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Page 1

STATE OF MISSOURI

PERSONAL CARE
MANUAL

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SECTION 1-PARTICIPANT CONDITIONS OF PARTICIPATION ........................................15
1.1 INDIVIDUALS ELIGIBLE FOR MO HEALTHNET, MANAGED CARE OR STATE
FUNDED BENEFITS........................................................................................................................15

1.1.A DESCRIPTION OF ELIGIBILITY CATEGORIES.............................................................15
1.1.A(1) MO HealthNet ...............................................................................................................15
1.1.A(2) MO HealthNet for Kids.................................................................................................16
1.1.A(3) Temporary MO HealthNet During Pregnancy (TEMP)................................................18
1.1.A(4) Voluntary Placement Agreement for Children .............................................................18
1.1.A(5) State Funded MO HealthNet .........................................................................................18
1.1.A(6) MO Rx...........................................................................................................................19
1.1.A(7) Women’s Health Services .............................................................................................19
1.1.A(8) ME Codes Not in Use ...................................................................................................20

1.2 MO HEALTHNET AND MO HEALTHNET MANAGED CARE ID CARD......................20
1.2.A FORMAT OF MO HEALTHNET ID CARD .......................................................................21
1.2.B ACCESS TO ELIGIBILITY INFORMATION.....................................................................22
1.2.C IDENTIFICATION OF PARTICIPANTS BY ELIGIBILITY CODES ...............................22

1.2.C(1) MO HealthNet Participants ...........................................................................................22
1.2.C(2) MO HealthNet Managed Care Participants..................................................................22
1.2.C(3) TEMP ............................................................................................................................22
1.2.C(4) Temporary Medical Eligibility for Reinstated TANF Individuals ................................23
1.2.C(5) Presumptive Eligibility for Children .............................................................................23
1.2.C(6) Breast or Cervical Cancer Treatment Presumptive Eligibility ......................................23
1.2.C(7) Voluntary Placement Agreement ..................................................................................23

1.2.D THIRD PARTY INSURANCE COVERAGE ......................................................................24
1.2.D(1) Medicare Part A, Part B and Part C ..............................................................................24

1.3 MO HEALTHNET, STATE FUNDED MEDICAL ASSISTANCE AND MO
HEALTHNET MANAGED CARE APPLICATION PROCESS .................................................24
1.4 AUTOMATIC MO HEALTHNET ELIGIBILITY FOR NEWBORN CHILDREN ...........25

1.4.A NEWBORN INELIGIBILITY ..............................................................................................26
1.4.B NEWBORN ADOPTION ......................................................................................................26
1.4.C MO HEALTHNET MANAGED CARE HEALTH PLAN NEWBORN ENROLLMENT..26

1.5 PARTICIPANTS WITH RESTRICTED/LIMITED BENEFITS ..........................................27
1.5.A LIMITED BENEFIT PACKAGE FOR ADULT CATEGORIES OF ASSISTANCE .........27
1.5.B ADMINISTRATIVE PARTICIPANT LOCK-IN .................................................................29
1.5.C MO HEALTHNET MANAGED CARE PARTICIPANTS .................................................29

1.5.C(1) Home Birth Services for the MO HealthNet Managed Care Program..........................31
1.5.D HOSPICE BENEFICIARIES ................................................................................................31
1.5.E QUALIFIED MEDICARE BENEFICIARIES (QMB) .........................................................32
1.5.F WOMEN’S HEALTH SERVICES PROGRAM (ME CODES 80 and 89)...........................33
1.5.G TEMP PARTICIPANTS........................................................................................................33

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Diagnostic and treatment services beyond the scope of the Medicaid state plan may require a plan of
care and prior authorization (see Section 9.13.A). Additional information regarding specialized
services can be found in Section 13, Benefits and Limitations.

9.12.A PRIOR AUTHORIZATION FOR NON-STATE PLAN SERVICES
(EXPANDED HCY SERVICES)

Medically necessary services beyond the scope of the traditional Medicaid Program may be
provided when the need for these services is identified by a complete, interperiodic or partial
HCY screening. When required, a Prior Authorization Request form must be submitted to the
MO HealthNet Division. Refer to instructions found in Section 13 of the provider manual for
information on services requiring prior authorization. Complete the Prior Authorization
Request form in full, describing in full detail the service being requested and submit in
accordance with requirements in Section 13 of the provider manual.

Section 8 of the provider manual indicates exceptions to the prior authorization requirement
and gives further details regarding completion of the form. Section 14 may also include
specific requirements regarding the prior authorization requirement.

9.13 PARTICIPANT NONLIABILITY

MO HealthNet covered services rendered to an eligible participant are not billable to the participant
if MO HealthNet would have paid had the provider followed the proper policies and procedures for
obtaining payment through the MO HealthNet Program as set forth in 13 CSR 70-4.030.

9.14 EXEMPTION FROM COST SHARING AND COPAY
REQUIREMENTS

Providers must refer to appropriate program manuals for specific information regarding cost sharing
and copay requirements.

9.15 STATE-ONLY FUNDED PARTICIPANTS

Children eligible under a state-only funded category of assistance are eligible for all services
including those available through the HCY Program to the same degree any other person under the
age of 21 years is eligible for a service. Refer to Section 1 for further information regarding state-
only funded participants.

9.16 MO HEALTHNET MANAGED CARE

MO HealthNet Managed Care health plans are responsible for insuring that Early and Periodic,
Screening, Diagnosis and Treatment (EPSDT) screens are performed on all MO HealthNet Managed
Care eligibles under the age of 21.

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The Omnibus Budget Reconciliation Act of 1989 (OBRA-89) mandated that Medicaid provide
medically necessary services to children from birth through age 20 years which are necessary to treat
or ameliorate defects, physical or mental illness, or conditions identified by an EPSDT screen
regardless of whether or not the services are covered under the Medicaid state plan. Services must be
sufficient in amount, duration and scope to reasonably achieve their purpose and may only be limited
by medical necessity. According to the MO HealthNet Managed Care contracts, the MO HealthNet
Managed Care health plans are responsible for providing all EPSDT/HCY services for their
enrollees.

Missouri is required to provide the Centers for Medicare & Medicaid Services with screening and
referral data each federal fiscal year (FFY). This information is reported to CMS on the CMS-416
report. Specific guidelines and requirements are required when completing this report. The health
plans are not required to produce a CMS-416 report. Plans must report encounter data for HCY
screens using the appropriate codes in order for the MO HealthNet Division to complete the CMS-
416 report.

A full EPSDT/HCY screening must include the following components:

a) A comprehensive unclothed physical examination

b) A comprehensive health and developmental history including assessment of both physical
and mental health development

c) Health education (including anticipatory guidance)

d) Appropriate immunizations according to age

e) Laboratory tests as indicated (appropriate according to age and health history unless
medically contraindicated)

f) Lead screen according to established guidelines

g) Hearing screen

h) Vision screen

i) Dental screen

Partial screens which are segments of the full screen may be provided by appropriate providers. The
purpose of this is to increase access to care to all children. Providers of partial screens are required to
supply a referral source for the full screen. (For the plan enrollees this should be the primary care
physician). A partial screen does not replace the need for a full medical screen which includes all of
the above components. See Section 9, page 5 through 8 for specific information on partial screens.

Plans must use the following procedure codes, along with a primary diagnosis code of Z00.00,
Z00.01, Z00.110, Z00.111, Z00.121, or Z00.129 when reporting encounter data to the MO
HealthNet Division on Full and Partial EPSDT/HCY Screens:

Full Screen 99381EP through 99385EP and 99391EP through 99395EP

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SECTION 23 - CLAIM ATTACHMENT SUBMISSION AND PROCESSING

This section of the manual provides examples and instructions for submitting claim attachments.

23.1 CLAIM ATTACHMENT SUBMISSIONS

Four claim attachments required for payment of certain services are separately processed from the
claim form. The four attachments are:

• (Sterilization) Consent Form

• Acknowledgment of Receipt of Hysterectomy Information

• Medical Referral Form of Restricted Participant (PI-118)

• Certificate of Medical Necessity (only for the Durable Medical Equipment Program)

These attachments should not be submitted with a claim form. These attachments should be mailed
separately to:

Wipro Infocrossing
P.O. Box 5900
Jefferson City, MO 65102

These attachments may also be submitted to Wipro Infocrossing via the Internet when additional
documentation is not required. The web site address for these submissions is www.emomed.com.

The data from the attachment is entered into MO HealthNet Management Information System
(MMIS) and processed for validity editing and MO HealthNet program requirements. Refer to
specific manuals for program requirements.

Providers do not need to alter their claim submittal process or wait for an attachment to be finalized
before submitting the corresponding claim(s) for payment. A claim for services requiring one of the
listed attachments remains in suspense for up to 45 days. When an attachment can be systematically
linked to the claim, the claim continues processing for adjudication. If after 45 days a match is not
found, the claim denies for the missing attachment.

An approved attachment is valid only for the procedure code indicated on the attachment. If a
change in procedure code occurs, a new attachment must be submitted incorporating the new
procedure code.

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23.2 CERTIFICATE OF MEDICAL NECESSITY FOR DURABLE
MEDICAL EQUIPMENT PROVIDERS ONLY

The data from the Certificate of Medical Necessity for DME services is entered into MMIS and
processed for validity editing and MO HealthNet program requirements. DME providers are
required to include the correct modifier (NU, RR, RB) in the procedure code field with the
corresponding procedure code.

A Certificate of Medical Necessity that has been submitted by a DME provider is reviewed and
approved or denied. Denied requests may be resubmitted with additional information. If approved, a
certificate of medical necessity is approved for six months from the prescription date. Any claim
matching the criteria on the Certificate of Medical Necessity for that time period can be processed
without submission of an additional Certificate of Medical Necessity. This includes all monthly
claim submissions and any resubmissions.

END OF SECTION
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