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Thanks for reading the 2025 Second Quarter edition of the MO HealthNet Provider Newsletter.
Our goal is to open the lines of communication between the MO HealthNet Division (MHD) and healthcare providers.
We're glad you're here!
In This Edition:
The Department of Social Services (DSS) is working to respond to the national and statewide fentanyl crisis. This includes services to families impacted by fentanyl in rural communities and where service providers are not always available, particularly in the field of drug testing and mobile drug testing services.
DSS Children’s Division (CD) is looking for vendors to respond to the Invitation for Bid for Children’s Treatment Services. Through this contract, CD will serve families in many ways, such as therapeutic services, drug testing, and parent aide services. CD desires to contract for more than 20 services.
We encourage vendors across Missouri to respond to the Invitation for Bid; however, there are some areas in Missouri with a greater need for drug testers and mobile testers in addition to the other services mentioned above. Areas we especially hope to see responses from include Adair, Andrew, Atchison, Bates, Barton, Benton, Buchanan, Carroll, Cedar, Chariton, Clark, Cooper, Dade, Dunklin, Franklin, Gasconade, Gentry, Grundy, Harrison, Henry, Holt, Knox, Lewis, Lincoln, Linn, Macon, Marion, Mercer, Monroe, Mississippi, Nodaway, Osage, Pike, Putnam, Ralls, Ray, Schuyler, Shelby, St. Clair, Sullivan, Vernon, and Worth counties.
Find the Children’s Treatment Services Invitation for Bid on the DSS Bid Proposals webpage.Â
Reporting Incurred Charges for Spend Down Made Easier for Providers and Participants
The new and simplified online MO HealthNet Spend Down Provider form allows providers to verify qualified medical expenses to meet a participant's spend down. The online form should be completed when the provider has a MO HealthNet participant who has qualified for spend down and an actual bill is not yet available. By completing the online form, providers verify that the participant has incurred, and personally owes payment for services they provided.
The new online form replaces the previously used MO HealthNet Spend Down Provider PDF form (MO 866-4501). However, if a provider still requires the PDF form, they should access the new MO HealthNet Spend Down Provider form (IM-29PROV).
Another new online form allows participants to provide proof of qualifying expenses and identify which months the expenses should be applied to. Participants should access the online MO HealthNet Spend Down Participant form to submit qualifying expenses.
For more information on the Spend Down Program, watch the MO HealthNet Provider Training Calendar for the Eligibility and Spend Down webinar. This training that offers over 100 seats fills fast! To review the information presented during this webinar, visit Eligibility and Spend Down training.
For additional resources, refer to the Education and Training Resources page and/or sign up for a live webinar by accessing our Provider Training Calendar or email MHD.Education@dss.mo.gov for more information.
Provider Training Scheduled Posted, April - June 2025
MHD Education and Training has posted the 2nd Quarter 2025 Provider Training Schedule. These live webinars can also be found on the Provider Training Calendar located on the Education and Training page.
For a recap of the information covered during our live webinars, review the MO HealthNet Provider Overview Guide.  For additional resources refer to the Education and Training Resources page.
Email MHD.Education@dss.mo.gov for more information.
Psychotherapy for Crisis
Psychotherapy for crisis is used to offer immediate, short-term help to patients who experience an event that produces emotional, mental, physical, and behavioral distress or problems. A crisis can refer to any situation in which the patient perceives a sudden loss of the ability to use effective problem-solving and coping skills. Psychotherapy for crisis aims to reduce the intensity of the patient's emotional, mental, physical, and behavioral reactions to a crisis and help the patient return to their level of functioning before the crisis. Psychotherapy for crisis is appropriate for children, adolescents, and younger and older adults. Psychotherapy for crisis must be a face-to-face contact to defuse a situation of immediate crisis.
Psychotherapy for crisis services cannot be scheduled in advance. If crisis occurs during an individual psychotherapy session, providers can choose to either bill psychotherapy for crisis or bill the appropriate individual psychotherapy code. However, providers should not bill for individual psychotherapy and crisis on the same day. To bill for psychotherapy for crisis, use the following guidelines:
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Procedure Code
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 Description
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90832
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If crisis is less than 30 minutes; maximum quantity one unit per day
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90839
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Initial 30 to 74 minutes; maximum quantity one unit per day
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90840
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Additional blocks of time up to 30 minutes each beyond the first 74 minutes; maximum quantity
three units per day
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There is a monthly limit on 90832 of 5 per month (5 per month of 90832, 90834, or 90837 or combination).
New Beneficiary Advisory Council
On May 10, 2024, the Centers for Medicare & Medicaid Services (CMS) published the Ensuring Access to Medicaid Services Final Rule, 89 FR 40542. This Rule required MHD to establish a Beneficiary Advisory Council (BAC). The MO HealthNet Community Connection will transition to meet the requirements of the BAC by July 2025.
The Community Connection will be a dedicated forum for people with lived experience of the Medicaid program to advise MHD on matters related to policy development and the effective administration of the program. Be on the lookout for how participants may apply and possibly be chosen to join the MO HealthNet Community Connection in the coming months! For questions, email MHD.CommunityConnection@dss.mo.gov.
Help Us Notify Participants Their FSD Benefits Portal Account Must Be Updated by April 15
DSS Family Support Division (FSD) Benefits Portal allows participants to complete their MO HealthNet annual renewals, check the status of their benefits, upload documents, and more.
FSD is transitioning all participant FSD Benefits Portal accounts to Single Sign-On (SSO) to enhance security and streamline access. With this transition, participants will be able to login to other official state of Missouri sites that use SSO using the same username and password. To ensure continued access to the FSD Benefits Portal, participants need to transition their accounts by April 15, 2025. If their accounts have not been transitioned by this date, they will be deleted, and the participant will have to create a new account to access their information in the FSD Benefits Portal.
When a participant attempts to log in to the Portal prior to April 15, they will be required to complete the necessary steps to transition their account. Also, participants with a FSD Benefits Portal login will receive an email with instructions. However, FSD would appreciate your help sharing this information with your participants. Â Please direct participants to How to Convert Your Account for the information they need in order to continue having access to their benefit information on the Portal.
Effective November 1, 2024, MHD enrolled providers who provide obstetric care/services, primary care, and emergency care to MHD participants were introduced to the new Notification of Pregnancy (NOP) and Risk Screening Portal. For more information, review the NOP and Risk Screening Bulletin.
During the NOP screening, the provider is asked to make a "warm handoff" by informing the member that she will be contacted by her Managed Care health plan for the purpose of offering the various types of assistance mentioned above. MHD developed a rack card with resources, available from all Managed Care health plans for providers of OB visits and those providing pregnancy tests and follow-up information.
As new providers begin to take part in the NOP process, MHD wants to ensure that they understand the vital role they play in educating their patients to expect a call from their Managed Care health plan. The call not only connects the member with benefits and supports, including care management, but also works to assist the member with any of the risk factors that were identified during their NOP screening.
MHD and the Managed Care health plans will continue to provide education and training to providers, including Local Public Health Agencies, regarding the importance of our NOP initiative. The long-term goal is that earlier connection to resources and assistance will result in better birth outcomes for mom and baby.
After reviewing the first three months of data since the state transitioned to using its new NOP and Risk Screening Portal statewide, MHD and its Managed Care health plans continue to see a positive impact. A few of the early goals of the initiative were:
Better Contact Rates: MHD wants to ensure that the Managed Care health plans are reaching their members when they contact them to offer pregnancy-related benefits and supports. Â
Better Care Management Engagement: Care management, which is tailored to the needs of the individual member, can be critical in helping higher-risk women navigate their pregnancies. Care managers also help to identify community resources.
Better Participation: MHD and the Managed Care health plans want to drive greater participation in additional health benefits (breast pumps, belly bands, home-delivered meals, and car seats) that are specifically designed to support pregnant and postpartum moms that are currently underutilized.
From the data below, we can see that the contact rate improved dramatically during the pilot period, from 29.3% to 59.8%. This has fallen off slightly to 54.3% upon statewide implementation.
The rate of engagement in care management services increased slightly during statewide implementation, up to 33.6%, well above the prior average rate of 17%.
 Medically Unlikely Edits (MUEs) in Medical BillingÂ
As the largest payer for health care services, the Centers for Medicare & Medicaid Services (CMS) programs are a target for improper payments and schemes to defraud federal health care programs. Accurate coding is a critical aspect of assuring proper payments. To address this, CMS developed and implemented the National Correct Coding Initiative (NCCI) to promote correct coding methodologies and control improper coding leading to inappropriate payment in the Medicare program. The NCCI program has since been expanded to include Medicaid.
The NCCI program includes three types of edits:
- Procedure-to Procedure (PTP) edits
- Medically Unlikely Edits (MUEs)
- Add-On Codes (AOC)
MO HealthNet implemented the PTP edits in 2013 and MUEs in 2022. AOC edits are optional for state Medicaid agencies and MO HealthNet does not use them.
MUEs prevent payment for an inappropriate number/quantity of the same service on a single day. An MUE for a Healthcare Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) code is the maximum number of units of service under most circumstances reportable by the same provider for the same beneficiary on the same date of service. CMS developed MUEs to reduce the paid claims error rate. Not all HCPCS/CPT codes have a MUE.
If you report a code with units greater than the MUE value assigned, the line and/or claim will be denied. If there is no MUE for a code, providers should use the MHD maximum quantity on the MHD Fee Schedule.
For questions regarding MUEs, contact Provider Communications via eMOMED or by calling (833) 222-7916.
Managed Care Health Plan Additional Benefits
As a provider with patients enrolled in MO HealthNet Managed Care health plans, sometimes it is difficult to remember what services and benefits each member may have access to.
For instance, did you know that pregnant members with Healthy Blue, Home State Health, and United Healthcare, can all receive a free electronic breast pump? Or that members who just delivered a baby can receive free healthy meals? Or that members may be eligible for gym memberships, blood pressure cuffs, Weight Watchers Program membership, or even equine therapy?
For a quick guide on what services are covered and the additional health benefits each of the MO HealthNet Managed Care health plans offer, refer to the Managed Care Health Plans Comparison Guide. Members can also Contact their Managed Care health plan directly for more information.
MO HealthNet's Primary Care Health Home (PCHH) initiative
PCHH provides intensive care coordination and care management while addressing social service needs for a medically complex population. There are currently more than 40 participating organizations with over 200 primary care health center locations that make up the MO HealthNet PCHH providers.
The PCHH providers enroll MO HealthNet participants who have two or more specific chronic health conditions or one specific chronic condition that puts them at risk for another chronic condition. These conditions include anxiety, asthma, chronic pain, chronic obstructive pulmonary disease (COPD), depression, developmental disabilities, diabetes, heart disease, obesity, overweight, substance use disorders, and tobacco use/nicotine dependency. The program emphasizes advanced team-based care with the integration of both primary care and behavioral health clinicians working side-by-side to achieve more rapid health outcomes in the most impactful patient-centered manner that supports the well-being of patients, as well as providers.
PCHH providers enroll new patients every month and referrals can be made by the primary care provider or patient, but there are many referral mechanisms including hospital staff, school nurses, and social workers. Providers can download and share a helpful patient flyer about PCHH.
MO HealthNet Participants with Third Party Liability Coverage
Before requesting prior authorization (PA) from MHD for any medication, please verify whether the participant has any other third-party liability (TPL). Providers must utilize all available third-party benefits, including exploring therapeutic alternatives, pursuing prior authorization through the third-party payer, and utilizing a preferred pharmacy before MHD will review PAs for participants with TPL. It is important to remember that obtaining PA approval from MHD does not exempt it from being the payer of last resort.
MHD will review PA requests in cases where third-party payers exclude all therapeutic alternatives from their coverage. These reviews are conducted on a case-by-case basis by Pharmacy Administration, and providers are required to submit documentation of the third-party PA denial along with an appeal of the coverage exclusion. Contact Pharmacy Administration at MHD.PharmacyAdmin@dss.mo.gov or (573) 751-6963.
Additionally, dual-eligible participants receive pharmacy benefits through their Medicare Part D plan (PDP). MORx is a secondary payer following the PDP. MORx does not maintain a formulary and only covers prescription drugs already covered by the PDP. If a participant's PDP does not cover a specific medication or denies a prior authorization, MORx will not provide coverage for that medication.
On January 27, 2025, an updated Hospital Provider Manual was published to the MHD Provider Manuals site. The updates include changes to dental procedures performed in the outpatient setting, discounts on multiple surgeries, and modifier 50 bilateral procedure billing.
For questions about these updates that have already been implemented, contact Provider Communications via eMOMED or by calling (833) 222-7916.
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