STATE OF MISSOURI MANUAL PERSONAL CARE

1 STATE OF MISSOURIPERSONAL care MANUALP ersonal CarePRODUCTION : 05/23/20182 SECTION 1-PARTICIPANT CONDITIONS OF INDIVIDUALS ELIGIBLE FOR MO HEALTHNET, MANAGED care OR STATE FUNDED DESCRIPTION OF ELIGIBILITY (1) MO (2) MO HealthNet for (3) Temporary MO HealthNet During Pregnancy (TEMP).. (4) Voluntary Placement Agreement for (5) STATE Funded MO (6) MO (7) Women s Health (8) ME Codes Not in MO HEALTHNET AND MO HEALTHNET MANAGED care ID FORMAT OF MO HEALTHNET ID ACCESS TO ELIGIBILITY IDENTIFICATION OF PARTICIPANTS BY ELIGIBILITY (1) MO HealthNet (2) MO HealthNet Managed care (3) (4) Temporary Medical Eligibility for Reinstated TANF (5) Presumptive Eligibility for (6) Breast or Cervical Cancer Treatment Presumptive (7) Voluntary Placement THIRD PARTY INSURANCE (1)

2 Medicare Part A, Part B and Part MO HEALTHNET, STATE FUNDED MEDICAL ASSISTANCE AND MO HEALTHNET MANAGED care APPLICATION AUTOMATIC MO HEALTHNET ELIGIBILITY FOR NEWBORN NEWBORN NEWBORN MO HEALTHNET MANAGED care HEALTH PLAN NEWBORN PARTICIPANTS WITH RESTRICTED/LIMITED LIMITED BENEFIT PACKAGE FOR ADULT CATEGORIES OF ADMINISTRATIVE PARTICIPANT MO HEALTHNET MANAGED care (1) Home Birth Services for the MO HealthNet Managed care HOSPICE QUALIFIED MEDICARE BENEFICIARIES (QMB).. WOMEN S HEALTH SERVICES PROGRAM (ME CODES 80 and 89).. TEMP CarePRODUCTION : 05/23 (1) TEMP ID (2) TEMP Service (3) Full MO HealthNet Eligibility After PROGRAM FOR ALL-INCLUSIVE care FOR THE ELDERLY (PACE).

3 MISSOURI 'S BREAST AND CERVICAL CANCER TREATMENT (BCCT) (1) Eligibility (2) Presumptive (3) Regular BCCT MO (4) Termination of TICKET TO WORK HEALTH ASSURANCE (1) (2) (3) Premium Payment and Collection (4) Termination of PRESUMPTIVE ELIGIBILITY FOR (1) Eligibility (2) MO HealthNet for Kids MO HEALTHNET COVERAGE FOR INMATES OF A PUBLIC (1) MO HealthNet Coverage Not (2) MO HealthNet VOLUNTARY PLACEMENT AGREEMENT, OUT-OF- HOME CHILDREN'S (1) Duration of Voluntary Placement (2) Covered Treatment and Medical (3) Medical Planning for Out-of-Home ELIGIBILITY PERIODS FOR MO HEALTHNET DAY SPECIFIC (1) Notification of Spenddown (2) Notification of Spenddown on New (3) Meeting Spenddown with Incurred and/or Paid (4) Meeting Spenddown with a Combination of Incurred Expenses and Paying the (5) Preventing MO HealthNet Payment of Expenses Used to Meet (6) Spenddown Pay-In (7) Prior Quarter (8) MO HealthNet Coverage End PRIOR QUARTER EMERGENCY MEDICAL care FOR INELIGIBLE PARTICIPANT ELIGIBILITY LETTERS AND CLAIMS NEW APPROVAL (1) Eligibility Letter for Reinstated TANF (ME 81) CarePRODUCTION.

4 05/23 (2) BCCT Temporary MO HealthNet Authorization (3) Presumptive Eligibility for Children Authorization PC-2 REPLACEMENT NOTICE OF CASE PARTICIPANT EXPLANATION OF MO HEALTHNET PRIOR AUTHORIZATION REQUEST PARTICIPANT SERVICES UNIT ADDRESS AND TELEPHONE TRANSPLANT COVERED ORGAN AND BONE MARROW/STEM CELL PATIENT SELECTION CORNEAL ELIGIBILITY MANAGED care MEDICARE COVERED 2-PROVIDER CONDITIONS OF PROVIDER QMB-ONLY NON-BILLING MO HEALTHNET PROVIDER ENROLLMENT ELECTRONIC CLAIM/ATTACHMENTS SUBMISSION AND INTERNET PROHIBITION ON PAYMENT TO INSTITUTIONS OR ENTITIES LOCATED OUTSIDE OF THE UNITED NOTIFICATION OF RETENTION OF ADEQUATE NONDISCRIMINATION

5 POLICY STATE S RIGHT TO TERMINATE RELATIONSHIP WITH A FRAUD AND CLAIM INTEGRITY FOR MO HEALTHNET POSTPAYMENT PREPAYMENT DIRECT DEPOSIT AND REMITTANCE 3 - STAKEHOLDER PROVIDER MHD TECHNICAL HELP MISSOURI Medicaid Audit & Compliance (MMAC).. PROVIDER ENROLLMENT PROVIDER COMMUNICATIONS INTERACTIVE VOICE RESPONSE (IVR) (1) Using the Telephone Key CarePRODUCTION : 05/23 MO HEALTHNET WRITTEN PROVIDER EDUCATION PARTICIPANT PENDING CLAIM FILING CLAIM ATTACHMENT SUBMISSION VIA THE Pharmacy & Clinical Services Pharmacy and Medical Pre-certification Help Third Party Liability (TPL)..79 SECTION 4 - TIMELY TIME LIMIT FOR ORIGINAL CLAIM MO HEALTHNET MEDICARE/MO HEALTHNET MO HEALTHNET CLAIMS WITH THIRD PARTY TIME LIMIT FOR RESUBMISSION OF A CLAIMS FILED AND CLAIMS FILED AND RETURNED TO CLAIMS NOT FILED WITHIN THE TIME TIME LIMIT FOR FILING AN INDIVIDUAL 5-THIRD PARTY GENERAL MO HEALTHNET IS PAYER OF LAST THIRD PARTY LIABILITY FOR MANAGED HEALTH care PARTICIPANTS LIABILITY WHEN THERE IS A PROVIDERS MAY NOT REFUSE SERVICE DUE TO HEALTH INSURANCE TPL SOLICITATION OF TPR INSURANCE COVERAGE COMMERCIAL MANAGED HEALTH care MEDICAL PROVIDER CLAIM DOCUMENTATION EXCEPTION TO

6 TIMELY FILING TPR CLAIM PAYMENT THIRD PARTY LIABILITY MO HEALTHNET INSURANCE RESOURCE REPORT (TPL-4).. LIABILITY AND CASUALTY TPL RECOVERY CarePRODUCTION : 05/23 TIMELY FILING ACCIDENTS WITHOUT RELEASE OF BILLING OR MEDICAL RECORDS OVERPAYMENT DUE TO RECEIPT OF A THIRD PARTY THE HEALTH INSURANCE PREMIUM PAYMENT (HIPP) DEFINITIONS OF COMMON HEALTH INSURANCE GENERAL INSTRUCTIONS FOR ADJUSTING CLAIMS WITHIN 24 MONTHS OF DATE OF NOTE: PROVIDERS MUST BE ENROLLED AS AN ELECTRONIC BILLING PROVIDER BEFORE USING THE ONLINE CLAIM ADJUSTMENT ADJUSTING CLAIMS (1) Options for Adjusting a Paid (1)(i) (1)(ii) (2) Options for Adjusting a Denied (2)(i) Timely (2)(ii) Copy Claim (2)(iii)

7 Copy Claim CLAIM STATUS INSTRUCTIONS FOR ADJUSTING CLAIMS OLDER THAN 24 MONTHS OF EXPLANATION OF THE ADJUSTMENT 7-MEDICAL CERTIFICATE OF MEDICAL CERTIFICATE OF MEDICAL NECESSITY FOR DURABLE MEDICAL EQUIPMENT INSTRUCTIONS FOR COMPLETING THE CERTIFICATE OF MEDICAL 8-PRIOR PRIOR AUTHORIZATION PROCEDURE FOR OBTAINING PRIOR EXCEPTIONS TO THE PRIOR AUTHORIZATION INSTRUCTIONS FOR COMPLETING THE PRIOR AUTHORIZATION (PA) REQUEST WHEN TO SUBMIT A PRIOR AUTHORIZATION (PA) MO HEALTHNET AUTHORIZATION A DENIAL OF PRIOR AUTHORIZATION (PA) MO HEALTHNET AUTHORIZATION DETERMINATION REQUEST FOR CHANGE (RFC) OF PRIOR AUTHORIZATION (PA) CarePRODUCTION : 05/23 WHEN TO SUBMIT A REQUEST FOR DEPARTMENT OF HEALTH AND SENIOR SERVICES (DHSS).

8 OUT-OF- STATE , NON-EMERGENCY EXCEPTIONS TO OUT-OF- STATE PRIOR AUTHORIZATION 9-HEALTHY CHILDREN AND YOUTH GENERAL PLACE OF SERVICE (POS).. DIAGNOSIS INTERPERIODIC FULL HCY/EPSDT QUALIFIED PARTIAL HCY/EPSDT DEVELOPMENTAL (1) Qualified UNCLOTHED PHYSICAL, ANTICIPATORY GUIDANCE, AND INTERVAL HISTORY, LAB/IMMUNIZATIONS AND LEAD (1) Qualified VISION (1) Qualified HEARING (1) Qualified DENTAL (1) Qualified ALL PARTIAL LEAD RISK ASSESSMENT AND TREATMENT HEALTHY CHILDREN AND YOUTH (HCY).. SIGNS, SYMPTOMS AND EXPOSURE LEAD RISK MANDATORY RISK ASSESSMENT FOR LEAD (1) Risk (2) Determining (3) Screening Blood (4) MO HealthNet Managed care Health LABORATORY REQUIREMENTS FOR BLOOD LEAD LEVEL BLOOD LEAD LEVEL RECOMMENDED (1) Blood Lead Level <10 (2) Blood Lead Level 10-19 (3) Blood Lead Level 20-44 (4) Blood Lead Level 45-69 (5) Blood Lead Level 70 g/dL or COORDINATION WITH OTHER ENVIRONMENTAL LEAD CarePRODUCTION.

9 05/23 (1) Environmental Lead LEAD CASE POISON CONTROL HOTLINE TELEPHONE MO HEALTHNET ENROLLED LABORATORIES THAT PERFORM BLOOD LEAD OUT-OF- STATE LABS CURRENTLY REPORTING LEAD TEST RESULTS TO THE MISSOURI DEPARTMENT OF HEALTH AND SENIOR HCY CASE VACCINE FOR CHILDREN (VFC).. ASSIGNMENT OF SCREENING PERIODICITY SCHEDULE FOR HCY (EPSDT) SCREENING DENTAL SCREENING VISION SCREENING HEARING SCREENING REFERRALS RESULTING FROM A FULL, INTERPERIODIC OR PARTIAL PRIOR AUTHORIZATION FOR NON- STATE PLAN SERVICES (EXPANDED HCY SERVICES).. PARTICIPANT EXEMPTION FROM COST SHARING AND COPAY STATE -ONLY FUNDED MO HEALTHNET MANAGED ORDERING HEALTHY CHILDREN AND YOUTH SCREENING AND HCY LEAD SCREENING 10 - FAMILY 11 - MO HEALTHNET MANAGED care PROGRAM DELIVERY MO HEALTHNET'S MANAGED care EASTERN MISSOURI PARTICIPATING MO HEALTHNET MANAGED care HEALTH CENTRAL MISSOURI PARTICIPATING MO HEALTHNET MANAGED care HEALTH SOUTHWESTERN MISSOURI PARTICIPATING MO HEALTHNET MANAGED care HEALTH WESTERN MISSOURI PARTICIPATING MO HEALTHNET MANAGED care HEALTH MO HEALTHNET MANAGED care HEALTH PLAN MO HEALTHNET MANAGED care HEALTH PLAN I NCLUDED MO HEALTHNET

10 MANAGED care HEALTH PLAN E XCLUDED MO HEALTHNET MANAGED care MEMBER CarePRODUCTION : 05/23 STANDARD BENEFITS UNDER THE MO HEALTHNET MANAGED care BENEFITS FOR CHILDREN AND WOMEN IN A MO HEALTHNET CATEGORY OF ASSISTANCE FOR PREGNANT SERVICES PROVIDED OUTSIDE THE MO HEALTHNET MANAGED care QUALITY OF IDENTIFICATION OF MO HEALTHNET MANAGED care NON-BILLING MO HEALTHNET EMERGENCY PROGRAM OF ALL-INCLUSIVE care FOR THE ELDERLY (PACE).. ELIGIBILITY FOR INDIVIDUALS NOT ELIGIBLE FOR LOCK-IN IDENTIFICATION OF PACE PACE COVERED 12 REIMBURSEMENT THE BASIS FOR ESTABLISHING A RATE OF PERSONAL care ONLINE FEE MEDICARE/MEDICAID REIMBURSEMENT (CROSSOVER CLAIMS).