and begin providing ABA services in the community and those that are included in a MO HealthNet participant’s individualized education program (IEP). ABA services included in an IEP must be billed by the school (96 provider type). ABA services that are not included in a participant’s IEP are not covered in place of service school (03).

Provisional licensed individuals must complete the payment information on the enrollment application with either the supervisor or employer’s name and the tax ID number assigned to the payee.

Provisional licensees must submit a copy of their permanent license to the Missouri Medicaid Audit and Compliance Provider Enrollment Unit upon receipt of license to be maintained as an MHD provider.

Behavior Analyst, Assistant Behavior Analyst (73), Applied Behavior Analysis (ABA) Providers (73, 49, and 50)

Each Behavior Analyst, Assistant Behavior Analyst, and Psychologist must enroll and bill individually. Required documentation must be submitted with the completed enrollment application. Out of state (non-bordering) providers cannot enroll.

Biopsychosocial Treatment of Obesity: (Provider type 50 and 59 with specialty C8 and Specialty BT) Effective for dates of service on or after February 1, 2024: A Smart Prior Authorization (PA) is required for Biopsychosocial Treatment of Obesity services and will be requested by the referring provider for participants of all ages.

All Biopsychosocial Treatment of Obesity providers must be enrolled as MO HealthNet providers.

In order to provide medical nutrition therapy (MNT) for obesity a provider is required to be licensed to practice as a registered dietitian and will need to obtain one of the following specialist certificates:

· Certificate of Training in Adult Weight Management Program;

· Certificate of Training in Obesity Interventions for Adults;

· Certificate of Training in Child and Adolescent Weight Management; or

· Completion of a state qualified training program attained through completion of a qualified training program.

Licensed registered dietitians are eligible to provide group intensive behavioral therapy (IBT) and/or family-based behavioral treatment (FBT) with a state specialist certification attained through completion of a qualified training program that addresses delivery of behaviorally based intervention for adult and/or youth participants diagnosed with obesity.

Eligible providers may provide Biopsychosocial Treatment of Obesity services without a certificate listed above if the provider has maintained the aforementioned license for a minimum of two (2) years; has documentation of a minimum of 2,000 hours of specialty practice experience delivering weight management MNT for individuals and/or families and youth with obesity diagnosis within the past five (5) years; and has documentation of a minimum of six (6) hours of obesity or weight management CEUs or professional equivalent.

Biopsychosocial Treatment of Obesity providers must maintain six (6) hours of obesity or weight management CEUs or professional equivalent every two (2) years for the patient population served.

Providers should reference Missouri state regulation 13 CSR 70-25.140 for more details regarding provider qualifications.

If you are already an enrolled provider and would like to participate in this new program to provide Biopsychosocial Treatment of Obesity services and have the proper credentials, you will need an additional provider specialty to bill for these services (Specialty BT).

Case Management (HCY) (18)

Must be in compliance according to 13.56 of the physician manual. This type of provider number can only be issued if there is not an active clinic/group enrollment record to add the case management specialty. Out of state (non-bordering) providers cannot enroll.

Chiropractor (23)

MO HealthNet Division (MHD) is implementing statewide complementary and alternative therapy services for chronic pain, effective for dates of service on or after April 01, 2019, for participants 21 years of age and older who have evidence of chronic pain. Eligible participants will receive complementary and/or alternative therapy services as deemed medically necessary.

Specialty 35 –Chiropractor Chiropractic services will require a Smart prior authorization (PA) for participants 21 years of age and older.
For participants to be eligible for complementary and alternative therapy services the individual must meet the following criteria:

Be currently enrolled in MO HealthNet, and

Be 21 years of age or older, and

Have chronic pain , and

Have diagnosis within the chronic pain list provided in the MO HealthNet Provider’s Manual for this program.

Chiropractors currently can enroll as a Qualified Medicare Beneficiary (QMB) provider type 75 and specialty 35. However, if Chiropractors wish to enroll under the new, alternative therapy provider type they will need to do one of the following:

Dis-enroll their currently enrolled number,

Enroll with a new National Provider Identifier (NPI),

Enroll with a taxonomy code to keep the same NPI for both the 75-provider type and the new provider type.

This will allow chiropractors to provide services under the Complementary and Alternative Therapies for Chronic Pain Management program and future chiropractic programs.

Clinic/Group (50)

Required documentation must be submitted with the original signed agreement. Each clinic/group provider must enroll and bill separately unless one or more locations are covered under the same clinic/group Medicare number.

A clinic/group is one or more individuals designated by Medicare as a clinic/group, or one or more individuals designated by MO HealthNet as a clinic/group.

If the clinic/group has a Medicare number, please list the Medicare number and individual members of the clinic/group with the members Medicare numbers. All individual providers practicing at the clinic/group must be enrolled individually. If submitting individual applications at the same time as the clinic/group, attach a cover letter referencing the individual provider applications submitted. If the individual providers are already enrolled, attach a list of their names and NPI numbers. The clinic/group and individual applications cannot be faxed as one transmission; each application and its required attachments must be faxed separately.

Community Based MR (85)

Must be prior approved by the Department of Mental Health (DMH) and enroll with MO HealthNet as enrolled with DMH. Contact DMH if you are interested in providing services; the Provider Enrollment Unit cannot forward these forms to you. Out of state providers cannot enroll.

Community Mental Health Center (CMHC) (56)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll.

Must be Medicare enrolled. Must also be approved by Department of Mental Health as a CMHC. All individual providers practicing in the clinic must enroll individually. Attach a cover letter referencing individual provider applications submitted. If the individual providers are already enrolled, attach a list of their names and NPI numbers. The CMHC and individual applications cannot be faxed as one transmission; each application and its required attachments must be faxed separately.

Community Psychiatric Rehabilitation Center (87)

Required documentation must be submitted with the completed enrollment application. Out of state providers cannot enroll.

Must be currently certified by the Department of Mental Health (DMH) as a community psychiatric rehabilitation center, submit a copy of the current Certification from DMH, and enroll with MO HealthNet as certified by DMH.

Must be currently licensed by the Children’s Division as a Residential Treatment Agency for Children and Youth or a Child Placing Agency. In order to provide residential rehabilitation treatment services to foster children and adoption or guardianship subsidy youth (RT Specialty) or to provide treatment foster care (FT Specialty), organizations must either already be enrolled as a 50 Clinic or go online and enroll as one.

If already enrolled as a 50 clinic, email MMAC.ProviderEnrollment@dss.mo.gov and request a Provider Type 87 paper application. If completing an online clinic 50 application, once that application has been approved, contact Provider Enrollment and request the Provider Type 87 paper application. For the (RT Specialty), please include a copy of the Children’s Division license stating your agency is a Residential Treatment Agency for Children and Youth. For the (FT Specialty), please include a copy of the Children’s Division license stating your organization is a Child Placing Agency.

Comprehensive Day Rehabilitation (76)

Required documentation must be submitted with the completed enrollment application. Out of state (non-bordering) providers cannot enroll.

Must be currently accredited by CARF and submit a copy of current CARF Accreditation.

CRNA (Certified Registered Nurse Anesthetist) (91)

Required documentation must be submitted with the original signed agreement. Graduates cannot enroll.

Must have a current permanent RN license and Document of Recognition as a CRNA. Must submit a copy of the current permanent license, Document of Recognition, and Medicare number if enrolled with Medicare. If applicant is located in a bordering state, a copy of the permanent RN license and current CCNA certification must be submitted. All CRNAs must enroll individually.

C-STAR (86)

Required documentation must be submitted with the completed enrollment application. Out of state providers cannot enroll.

Must be currently certified by the Department of Mental Health and submit a copy of the current Certification and enroll with Medicaid as certified by DMH.

Dental Hygienist (74)

Required documentation must be submitted with the original signed agreement.

Out of state (non-bordering) providers cannot enroll.

Dental Hygienist services are for patients 20 and under ONLY.

A Dental Hygienist must be licensed for at least 3 years and employed by a public health department, Rural Health Clinic, or FQHC.

The Dental Hygienist must enroll using the payment name and tax ID of the public health entity, payment is not made directly to the dental hygienist. Each Dental Hygienist must enroll individually, bill under their individual NPI number, and must apply for a separate provider enrollment record for each public health entity at which they are employed. Each application with its required attachments must be submitted separately.

Dentist (40)

Required documentation must be submitted with the original signed agreement.

Must have a current permanent license and submit a copy of the license. If enrolled with Medicare, please supply us with the Medicare number. If a CORP dentist, submit a copy of CORP Dentist orders and a copy of the current permanent license from the home state.

Only dental providers selecting a specialty of general anesthesia (DS), parenteral conscious sedation (PC) or enteral conscious sedation (EC) must have a current certificate/permit to perform DS, PC or EC and a copy of the certificate/permit must be submitted.

Preventive Care (37)

MO HealthNet Division (MHD) is implementing Diabetes Prevention Program Services for adult participants effective July 1, 2020. The specialty will be DP – Diabetes Prevention.

These services are Centers for Disease Control and Prevention (CDC) recognized diabetes prevention program services to at risk individuals intended to prevent or delay the progression to Type-2 Diabetes. Diabetes prevention program services include the core services period months 1 through 12, and the curriculum focuses on making lifestyle changes and monitoring of weight, BMI, and physical activity to name a few. Participants that meet continuation criteria will receive an additional 12 months of ongoing maintenance services that emphasize maintaining the lifestyle changes.

For participants to be eligible for diabetes prevention program services the following criteria must be met:

Be 21 years of age and older and currently enrolled as a MO HealthNet participant; and

Not currently pregnant; and

Have, as of the date of attendance at the first core session, a BMI equal to or greater than 25 or a BMI of 23 if of Asian descent; and

Have no previous diagnosis of type one (1) or two (2) diabetes with the exception of gestational diabetes; and

Have had within the last twelve (12) months:

Hemoglobin A1C test with a value of 5.7% to 6.4%; or

A fasting plasma glucose of 100 mg/dl to 125 mg/dl; or

A 2-hour plasma glucose of 140 to 199 mg/dl after the 75 oral glucose tolerance test.

For participants to be eligible for the ongoing maintenance services the following criteria must be met:

The participant has achieved and maintained a minimum of 5% weight loss at the end of the first 12 months.

Providers of diabetes prevention program services include individuals and/or organizations with diabetes prevention programs that have pending, preliminary, or full recognition status from the CDC’s Diabetes Prevention Recognition Program, and enrolled as MO HealthNet providers.

Providers should reference Missouri state regulation 13 CSR 70-25.130 for more details regarding provider qualifications.

If you are an already enrolled provider and would like to participate in this new program to provide DPP services and have the proper CDC recognition status, you can do one of the following

Keep your existing provider number or dis-enroll your currently enrolled number, either way you will need to enroll as a 37 Provider to participate in this new program.

Enroll with a new National Provider Identifier (NPI) for the Provider Type 37 or if you choose to use the same NPI for both provider types, you will need to enroll with a taxonomy code for each.

Dialysis Center (50)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll.

Must be currently certified by Medicare as a Dialysis Center. The medical director must be enrolled. Attach a cover letter stating the medical director's name. Each dialysis center that is Medicare certified must enroll and bill separately. The dialysis center and physician application cannot be faxed as one transmission; each application and its required attachments must be faxed separately.

Disease Management (35)

Required documentation must be submitted with the original signed agreement.

Within the Disease Management program is Diabetes Self-Management Training Services and Disease State Management Training Services. Please make sure you submit the appropriate documentation for the service you will be providing as indicated below.

Diabetes Self-Management Training Services

CDE applicants:

Must submit a copy of current certification by the National Certification Board for Diabetes Educators (NCBDE) for CDEs through the American Association of Diabetes Educators;

If CDE is a nurse or physician:

Submit a copy of current RN or physician license, and a copy of a current certification listed above.

Licensed Dietitian applicants:

Must submit a copy of your current license as a Licensed Dietitian (LD).

Pharmacist applicants:

Must submit a copy of current Pharmacist license AND a copy of appropriate certification from: the National Community Pharmacists Association (NCPA) "Diabetes Care Certification Program", OR the American Pharmaceutical Association (APhA)/American Association of Diabetes Educators (AADE) certification program "Pharmaceutical Care for Patients With Diabetes", OR completed the Drake University, College of Pharmacy and Health Sciences, certification program "Developing Skills for Diabetes Care".

Bordering state CDE, LD, or RPh applicants must be licensed by their state and/or certified by the above mentioned certifying boards. Out of state (non-bordering) pharmacy providers cannot enroll.

Disease State Management Training Services

Physician applicants:

Must submit a copy of current physician license and a copy of your signed Disease State Management Training Agreement form.

Pharmacist applicants:

Must submit a copy of current pharmacist license and a copy of your signed Disease State Management Training Agreement form.

Out of State applicants are not eligible to enroll for this service.

Asthma Education Provider Applicants: (Provider type 35AE)

· All asthma education providers must submit a copy of current national or Missouri State Certification.

· If the certified asthma educator holds a current license as a nurse, physician, or respiratory therapist a current copy of the license must be submitted in addition to a copy of the asthma education certificate.

· If the certified asthma educator holds a current professional license or certificate a copy of the professional license or certificate must be submitted with the asthma education certificate.

· Out of State applicants are not eligible to enroll for this service.

In-Home Environmental Assessor Applicants: (Provider type 35AH)

· All asthma in-home environmental assessment providers must submit a copy of current National Environmental Health Association (NEHA) Healthy Home Specialist Certification, a NEHA Health Home Evaluator Micro-Credential certification, or Missouri state certification.

· If the certified asthma educator holds a current professional license or certificate a copy of the professional license or certificate must be submitted with the asthma education certificate.

· Out of State applicants are not eligible to enroll for this service.

Biopsychosocial Treatment of Obesity: (Provider type 35 Specialty BT) Effective for dates of service on or after September 1, 2021: A Smart Prior Authorization (PA) is required for Biopsychosocial Treatment of Obesity services and will be requested by the referring provider for participants of all ages.

All Biopsychosocial Treatment of Obesity providers must be enrolled as MO HealthNet providers.

Certificate of Training in Adult Weight Management Program;

Certificate of Training in Obesity Interventions for Adults;

Certificate of Training in Child and Adolescent Weight Management; or

Completion of a state qualified training program attained through completion of a qualified training program.

Biopsychosocial Treatment of Obesity providers must maintain six (6) hours of obesity or weight management CEUs or professional equivalent every two (2) years for the patient population served.

Providers should reference Missouri state regulation 13 CSR 70-25.140 for more details regarding provider qualifications.

DME (Durable Medical Equipment) (62)

Required documentation must be submitted with the completed enrollment application. Each DME supplier who has a Medicare number must enroll and bill separately. Representatives of the DME supplier are not eligible to enroll.

Out of state (non-bordering) applicants are not permitted to enroll unless pre-approved by MMAC. Before enrollment forms are sent, you must indicate the recipient name, DCN, and date of service that has been provided.

MO HealthNet participants are required to obtain services from Missouri or bordering state providers. MO HealthNet considers enrollment of an out of state (non-bordering) provider only if Medicare coinsurance and/or deductible amounts on covered services are provided to patients who have both MO HealthNet and Medicare, or the item needed is NOT available in Missouri or a bordering state of Missouri. If prior authorization is approved and reimbursement is made for equipment, supplies, or services for a Missouri Medicaid patient who is not Medicare eligible, or for services that are available in Missouri or a bordering state, reimbursement may be recouped on any amounts paid.

Must submit a copy of the current Certificate of Incorporation (if a corporation), and a copy of the pharmacy permit if also registered as a pharmacy. DME providers must enroll with the same name and address as their Medicare number is issued.

Environmental Lead Inspector (39)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll.

Must have a current permanent license as a Lead Inspector or Lead Risk Assessor and submit a copy of the current permanent license and Medicare number if enrolled with Medicare. Each inspector must enroll individually.

FQHC (Federally Qualified Health Center) (50)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll. Each individual practicing at the FQHC must be enrolled. Attach a cover letter stating the individual provider names practicing at the FQHC. Each FQHC that is Medicare certified must enroll and bill separately. The FQHC and individual applications cannot be faxed as one transmission; each application and its required attachments must be faxed separately.

For purposes of providing covered services under MO HealthNet, an FQHC must:

· receive a grant under Section 329, 330 or 340 of the Public Health Services Act or the Secretary of Health and Human Services (HHS) may determine that the health center qualifies by meeting other requirements OR

· must be Medicare certified as a FQHC.

FQHC COVERED SERVICES

MO HealthNet covered FQHC services include core services, defined generally in Section 1861 (aa) (1)

(A)-(C) of the Social Security Act and any other ambulatory services provided for under the Missouri State Plan, which are furnished by the FQHC. FQHC services are subject to benefit limitations as described in the applicable Medicaid program manuals and bulletins. Reimbursement methods for these services are described in 13 CSR 70-26.010.

Covered services include, but are not limited to:

· physician services;

· services and supplies incident to physician services (including drugs and biologicals that cannot be self-administered);

· pneumococcal vaccine and its administration and influenza vaccine and its administration;

· physician assistant services (cannot enroll individually);

· nurse practitioner services;

· clinical psychologist services;

· clinical social worker services;

· services and supplies incident to clinical psychologist and clinical social worker services as would otherwise be covered if furnished by or incident to physician services; and

· part-time or intermittent nursing care and related medical supplies to a homebound individual when the FQHC is located in an area designated by HCFA as a home health agency shortage area.

While dental, podiatry, optical and audiology services may be included as covered services in the FQHC, these services must be billed using the individual NPI number and using procedure codes specifically approved for that program, as opposed to billing with the clinic number. These providers are all subject to the co-payment requirement, which mandates that their services not be billed under a clinic number.

FQHC BILLING PROCEDURES

Please refer to the appropriate Provider Manual and Training Booklet for the FQHC Billing Procedures. The link to the Provider Manual and the Training Booklet can be found on the MHD website on the Provider Participation page.

The link to the Provider Participation page is:

http://dss.mo.gov/mhd/providers/index.htm

FQHC RECORD KEEPING REQUIREMENTS

Health Center records must be sufficient to allow completion and audit of the Medicare FFHC

(HCFA 242) cost report and supplemental Missouri FQHC reporting forms. The supplemental Missouri forms include an income statement, a summary of MO HealthNet, Medicare and total charges by program, and a statistical schedule of MO HealthNet, Medicare and total encounters. A uniform charge structure must be established to ensure charges for MO HealthNet participants are the same as charges assessed to all other recipients for similar services. Failure to maintain adequate accounting records results in recovery of all funds paid in excess of the established fee schedules. All providers are further required to maintain adequate fiscal and Medical records for a period of five years, to fully disclose services rendered to Title XIX Medicaid participants.

Laboratory - Independent (70)

Required documentation must be submitted with the completed enrollment application. The physicians working in the lab cannot enroll. All applicants must submit a copy of the current CLIA Certificate as an Independent Lab and Medicare number. Each Independent Lab must enroll and bill individually.

Out of State (Non-Bordering): MO HealthNet considers enrollment of an out of state provider if at least one of the following conditions is met:

Services were a result of a MEDICAL EMERGENCY* (including ambulance);

*Emergency services are defined as those services provided in a hospital, clinic/group, office or other

facility that is equipped to furnish the required care, after sudden onset of medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in (a) placing the patient health in serious jeopardy; (b) serious impairment to bodily functions; or a serious dysfunction of any body organ or part.

Services were provided to a MEDICARE/MO HEALTHNET RECIPIENT with Medicare as primary

payor;

Provider of service is located in a BORDERING STATE OF MISSOURI**

Services were provided to a FOSTER CARE CHILD not residing in Missouri**

Services were provided by an INDEPENDENT LAB

Services were PRIOR AUTHORIZED by the Missouri State consultant

**Services which routinely require prior authorization or have other limitations continue to require prior authorization and be subject to established limitation, policies and procedures applicable to the Missouri Medicaid programs.

If your claim DOES NOT meet one of the specific conditions listed above, the recipient is responsible for the charges, and you DO NOT need to enroll as a MO HealthNet provider. If you determine your claim(s) meets one of the specific conditions listed above, you must request a paper application. All services must meet timely filing requirements. ENROLLMENT DOES NOT GUARANTEE PAYMENT.

It is your responsibility to verify the recipient eligibility for dates of service provided. If the recipient is enrolled with a Missouri Managed Care Health Plan, you must contact the Managed Care Health Plan concerning services provided, MO HealthNet is not responsible for those services. It is not necessary that you enroll with MO HealthNet unless you have provided services to recipients who ARE NOT enrolled with a Managed Care Health Plan.

Licensed Marital and Family Therapists (LMFT) and Provisional Licensed Marital and Family Therapists (PLMFT) (49)

LMFTs and PLMFTs must have and maintain a valid permanent or provisional license issued by the Missouri State Committee of Marital and Family Therapists, if practicing in Missouri, or by the relevant state licensure board, if practicing in a bordering state.

PLMFTs are not permitted to receive payment directly from MO HealthNet and are not permitted to have an independent practice. Provisional licensed individuals must complete the payment information on the enrollment application with either the supervisor or employer’s name and the tax ID number assigned to the payee. PLMFTs must submit a copy of their permanent license to the Missouri Medicaid Audit and Compliance Provider Enrollment Unit upon receipt of license to be maintained as an MHD provider.

Biopsychosocial Treatment of Obesity: (Provider type 49 Specialty BT) Effective for dates of service on or after September 1, 2021: A Smart Prior Authorization (PA) is required for Biopsychosocial Treatment of Obesity services and will be requested by the referring provider for participants of all ages.

All Biopsychosocial Treatment of Obesity providers must be enrolled as MO HealthNet providers.

In order to provide individual and/or group intensive behavioral therapy (IBT) and/or family-based behavioral treatment (FBT) providers are required to be licensed to practice as a psychiatrist, clinical social worker, psychologist, professional counselor, martial and family therapist, or psychiatric advanced practice registered nurses and are required to have a state specialist certification attained through completion of a qualified training program that addresses delivery of behaviorally based intervention for adult and/or youth participants diagnosed with obesity.

Biopsychosocial Treatment of Obesity providers must maintain six (6) hours of obesity or weight management CEUs or professional equivalent every two (2) years for the patient population served.

Providers should reference Missouri state regulation 13 CSR 70-25.140 for more details regarding provider qualifications.

Nurse - Advanced Practice Nurse (42)

Required documentation must be submitted with the original signed agreement. Each advanced practice nurse must enroll individually.

Nurse practitioners and clinical nurse specialists must be currently licensed as registered professional nurses and recognized as an advanced practice nurse within a specific clinical specialty area and role by the Missouri State Board of Nursing pursuant to 4 CSR 200-4.100 Advanced Practice Nurse. Prescribing nurses must have a current Collaborative Practice Agreement with one or more physicians that authorize them to prescribe. The Collaborative Practice Agreement must meet the requirements of statutes 334.104.1, 334.104.2, state regulation 4CSR 200-4.200, and any other Board of Nursing or Healing Arts statutes or regulations that may apply.

Missouri Applicant:

Must submit a copy of current permanent RN license and current Document of Recognition for specialty of practice. Supply us with the Medicare number if enrolled with Medicare.

Bordering State Applicant - Certifying body documentation to be submitted:

American Academy of Nurse Practitioners (AANP), Capital Station, LBJ Building, PO box 12846, Austin, TX 78711, (512)442-4262 extension 14. Advanced Practice Nurse Specialty Area Certifications: adult nurse practitioner and family nurse practitioner.

American Nurses Credentialing Center (ANCC), 600 Maryland Avenue Southwest, Suite 100 West, Washington DC 20024-2571, (800) 284-2378 Advanced Practice Nurse Specialty Area Certifications: adult nurse practitioner, family nurse practitioner, gerontological nurse practitioner, pediatric nurse practitioner, clinical nurse specialist in adult psychiatric and mental health nursing or child and adolescent psychiatric and mental health nursing, clinical nurse specialist in gerontological nursing, clinical specialist in community health nursing, and clinical specialist in medical-surgical nursing.

Biopsychosocial Treatment of Obesity: (Provider type 42 Specialty BT) Effective for dates of service on or after September 1, 2021: A Smart Prior Authorization (PA) is required for Biopsychosocial Treatment of Obesity services and will be requested by the referring provider for participants of all ages.

In order to provide individual and/or group intensive behavioral therapy (IBT) and/or family-based behavioral treatment (FBT) providers are required to be licensed to practice as a psychiatric advanced practice registered nurses and are required to have a state specialist certification attained through completion of a qualified training program that addresses delivery of behaviorally based intervention for adult and/or youth participants diagnosed with obesity.

Biopsychosocial Treatment of Obesity providers must maintain six (6) hours of obesity or weight management CEUs or professional equivalent every two (2) years for the patient population served.

Providers should reference Missouri state regulation 13 CSR 70-25.140 for more details regarding provider qualifications.

National Certification Corporation for the Obstetric, Gynecologic and Neonatal Nursing Specialties (NCC), PO Box 11082, Chicago, IL 60611-0082, (800) 367-5613 Advanced Practice Nurse Specialty Area Certifications: neonatal nurse practitioner, women 's health care nurse practitioner.

National Certification Board of Pediatric Nurse Practitioners and Nurses (NCBPNP/N), 416 Hungerford Drive, Suite 222, Rockville MD 20850, (301) 340-8213 Advanced Practice Nurse Specialty Area Certification: pediatric nurse practitioner.

Nurse Mid-Wife (25)

Required documentation must be submitted with the original signed agreement. Each nurse mid-wife must enroll individually.

Must be currently licensed as a RN and have a current Document of Recognition for the specialty of practice if practicing in Missouri. Must submit a copy of current permanent RN license & current Document of Recognition. If enrolled with Medicare please supply us with the Medicare number. Bordering state applicants must have a current permanent RN license and submit a copy of their current permanent RN license and ACNM Certificate. Prescribing nurses must have a current Collaborative Practice Agreement with one or more physicians that authorize them to prescribe. The Collaborative Practice Agreement must meet the requirements of statutes 334.104.1, 334.104.2, state regulation 4CSR 200-4.200, and any other Board of Nursing or Healing Arts statutes or regulations that may apply.

Nursing Facility (10)

Must be currently licensed by Department of Health & Senior Services (DHSS). Enrollment forms are not sent until the appropriate paperwork is received by the Provider Enrollment Unit from DHSS. Any changes to a nursing facility must be approved by DHSS prior to enrollment sending forms. Bordering state nursing homes are not enrolled unless the recipient has been prior authorized by DHSS to be placed in the bordering state facility. Recipients wishing to be placed in an out of state facility must apply for Medicaid in the state the facility is located. Out of state providers cannot enroll.

Occupational Therapy (47)

These services are for patients under 21 only. Required documentation must be submitted with the original signed agreement. Each occupational therapist must enroll individually.

Must be current and permanently licensed as an occupational therapist and submit a copy of the current license.

Optometrist (31)

Required documentation must be submitted with the original signed agreement. Each optometrist must enroll individually.

Must be current and permanently licensed and submit a copy of the current license and Medicare number if enrolled with Medicare.

Optician (32)

Required documentation must be submitted with the original signed agreement.

Please supply us with the Medicare number if enrolled with Medicare.

Personal Care (26)

Required documentation must be submitted with the completed enrollment application. Out of state (non-bordering) providers cannot enroll.

Personal Care - Residential Care Facility (RCF)

Must be currently licensed as an RCF and submit a copy of the current RCF license. If RCF will be providing services in the community RCF must receive approval from Division of Senior Services, Quality Assurance (QA) as a Social Services Block Grant (SSBG) provider BEFORE submitting enrollment forms.

Personal Care - SSBG Contract

Must receive and maintain enrollment with the Division of Senior Services, Quality Assurance (QA) as an SSBG provider. Must enroll with Medicaid using the same provider information as used with QA.

Personal Care - Department of Health and Senior Services (DHSS)

Must be pre-approved by DHSS and attach DHSS approval documentation.

Personal Care - Department of Mental Health (DMH)

Must be pre-approved by DMH and attach DMH approval documentation.

Advanced Personal Care (APC)

Must complete the MO HealthNet Advanced Personal Care Program Addendum to Title XIX Participation Agreement. This form is available at the MO HealthNet website under MO HealthNet Forms. This form is used for new applicants as well as providers who decide to provide this service after they are enrolled.

Physical Disability Waiver (PDW)

Must complete the Physical Disability Waiver Services Addendum to Title XIX Participation Agreement for Home Health, Private Duty Nursing, or Personal Care Provider. This form is available at the MO HealthNet website under MO HealthNet Forms. This form is used for new applicants as well as providers who decide to provide this service after they are enrolled.

Pharmacy (60)

Each licensed pharmacy must enroll and bill separately. Required documentation must be submitted with the completed enrollment application. Out of state (non-bordering) pharmacy providers cannot enroll unless they are approved by MHD. Out of state (non-bordering) pharmacies must either see a participant or supply a medication that is not supplied in Missouri or a bordering state.

Must submit a copy of the current Pharmacy Permit if pharmacy is located in Missouri. If pharmacy is located in a bordering state and the scripts will be mailed to a recipient in Missouri, a copy of the current Missouri Non-Resident Pharmacy Permit and a copy of the current pharmacy permit for the state in which the pharmacy is located must be submitted. A physician is not issued a Pharmacy Dispensing provider number unless they are more than 15 miles from a Pharmacy.

Long Term Care

Must complete the MO HealthNet Long Term Care Pharmacy Dispensing Fee Provider Specialty form showing the nursing home name and type of packaging being dispensed before the specialty can be added. This form is available at the MMAC website under MO HealthNet Forms. This form is used for new applicants as well as providers who decide to provide this service after they are enrolled.

Physical Therapy (48)

MO HealthNet Division (MHD) is implementing statewide complementary and alternative therapy services for chronic pain, effective for dates of service on or after April 01, 2019, for participants 21 years of age and older who have evidence of chronic pain. Eligible participants will receive complementary and/or alternative therapy services as deemed medically necessary.

Physical Therapy provider types can currently enroll with a provider type 48 and provider specialty type of 44.

Physical Therapy services will require a Smart prior authorization (PA) for participants 21 years of age and older.

For participants to be eligible for complementary and alternative therapy services the individual must meet the following criteria:

Be currently enrolled in MO HealthNet, and

Be 21 years of age or older, and

Have chronic pain , and

Have diagnosis within the chronic pain list provided in the MO HealthNet Provider’s Manual for this program.

Physician (MD & DO - 20) (Instate and Bordering)

Required documentation must be submitted with the original signed agreement.

Physicians who work for a Rural Health Clinic (RHC) may only bill for NON-RHC services.

Must submit a copy of current permanent license and Medicare number (if enrolled with Medicare).

Physician (MD & DO - 20) Out of State (Non-Bordering)

Missouri Medicaid considers enrollment of an out of state provider if at least one of the following conditions is met:

Services were a result of a MEDICAL EMERGENCY* (including ambulance);

*Emergency services are defined as those services provided in a hospital, clinic, office or other facility that is equipped to furnish the required care, after sudden onset of medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in (a) placing the patient 's health in serious jeopardy; (b) serious impairment to bodily functions; or a serious dysfunction of any body organ or part.

Services were provided to a MEDICARE/MEDICAID RECIPIENT with Medicare as primary payor;

Provider of service is located in a BORDERING STATE OF MISSOURI**

Services were provided to a FOSTER CARE CHILD not residing in Missouri **

Services were provided by an INDEPENDENT LAB

Services were PRIOR AUTHORIZED by the Missouri State consultant

**Services which routinely require prior authorization or have other limitations will continue to require prior authorization and be subject to established limitation, policies and procedures applicable to the MO HealthNet programs.

If your claim DOES NOT meet one of the specific conditions listed above, the recipient is responsible for payment, and you DO NOT need to enroll as a MO HealthNet provider. If you determine your claim(s) meets one of the specific conditions listed above, you must request a paper application. All services must meet timely filing requirements. ENROLLMENT DOES NOT GUARANTEE PAYMENT.

It is your responsibility to verify the recipient eligibility for dates of service provided. If the recipient is enrolled with a Missouri Managed Care Health Plan, you must contact the Missouri Managed Care Health Plan concerning services provided, MO HealthNet is not responsible for those services. It is not necessary that you enroll with MO HealthNet unless you have provided services to recipients who ARE NOT enrolled with a Managed Care Health Plan.

Must maintain and submit a current permanent license and Medicare number if enrolled with Medicare. Each physician must enroll and bill separately. If enrolling clinic and physicians at the same time, the clinic and individual applications cannot be faxed as one transmission; each application and its required attachments must be faxed separately.

Biopsychosocial Treatment of Obesity: (Provider type 20/24 Specialty BT) Effective for dates of service on or after September 1, 2021: A Smart Prior Authorization (PA) is required for Biopsychosocial Treatment of Obesity services and will be requested by the referring provider for participants of all ages.

In order to provide individual and/or group intensive behavioral therapy (IBT) and/or family-based behavioral treatment (FBT) providers are required to be licensed to practice as a psychiatrist and are required to have a state specialist certification attained through completion of a qualified training program that addresses delivery of behaviorally based intervention for adult and/or youth participants diagnosed with obesity.

Biopsychosocial Treatment of Obesity providers must maintain six (6) hours of obesity or weight management CEUs or professional equivalent every two (2) years for the patient population served.

Providers should reference Missouri state regulation 13 CSR 70-25.140 for more details regarding provider qualifications.

Assistant Physician (21)

Required documentation must be submitted with the completed enrollment application.

· Assistant Physician Provider Questionnaire

· Title XIX Participation Agreement;

· Missouri Medicaid Enrollment Application;

· Current permanent Assistant Physician license;

If you are an individual applicant and the payee indicated in field 11 of the Provider Questionnaire is either to yourself or a group that is not Missouri Medicaid enrolled, you must submit the following documents. If you are an individual applicant and the payee is a group that is enrolled with Missouri Medicaid, you do not need to submit the following documents.

· Ownership Disclosure; and

· Electronic Funds Transfer (EFT) Authorization Agreement

Physician Assistants (22)

Required documentation must be submitted with the completed enrollment application.

· Physician Assistant Provider Questionnaire

· Title XIX Participation Agreement;

· Missouri Medicaid Enrollment Application;

· Current permanent Physician Assistant license;

· Ownership Disclosure; and

· Electronic Funds Transfer (EFT) Authorization Agreement

Planned Parenthood Clinic (52)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll.

If you are enrolled with Medicare, please supply us with your Medicare number, and individual members of the clinic and their Medicare numbers if enrolled with Medicare. Each individual practicing at the clinic must also be enrolled. Attach a cover letter stating the individual provider names practicing at the clinic. If enrolling clinic and physicians at the same time, the clinic and individual applications cannot be faxed as one transmission; each application and its required attachments must be faxed separately.

Podiatrist (30)

Required documentation must be submitted with the original signed agreement.

Must submit a copy of the current permanent license and Medicare number if enrolled with Medicare. Each podiatrist must enroll individually.

Private Duty Nursing Care (94)

Required documentation must be submitted with the completed enrollment application. Out of state providers cannot enroll. Each PDN provider must enroll separately.

Must submit the MO HealthNet home health provider number, a written proposal, or a copy of JCAHO or CHAPS Accreditation. Must maintain bonding, personal & property liability and Medical malpractice insurance coverage on employees delivering services in client's homes.

Physical Disability Waiver Services

Must complete the Physical Disability Waiver Services Addendum to Title XIX Participation Agreement for Home Health, Private Duty Nursing, or Personal Care Provider. This form is available at the MO HealthNet Division website under MO HealthNet Forms. This form is used for new enrollees as well as providers who decide to provide this service after they are enrolled.

Psychologist, Professional Counselor, Social Worker (49)

Each Psychologist, Professional Counselor, and/or Social Worker must enroll individually. Professional Counselor and Social Worker services are for patients under 21 only. Required documentation must be submitted with the original signed participation agreement.

Psychologist: must submit a copy of their current permanent license and their Medicare number, if enrolled with Medicare.

School Psychologist: must submit a copy of their Nationally Certified School Psychologist certificate. Must enroll as a performing provider with a MO HealthNet enrolled public or charter school district in the State of Missouri.

Professional Counselor or Social Worker: must submit a copy of their current permanent or provisional license. If the professional counselor or social worker is provisionally licensed, the applicant must have a license at each location of practice, and must send permanent license when it is issued. All providers, whether permanently or provisionally licensed, must provide all of their practice locations.

Provisionally licensed professional counselors and social workers are not permitted to receive payment directly from MO HealthNet and are not permitted to have an independent practice. Provisionally licensed individuals must complete the payment information on the enrollment application with either the supervisor or employer’s name and the tax ID number assigned to the payee. If you have questions regarding either of these issues contact your license board.

Psychiatric Residential Treatment Facilities (04)

Effective October 1, 2021, MO HealthNet Division (MHD) is now allowing private PRTF facilities to provide inpatient psychiatric services for individuals under age 22.

Required documentation must be submitted with the original signed agreement.

Private Facilities interested in providing PRTF services must follow steps 1-3 below to initiate the process of certification by the Department of Health and Senior Services (DHSS). DHSS certification is necessary prior to enrolling with the MO HealthNet Division (MHD) as a PRTF. DHSS certification is limited to facilities located in Missouri. Facilities located in a bordering state must be certified as a PRTF by that state’s designated survey agency. Out of State Non Bordering providers are not allowed to enroll.

1. Consult with DHSS at CONP@health.mo.gov or (573) 751-6403 regarding whether a Certificate of Need application must be submitted pursuant to 197.300 – 197.367 RSMo and 19 CSR 60-50.010 – 19 CSR 60-50.900. Additional information about the Certificate of Need program is available on the DHSS website.

2. Submit an attestation that includes all required elements as specified in Section 2832A of Chapter 2 of the Centers for Medicare & Medicaid Services (CMS) State Operations Manual to DHSS at hospitallicensure@health.mo.gov. Additional contact information for the DHSS Bureau of Hospital Standards is available here. PRTFs must satisfy all requirements in 42 CFR 441 Subpart D and 42 CFR 483 Subpart G. Interpretive guidelines for surveyors are contained in Appendix N of the State Operations Manual. In addition, once enrolled with MHD, PRTFs must submit attestation statements to MHD annually by July 21st of each fiscal year.

3. PRTFs must be accredited by:

the Joint Commission, or

the Commission on Accreditation of Rehabilitation Facilities, or

the Council on Accreditation of Services for Children and Families.

PRTFs must submit a copy of the most recent accrediting organization survey to DHSS for review along with the attestation noted in #2 above. DHSS will review the attestation and the accrediting organization survey and will make a certification decision. DHSS will send a letter to the facility indicating approval or denial of PRTF certification

In order to enroll as a provider with MHD, facilities located in Missouri must submit a copy of the DHSS PRTF certification letter along with the attestation noted in #2 above to MMAC.ProviderEnrollment@dss.mo.gov and request an enrollment application packet. MHD provider enrollment for PRTFs is by paper only.

Facilities located in bordering states must submit a copy of the certification letter from that state’s surveying agency in order to request an enrollment packet.

Out of State Non Bordering Providers cannot enroll.

Public Health Dept. Clinic (51)

Required documentation must be submitted with the original signed agreement. Out of state providers cannot enroll. Each Public Health Department must enroll individually.

Must be listed by Department of Health & Senior Services as a Public Health Dept. One physician or each advanced practice nurse employed must be enrolled. If the physician is enrolled, all services provided at the health department, other than advanced practice nurse services, can be filed using his/her provider number as performing provider in field 24K of the claim form. If the advanced practice nurse is enrolled instead of a physician he/she is only permitted to be used as the performing provider for the services they actually perform, not for any other service provided by the health department. If enrolling clinic, physicians, and/or nurses at the same time, the clinic and individual applications cannot be faxed as one transmission; each application and its required attachments must be faxed separately.

Qualified Medicare Beneficiary (QMB) (75)

Required documentation must be submitted with the completed enrollment application. Out of state (non-bordering) providers cannot enroll. Each QMB provider who has a Medicare number must enroll individually.

Must submit a copy of the current permanent license and Medicare number. Applicants must accept assignment and must have seen a QMB eligible recipient before enrollment is granted. Only QMB eligible recipients are covered under this program, many Medicare recipients are not QMB eligible.

Rehabilitation Center - Outpatient (57)

Required documentation must be submitted with the completed enrollment application. Out of state (non-bordering) providers cannot enroll.

Must be certified by Department of Health & Senior Services & Medicare. Please supply us with your Medicare number.

Rural Health Clinic (RHC) (59)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll. Each RHC that is Medicare certified must enroll and bill separately.

Please supply us with your Medicare number and the RHC rate letter. Individual practitioners may only bill for NON-RHC services.

Individual providers at a RHC may also maintain a clinic/group and individual NPI numbers at the rural health location. However, per the Centers for Medicare & Medicaid Services (CMS) the following specific documentation must be maintained by the provider and made available to the state Medicaid agency, upon request, which includes:

A list of services that will be provided on site through the clinic/group and practitioner NPI numbers;

Documentation of the costs associated with services provided through the clinic/group and practitioners; and

Contract between the provider and the RHC defining which services provided off-site will be provided through the clinic/group and practitioners and which will be provided as an employee of the RHC. The list of on-site services and the contract for off-site services must be submitted with the RHC annual cost report.

Please note: The costs associated with services provided through the clinic/group and practitioners NPI number, off and on-site, must be excluded from the cost report submitted to the Medicare intermediary for the RHC. The RHC rate is based on the actual costs associated with the RHC services only, therefore, any changes in the costs reported is reflected in the RHC rate. The list of on-site services and the contract for off-site services must be submitted with the RHC annual cost report.

School District (96)

Must be a Department of Elementary and Secondary Education recognized public or charter school district in the State of Missouri. May only be reimbursed for MHD covered services that are in the Individualized Education Plan (IEP).

Speech/Language Therapy (46)

These services are for patients under 21 only. Required documentation must be submitted with the original signed agreement.

Must submit a copy of current permanent Speech Language Pathologist license. If enrolling with a school you may submit a copy of the current permanent Teacher Certificate showing speech. Provisional license or provisional Teacher Certificate is not acceptable. Each therapist must enroll individually.

Teaching Institution Department (hospital based) (54)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll.

If each department has a clinic/group Medicare number then each department must enroll and all practitioners in each department must be enrolled individually. If one Part B clinic/group Medicare number is issued for the entire hospital then only one All Department number is issued. If enrolling the department, physicians, and/or other individual practitioners at the same time, the clinic/group and individual applications cannot be faxed as one transmission; each application and its required attachments must be faxed separately.

Teaching Institution (not hospital based) (55)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll.

Please supply us with your Medicare number, and individual members of the department and their Medicare numbers. If the departments are not enrolled with Medicare separately they are not enrolled with MO HealthNet separately. All individuals practicing in each department must be enrolled individually. Attach a cover letter stating the individual provider names practicing in each department. If enrolling the department, physicians, and/or other individual practitioners at the same time, the clinic and individual applications cannot be faxed as one transmission; each application and its required attachments must be faxed separately.

Third Party Assessor - Reassessments (27)

Applicant must have an active Personal Care (26), Homemaker/Chore/Respite (28) or Adult Day Care (29) enrollment to apply for a Third Party Assessor provider number. Out of state providers cannot enroll.

Applicants must submit the required documents found at:
http://mmac.mo.gov/providers/provider-enrollment/home-and-community-based-services/reassessment-packet/.

Questions can be directed to: mmac.ihscontracts@dss.mo.gov.

X-Ray – Portable X-Ray/IDTF (71)

Required documentation must be submitted with the original signed agreement. Out of state (non-bordering) providers cannot enroll.

Must be certified through the Department of Health and Senior Services as a Portable X-Ray or IDTF and must submit a copy of the Portable X-Ray or IDTF Medicare number. Out of state (non-bordering) providers cannot enroll. Individuals working for a Portable X-Ray or IDTF cannot enroll since all services are covered under the Portable X-Ray or IDTF.

OUT OF STATE (NON-BORDERING) APPLICANTS/PROVIDERS

Enrollment requirements for out of state (non-bordering) applicants: MO HealthNet recipients are required to obtain services from Missouri or bordering state providers. If a MO HealthNet participant leaves the state of Missouri and requires services, one of the following conditions must be met before the services are considered for reimbursement:

Missouri Medicaid considers enrollment of an out of state provider if at least one of the following conditions is met:

Services were a result of a MEDICAL EMERGENCY* (including ambulance);

*Emergency services are defined as those services provided in a hospital, clinic, office or other facility that is equipped to furnish the required care, after sudden onset of medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in (a) placing the patient health in serious jeopardy; (b) serious impairment to bodily functions; or a serious dysfunction of any body organ or part.

Services were provided to a MEDICARE/MO HEALTHNET PARTICIPANT with Medicare as primary

payor;

Provider of service is located in a BORDERING STATE OF MISSOURI**

Services were provided to a FOSTER CARE CHILD not residing in Missouri**

Services were provided by an INDEPENDENT LAB

Services were PRIOR AUTHORIZED by the Missouri State consultant

**Services which routinely require prior authorization or have other limitations continues to require prior authorization and be subject to established limitation, policies and procedures applicable to the MO HealthNet programs.

When the participant is in Missouri and receiving services from an out of state provider: MO HealthNet considers enrollment of an out of state (non-bordering) provider only if Medicare coinsurance and/or deductible amounts on covered services are provided to patients who have both MO HealthNet and Medicare, or if the item/services needed are not available in Missouri or a bordering state of Missouri. If prior authorization is approved and reimbursement is received for equipment, supplies, or services for a MO HealthNet patient who is not Medicare eligible, or for services that are available in Missouri or a bordering state, reimbursement may be recouped on any amounts paid.

If the recipient is enrolled with a Missouri MC+ health plan on the date(s) of service provided, the provider must contact the MC+ health plan concerning the services. It is not necessary to enroll with MO HealthNet unless the services are for recipients who ARE NOT enrolled with a Managed Care Health Plan and one of the conditions stated above is met.

If the claim DOES NOT meet one of the specific conditions listed above, the participant is responsible for the services, and enrollment is not granted.

If the claim meets one of the specific conditions listed above contact the Provider Enrollment Unit via email at: MMAC.providerenrollment@dss.mo.gov for the proper enrollment forms, have the participant ID and date of service available. All services must meet timely filing requirements.

Submitting enrollment forms does not guarantee enrollment and receiving a provider number does not guarantee reimbursement

INSTRUCTIONS FOR COMPLETION OF MO HEALTHNET

INTERNET ENROLLMENT FORMS

DO NOT USE HIGH LIGHTERS OR MARKERS ON ANY FORMS.

FOLLOW INSTRUCTIONS CAREFULLY.

The Provider Enrollment Application site is best viewed with the latest version of Internet Explorer, or Netscape Navigator. This site does not support the AOL browsing software. Please install the latest version of either Internet Explorer or Netscape Navigator before using this site.

Instructions for each field of the MO HealthNet Enrollment Application are listed on the bottom bar of the application screen. Use HELP for more detailed instructions on completing the enrollment application.

If you have problems faxing or using this site contact the Help Desk at 573-635-3559. General enrollment questions should be e-mailed to: MMAC.providerenrollment@dss.mo.gov. Please fax the signature page and required attachments in an upright position to 573-634-3105. Make sure the forms and attachments are of good quality so when they are faxed they are legible. Illegible forms or attachments are automatically denied.

Altered forms are automatically denied. Forms complete d by typewriter or hand written are automatically be denied. Fields cannot be blacked out, whited out or crossed out, writing information on the forms is not acceptable, however, the provider must sign with their original wet signature.

All forms must be completed while on the Internet before they can be submitted and printed. Applications printed prior to being completed on the Internet are denied. The signature page of the application and ALL REQUIRED ATTACHMENTS must be faxed in one transmission. Partial applications are not processed. The provider is responsible to retain printed pages of the enrollment application, including the signature page showing the original wet signature.

1) Once all fields on the first page of the application are completed, click on Continue; the screen to verify the information entered appears. After all fields are verified and correct, choose: Edit or Continue.

a) Edit: returns to the previous screen and allows changes to be made to any field on the current part,

or to enter information in fields that may have been missed.

b) Continue: takes applicant to the print page. Your choices from this screen are to:

i) Print for Your Records: allows applicants the opportunity to print their application and

retain for audit purposes. Each part must be printed before advancing to the next page.

The Back button CANNOT be used to go back and edit or print previous pages after

you have hit "Continue" on the review screen.

ii) Continue: takes the applicant to the next page.

iii) Finish Remaining Pages Later: one or more pages can be completed and retrieved

at a later date. In order to finish remaining pages later, the full page must be completed

before it can be it can be saved. The PIN number at the top of the page must be used to

retrieve the application in the event that all parts of the application are completed during the same session.

2) The Confirmation page has additional instructions. If changes are necessary, a new application must

be completed.

Only one signature page and its required attachments is accepted per fax transmission. If sending multiple signature pages along with required attachments, each signature page along with its required attachments must be faxed separately. In order for the signature page along with required attachments to be submitted by fax separately, make sure that each time a fax is completed, the fax machine being used is not only finished moving the pages through the machine, but has finished the transmission and has disconnected from the fax number dialed. Then re-dial to submit the next signature page along with required attachments.

The enrollment fax database number (573-634-3105) is used exclusively for submitting enrollment applications. All other faxes are disregarded. This is the only number that may be used to fax a signature page along with its required attachments.

All communications regarding Provider Enrollment are now communicated via e-mail at MMAC.providerenrollment@dss.mo.gov A valid e-mail address must be included with all correspondence and applications. The Provider Enrollment Unit also has an auto-responder that confirms the receipt of the e-mail. E-mails are processed in date order as they are received. Your patience is appreciated.

MO HealthNet Provider Agreement Signature Form Help

Instructions for completion of the MO HealthNet Provider Agreement Signature Form

Print the agreement signature form page by selecting the "Print Confirmation Page" button at the bottom of the form. Read the form carefully, sign with original signature, date, and fax it to the Provider Enrollment Unit at 573-634-3105. This is a fax database, not a regular fax machine. The applicant must submit the required documentation as listed on this page as well as any additional information needed from the completion of the provider application.

INSTRUCTIONS FOR COMPLETION OF MO HEALTHNET

PAPER ENROLLMENT FORMS

DO NOT USE HIGHLIGHTERS OR MARKERS ON ANY FORMS

DO NOT PUNCH HOLES IN ANY FORMS;

FOLLOW INSTRUCTIONS CAREFULLY;

ANY MO HEALTHNET ENROLLMENT FORM THAT HAS BEEN DUPLICATED OR ALTERED IN ANY MANNER IS AUTOMATICALLY DENIED.

PAPER PROVIDER QUESTIONNAIRE INSTRUCTIONS

1. PROVIDER NAME: Enter name of applying provider. If enrolling as a hospital, optical company, DME company, pharmacy, etc., use license or certification name (if applicable), or business/DBA name if not licensed or certified.

2. BUSINESS PHONE: Enter business telephone number for applying provider. This number is used by recipients, providers, and MO HealthNet employees, etc.

3. PRESENT NPI NUMBER(s): Enter ALL existing MO HealthNet provider numbers for the applying provider.

4. PROVIDER ADDRESS: A street address must be entered in this field either alone or with a post office box or route number, a P.O. Box alone is not an acceptable address, as correspondence may be sent by a commercial carrier, such as UPS. If mail is returned to our office the provider number is made inactive. If you participate with Medicare each physical location that is issued a Medicare number must also enroll with a separate MO HealthNet enrollment record.

5-8. CITY, COUNTY, STATE, and ZIP CODE: Enter appropriate information for provider address.

9. PAYMENT NAME ( name as registered with IRS): Enter the name that the payment should be taxed to. If using a Federal Tax Identification Number to report income to the IRS, the name must be the exact same name as registered with IRS. If using a Social Security Number the name must be the exact same name as used with the Social Security Administration. This information must be entered correctly even if payment is direct deposited. The name completed in this field appears on the paper check (if you do not participate in direct deposit), the paper remittance advice, and the 1099 tax form at the end of the year. If there is a DBA name please enter it after the appropriate payment name. Name/number mismatches for this field results in the incorrect issuance of 1099 tax forms to the provider and may cause withholding of reimbursement. Corrected 1099 tax forms are NOT issued by the Missouri Medicaid Audit and Compliance. If you think you are using an incorrect name and Federal Tax Identification Number combination, or need verification of the name matching the Federal Tax Identification Number, contact IRS at 800-829-1040. When using a Federal Tax Identification Number, also submit a copy of one of the following PREPRINTED Federal documents to verify the legal name used with IRS: CP 575 or 147C letter; or letter from IRS with the Federal Tax Identification number and legal name. A W-9 is not acceptable.

10-13 PAYMENT, REMITTANCE, and 1099 ADDRESS: Enter the address that a 1099 should be sent to. Provider Enrollment must be notified in writing of remittance address changes.

14. TAX IDENTIFICATION NUMBER: Enter the Federal Tax Identification Number or Social Security Number that payment should be taxed to, the number assigned to the name listed in field 9. This may be a Social Security Number or a Federal Tax Identification Number depending on how income is reported to IRS. If using a Federal Tax Identification number the tax number must match the name as registered with IRS. If using a SSN the number must match the name as you are registered with the Social Security Administration. This information must be entered correctly even if payment is direct deposited. The name completed in this field appears on the paper check if you do not participate in direct deposit, the paper remittance advice, and the 1099 tax form at the end of the year. If there is a DBA name please enter it after the appropriate payment name. Name/number mismatches in this field results in the incorrect issuance of 1099 tax forms to the provider and may cause withholding of reimbursement. Corrected 1099 tax forms are NOT issued by the MO HealthNet Audit and Compliance. If you think you are using an incorrect name and Federal Tax Identification Number combination, or need verification of the name matching the Federal Tax Identification number, contact IRS at 800-829-1040. When using a Federal Tax Identification Number, also submit a copy of one of the following PREPRINTED Federal documents to verify the legal name used with IRS: CP 575 or 147C letter; or letter from IRS with the Federal Tax Identification number and legal name. A W-9 is not acceptable.

15. Individual applicants only.

16. MEDICARE NUMBER: (if applicable) Enter the Medicare number(s) assigned to the applying provider's physical location address listed in fields 4-8. This information allows Medicare claims to crossover automatically to Missouri MO HealthNet. If the Medicare number covers more than one office location, complete the forms with the physical location address the Medicare number is issued to. If there are separate Medicare numbers for different locations, each location must enroll with MO HealthNet as with Medicare. It is the provider's responsibility to file claims for all Medicare/MO HealthNet claims that do not crossover electronically for whatever reason.

17. MEDICARE CARRIER: Enter name(s) of Medicare carrier for Medicare number(s) listed in field 16 (i.e. Medicare Services, Blue Cross/Blue Shield, etc.).

18. STATE LICENSE NUMBER: Enter the State license number for the applying provider. Any provider that is issued a license to practice must submit a copy of current, permanent license unless otherwise requested.

19. NABP/NCPDP NUMBER: (Pharmacies only) Enter your NABP/NCPDP number. This number is used for MMAC tracking purposes and must be included on all applications.

20. TYPE OF PRACTICE: Check box identifying type of practice/business. If box indicating City, Municipal, County, Dist. or State-owned is checked, underline the type of agency.

21. PROVIDER TYPE: P rovider types and specialties are already indicated on the questionnaire.

22. CLIA: Enter Clinical Laboratory Improvement Act (CLIA) Identification number issued to the practice location of enrollment. CLIA numbers are obtained from CMS and documentation of this number is required to bill for laboratory services. (must also attach a copy of CLIA Certificate).

23. CRNA: Indicate if you employ or have any CRNAs under contract. All CRNAs must enroll individually via the Internet as individual MO HealthNet providers.

24. PROVIDER SPECIALTY: Circle all specialties licensed/certified to perform. This information is needed for correct payment of claims. ATTACH A COPY OF ALL APPROPRIATE LICENSES/CERTIFICATION TO SUPPORT SPECIALTIES INDICATED.

SECTION II: To be completed by Nursing Home Providers ONLY

25. NURSING HOME ADMINISTRATOR: Enter name of current nursing home administrator.

26. FISCAL YEAR END DATE: Enter the fiscal year month end date for the nursing home.

SECTION III: To be completed by Hospitals ONLY

27. CERTIFIED BEDS: Enter number of certified beds in the hospital.

28. FISCAL YEAR END DATE: Enter the fiscal year month end date for the hospital.

SECTION IV: To be completed by Pharmacies & DME (if also a Pharmacy) ONLY

29. PHARMACY OWNER: Enter name of Pharmacy owner.

SECTION V: To be completed by Home Health & Hospice ONLY

30. FISCAL YEAR END DATE: Enter the fiscal year month end date for Home Health or Hospice agency.

SECTION VI: To be completed by Nursing Homes ONLY

31. NURSING HOME ADMINISTRATOR SIGNATURE: Must be Nursing Home Administrator's ORIGINAL signature.

PAPER TITLE XIX PARTICIPATION AGREEMENT INSTRUCTIONS

(the back side of the Provider Questionnaire, blue form)

Read the agreement carefully.

The Title XIX Participation Agreement MUST contain the signature of the person the provider has indicated to sign. An authorized representative of the owner may sign for a facility, clinic, or other entity. Billing agents etc. are prohibited from signing.

Indicate the title of the person signing and the date signed.

PAPER MO HEALTHNET PROVIDER ENROLLMENT APPLICATION INSTRUCTIONS

(white form, front and back)

All questions must be answered.

Field number 1: If you do not have any other NPI numbers enrolled, put none.

This form MUST contain the signature of the person the provider indicates to sign, see Title XIX Participation Agreement. An authorized representative of the owner may sign for a facility, clinic, or other entity. All forms must be signed by the same person.

Indicate the title of the person signing and the date signed.

CIVIL RIGHTS COMPLIANCE

All applicants are required to be in compliance with the Office of Civil Rights. Applicants are required to review the civil rights information via the Internet at www.dss.mo.gov/mhd to ensure compliance is met. Click on Providers, under Provider Enrollment select civil rights.

MO HealthNet providers must enroll and bill MO HealthNet in the same manner they enroll and bill Medicare in order for Medicare/MO HealthNet claims to crossover electronically and be reimbursed appropriately. MO HealthNet providers must enroll at the physical practice location the Medicare number is issued.

Physicians, APNs, and CRNAs are no longer required to enroll at each Medicare or MO HealthNet practice location. However, they are still required to submit Medicare documentation so the claims can crossover automatically.

It is the provider's responsibility to file claims to MO HealthNet for any Medicare/MO HealthNet crossover claims that do not crossover automatically; wait 60-90 days before submitting claims. Duplicate billing of crossover claims is considered MO HealthNet fraud.

MO HealthNet has a contract with several carriers to automatically crossover Medicare/MO HealthNet claims. If you have a Medicare number with more than one carrier please submit documentation for all carriers, separate MO HealthNet provider records may be necessary in some cases.

Some MO HealthNet providers are only permitted to be reimbursed for crossover claims on QMB-ONLY participants; therefore not all of their Medicare claims are paid.

If services are provided to MO HealthNet participants at different office locations that have separate Medicare numbers for each location, separate MO HealthNet enrollment records must be created for all providers and the providers must bill under the appropriate Medicare and MO HealthNet record for each location. This applies to all providers except: Physicians, APNs, and CRNAs.

If services are provided to MO HealthNet participants at different office locations and all locations are approved by Medicare to use one Medicare number, then all providers must enroll with MO HealthNet in the same manner and bill with one Medicare number and MO HealthNet enrollment record. Since all offices are permitted to use the same Medicare number in this instance, all providers must enroll at the physical location the Medicare number is issued even if they do not practice at that location.

Medicare/MO HealthNet services that have been issued a Clinic Medicare number must automatically crossover to a Clinic MO HealthNet provider record. If the clinic is not enrolled, the Medicare/MO HealthNet claims do not crossover automatically. Physician, Advanced Practice Nurse, CRNA, Podiatrist, and Diabetes Self-Management individuals must enroll and bill as MO HealthNet performing providers. All other provider members must enroll and bill under their individual provider name and record.

When the clinic is issued a Medicare number, each individual provider is also issued a number as a member of the clinic. The clinic Medicare number is three digits followed by zeros and sometimes an alpha character. The member of the clinic is enrolled as a performing provider. The Medicare number will be the clinic's first three digits followed by at least four digits indicating their individual Medicare number with the clinic. The Medicare clinic and performing provider records are matched to the MO HealthNet clinic and performing provider records. The Medicare claims crossover automatically and are reimbursed under the Clinic MO HealthNet provider record. Therefore, if the clinic is not enrolled, an individual member of the clinic who is providing Medicare/MO HealthNet services is not enrolled, or, if the Medicare number is not showing on the MO HealthNet provider enrollment file, the Medicare numbers cannot be matched and crossover claims are not reimbursed.

When the clinic is issued a "Clinic or Group Medicare number" (i.e. 000012345), each individual is also issued a number as a member of the clinic, in this instance the clinic must enroll in order for the Medicare/MO HealthNet claims to crossover automatically. The Medicare claims crossover and pay under the clinic MO HealthNet provider record. The performing providers are not verified during this process, therefore, a list of all members must be submitted and all members of the clinic must be enrolled with MO HealthNet or a clinic MO HealthNet provider record is not created. If the clinic enrolls but each member is not enrolled and the clinic receives Medicare/MO HealthNet payment for non-enrolled members of the clinic, it is considered MO HealthNet fraud. If any physicians, advanced practice nurses, CRNAs, or podiatrists refuse to enroll as performing providers and MO HealthNet pays for Medicare claims that automatically crossover, it is considered fraud. MO HealthNet claims must be billed using the clinic provider name and number as the billing provider and the individual physician, advanced practice nurse, CRNA, podiatrist, and diabetes self-management as the performing provider.

Medicare number to be submitted to MO HealthNet so the Medicare number can be added to the provider file: all providers must submit a copy of the letter received from Medicare, the letter must show the clinic name, Medicare provider number, and practice address if possible. The letter must include the names and Medicare numbers of all members within the clinic. If the letter is not available, request a letter from Medicare verifying the clinic Medicare number and the Medicare number of all members within the clinic.