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Thank you for taking the time to read the MO HealthNet Provider Newsletter. We value your partnership and the vital work you do every day. We’re glad you’re here and look forward to keeping you informed.
For questions, email the MO HealthNet Division (MHD): Ask.MHD@dss.mo.gov.
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Rural Health Transformation Program (RHTP) Updates
RHTP is a landmark $50 billion federal initiative designed to strengthen and modernize healthcare in rural communities across America.
This five‑year program is not a short‑term grant. It represents a long‑term opportunity to build a more resilient, sustainable rural healthcare system. The state of Missouri was awarded more than $216 million in funding for the first year of the RHTP.
Strategy
Missouri’s rural health strategy focuses on the following priorities:
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Innovative Payment Models: Implementing financial structures that support providers and reward improved patient outcomes.
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Strategic Alignment: Strengthening partnerships with other Missouri agencies to improve provider coordination, service delivery, and access for individuals and families in rural communities.
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Stakeholder Integration: Collaborating across stakeholder groups, including CMS, health associations, and higher education institutions.
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Accountability: Managing a diverse RHTP portfolio with clear performance measures and transparent reporting.
Updates
- RHTP budget was approved.
- RHTP will create community hubs, supported by regional networks, as the backbone that connects every rural resident to care. The Hub Map will be announced soon.
- A new Rural Health Transformation Office (RHTO) has been established within MHD. The RHTO was created to provide centralized leadership, coordination, and technical support for rural hospitals, clinics, and behavioral health providers participating in the RHTP.
- Joseph (Joe) Miller has been appointed as Director of the RHTO. Miller has spent his career supporting rural providers, specifically partnering with Federally Qualified Health Centers (FQHCs) and Certified Community Behavioral Health Centers (CCBHCs) to streamline and expand access to essential care. Miller began his role on March 30, 2026.
Please visit the DSS Rural Health Transformation webpage for ongoing updates.
For questions, contact DSS.RHTP@dss.mo.gov.
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New Pharmacy Director
We are pleased to announce the appointment of Mangesh Joglekar, MBA-HCA, MS–HPMA, PharmBS, SSGB, RPh, as the new Director of Pharmacy for MO HealthNet, where he will lead the MHD Pharmacy Unit.
Mangesh brings extensive experience in Medicaid policy, clinical program development, and fiscal stewardship, most recently serving as the Chief of Clinical Services for Maryland Medicaid. His strong leadership, collaborative style, and proven commitment to advancing high‑quality, cost‑effective care will support MO HealthNet’s ongoing efforts to better serve Missouri’s most vulnerable residents.
Please join us in welcoming Mangesh to Missouri and congratulating him on this important role. We look forward to the expertise and vision he will bring to MHD.
Updated Regional Office Maps
The MHD Provider Forms webpage has been updated to include links to the following revised Department of Health and Senior Services (DHSS) regional office maps:
These maps offer regional office contact information for participants and providers who have participant referrals or questions about DHSS home and community-based services offered in their area, as well as Department of Mental Health (DMH) regional centers.
For details, refer to Hot Tip: Updated DHSS Regional Office Maps.
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MHD Expands Access to New Sickle Cell Gene Therapies
MHD is participating in a new federal model that helps cover the cost of groundbreaking gene therapies for sickle cell disease. Under this approach, drug manufacturers are paid in full only if the treatment works — protecting taxpayer dollars while expanding access to life‑changing care.
About 30 MO HealthNet participants are expected to receive the therapy in the first three years, with early results showing promise.
Read the full article: Medicaid Tries New Approach With Sickle Cell - KFF Health News
MHD Education & Training: Transforming Provider Support
The MHD Education and Training Unit is comprised of two key teams:
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Managed Care (MC) Liaisons – Assists providers with issues that cannot be resolved directly with the MC health plans
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Education Specialists – Educates MO HealthNet providers on billing, policy, processes, and more
Managed Care (MC) Liaisons
Since 2023, the number of issues handled by MC Liaisons has decreased by more than 50%. This decrease can be attributed to several factors, including improvements to Third Party Liability (TPL) and eligibility processes, providing additional trainings, customer service, the MC plans educating providers when there is an issue, and the teamwork of MHD and the MC plans on larger issues.
If providers are unable to resolve an MC issue directly with a health plan, they should contact a MC Liaison by completing a MC Provider Request for Information.
Education Specialists
MHD Education Specialists have trained over 40% more providers in 2025 than in 2023. Training attendees are asked to complete evaluations. Evaluation responses have increased by 60% since 2023. The information provided in these evaluations is invaluable and improves MHD training content and processes.
The MHD Education and Training team offers virtual and in-person training to providers and partners. Topics include navigating provider resources, proper billing methods, procedures for claim filing via eMOMED, and other requested topics. All trainings include a live Q&A.
To learn more:
New Eligibility and Spend Down Resource
MHD Education and Training created a new self-paced training course covering MO HealthNet Eligibility and the Spend Down Program. Providers can review this course for policy, process, step-by-step eMOMED instructions, participant scenarios, and more.
The upcoming Eligibility and Spend Down webinar is on May 26, 2026. Register soon, this class fills up quickly!
Administrative Lock-In Emergency Services Process
Some MO HealthNet participants are restricted or locked in to authorized MO HealthNet providers for certain services to help the participant use the MO HealthNet Program properly. When the participant has an administrative lock-in provider, the provider’s name and telephone number are identified on eMOMED when verifying eligibility.
Payment for outpatient hospital or physician services for a locked-in participant is only made to the authorized provider, unless the payment is for emergency services or authorized referral services.
Emergency services
Emergency services are considered for payment only when the claim includes medical records documenting the emergency circumstances.
When emergency services are administered to a locked-in participant, the paper claim, with EMERGENCY noted at the top of the claim and medical records supporting the emergency room service must be submitted.
Referrals
When a physician is the designated/authorized provider, they are responsible for the participant’s primary care and for making necessary referrals to other providers as medically indicated.
When a referral is necessary, the authorized physician must complete a Medical Referral Form of Restricted Participant (PI-118). This referral is only good for 30 days from the date of service (DOS). This form must be submitted by the unauthorized provider.
To learn more:
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2026 Healthcare Common Procedure Coding System (HCPCS)
Providers may now resubmit/adjust claims for proper payment using the corrected 2026 HCPCS codes. MHD requires the 2026 versions of the Current Procedural Terminology (CPT) and the HCPCS medical code sets. The 2026 versions apply to all MO HealthNet Fee-for-Service (FFS) and Managed Care enrolled providers. Providers should reference the appendix of the CPT and HCPCS books for a summary of the additions, deletions, and revisions.
For dates of service prior to January 1, 2026, claims must be billed with the 2025 version of CPT and HCPCS codes and modifiers. HCPCS codes that were deleted by the Centers for Medicare & Medicaid Services (CMS) for 2026 are not payable for dates of service January 1, 2026, and after. Claims billed with these codes will be denied. Claims submitted and paid for dates of service on or after January 1, 2026 using deleted codes may be recouped by MHD.
If you have questions concerning how to submit a claim adjustment, please contact Provider Communications using the Provider Communications Management secure direct messaging option in eMOMED or by phone at (833) 222-7916, option 3.
For MHD coverage information, including fees and restrictions, reference the MHD Fee Schedule. The Fee Schedule will not be updated until after the HCPCS system updates are completed.
To attend a program specific webinar to assist with navigating the MHD website and how to read the Fee Schedule, visit the Provider Training Calendar.
Prior Authorization (PA) for Cardiology and Radiation Therapy
Effective with dates of service on or after February 2, 2026, MHD's Radiology Benefit Manager, HealthHelp, began managing Cardiology, Radiation Therapy Services, and Automatic External Defibrillator Garments. PAs are required for the newly added procedure codes.
For more information, review the Revised Prior Authorization for Cardiology and Radiation Therapy Bulletin.
Electronic Visit Verification (EVV) Aggregator Solution (EAS) Next Phase of Claims Validation
The soft launch of claims validation for services requiring EVV on January 7, 2026, was a success. MHD has been matching submitted claims for personal care and home health care services to visits in the EAS. Most claims are finding matches in EAS, indicating that they would be paid following the implementation of hard edits.
Given the success of the soft launch, hard edits for personal care service providers delivering EVV-required services authorized by the DHSS, Division of Senior and Disability Services (provider types 26 and 28), will proceed as scheduled on April 1, 2026. After this implementation, claims that do not match visits in EAS will be denied payment.
Refer to Hot Tip: EVV Claims Validation: Key Updates for Providers.
For more information on claims validation, please refer to the EVV provider page or contact Ask.EVV@dss.mo.gov.
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Structured Family Caregiving Waiver Daily Documentation Reminder
The Structured Family Caregiving Waiver (SFCW) was developed to provide a comprehensive and cost-effective Home and Community-Based Service (HCBS) option for individuals ages 21 and older diagnosed with Alzheimer's or a related disorder who wish to live at home in the community and would otherwise require institutionalization in a nursing facility.
SFCW caregivers must adequately document on a daily basis the services provided to participants and submit this documentation to the provider agency to prove services were rendered. This daily documentation to support services rendered includes caregiver notes that record the participant’s status, any updates or significant changes in their health or behavior, participation in community-based activities, medication management records, and other notable or reportable events.
For more information, refer to:
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Provider Reminder: OTC Products Covered by MHD
Select over-the-counter (OTC) products are reimbursable through the MHD Pharmacy Program with a prescription. Although OTC items do not require a prescription for public sale, a prescription is necessary for MO HealthNet participants to obtain coverage. Please refer to the Pharmacy Clinical Edits and Preferred Drug Lists OTC Covered Products List for details on eligible items.
Note: MHD requires a 90-day supply for select OTC prescriptions. The Pharmacy Clinical Edits and Preferred Drug Lists Extended Supply Fiscal Edit contains the complete list of products with this requirement. Additionally, OTC preparations included in the nursing home per diem cannot be billed to the MHD Pharmacy Program; they are the nursing home's responsibility.
For questions, contact MHD.PharmacyAdmin@dss.mo.gov or call (573) 751-6963.
Training Opportunities
The MO HealthNet Pharmacy Program has three different advisory committees:
- Drug Prior Authorization Advisory Committee
- Drug Utilization Review Board
- Advisory Council on Rare Diseases and Personalized Medicine.
For more information, please visit the MO HealthNet Pharmacy Advisory Committee page. The advisory committees meet quarterly, and MHD invites providers to join to learn about upcoming policy changes. Pharmacists can also earn Missouri Board of Pharmacy-approved Continuing Education (CE) credit for attending
Upcoming meetings:
- Advisory Council on Rare Diseases and Personalized Medicine: April 8, 2026
- Drug Prior Authorization Advisory Committee: April 14, 2026
- Drug Utilization Review Board: April 15, 2026
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Need to Contact the Managed Care Health Plans? |
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Thank you for serving MO HealthNet participants. We appreciate your partnership and look forward to connecting with you next quarter. For any questions, contact Ask.MHD@dss.mo.gov.
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