Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 4 - Conditions of Participant Participation, Rights and Responsibilities › Section 13 CSR 70-4.030 - Participant Liability for Medical Services Not Reimbursable to the Provider by the MO HealthNet Agency

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule establishes the guidelines for
				  determination of participant liability for medical services not reimbursable to
				  the provider by the MO HealthNet agency.
(1) When an enrolled MO HealthNet provider
				provides an item or service to a MO HealthNet participant eligible for the item
				or service on the date provided, there shall be a presumption that the provider
				accepts the participant's MO HealthNet benefits and seeks reimbursement from
				the MO HealthNet agency in accordance with all of the applicable MO HealthNet
				rules. This presumption shall be overcome only by written evidence of an
				agreement between the provider and the participant indicating that MO HealthNet
				is not the intended payor for the specific item or service but rather that the
				participant accepts the status and liabilities of a private pay patient. All
				third-party resource benefits must be exhausted before payment will be made by
				the division for the item or service rendered to that participant. For purposes
				of this rule, neither the provider nor the participant shall be required to
				exhaust all third-party resources in those situations where the provider or
				participant elect not to pursue contingent liability from a third-party
				tortfeasor. Both the provider and the participant have an affirmative duty to
				report the existence of contingent liability to the MO HealthNet Division and
				the participant has the duty to cooperate with the MO HealthNet Division if the
				division elects to pursue the contingent liability.
(2) When an item or service is rendered to a
				MO HealthNet participant who was eligible for the item or service on the date
				provided and provision of the item or service is billed to the MO HealthNet
				agency by an enrolled MO HealthNet provider who is not reimbursed by the agency
				for the item or service claimed, the item or service will not be the liability
				of the participant if the item or service would have been otherwise payable by
				the MO HealthNet agency at the MO Health-Net allowable amount had the provider
				followed all of the policies, procedures and rules applicable to the item or
				service as of the date provided. If the item or service is not otherwise
				payable for reasons unrelated to the actions of the provider, the participant
				is liable to the provider for payment of the item or service.
(3) The creation of a presumptive acceptance
				by a provider of the MO HealthNet benefits for a MO HealthNet covered service
				and the requirement for written evidence of an agreement to overcome
				presumptive acceptance, as established in this rule, shall not be applicable to
				services provided to a participant who is dually eligible and entitled to both
				MO HealthNet and Medicare Part B medical insurance benefits.
(4) The provisions of this rule shall apply
				to items or services provided on or after July 11, 1985.
*Original authority: 207.020, RSMo 1945, amended 1961,
					 1965, 1977, 1981, 1982, 1986, 1993; 208.152, RSMo 1967, amended 1969, 1971,
					 1972, 1973, 1975, 1977, 1978(2), 1981, 1986, 1988, 1990, 1992, 1993, 2004,
					 2005, 2007; and 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991,
					 2007.