Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 2 - General Scope of Medical Service Coverage › Section 13 CSR 70-2.100 - Title XIX Procedure of Exception to Medical Care Services Limitations

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment updates approving division's
				  name. Language updated and/or removed to be in line with current
				  policy.
(1) Under the
				requirements of this rule, the MO HealthNet Division may approve and authorize
				payment for the provision to a Medicaid-eligible recipient of an essential
				medical service or item that would otherwise exceed the benefit limitations of
				the medical assistance program. An administrative exception may be made on a
				case-by-case basis to limitations and restrictions. The director of the DMS
				will have the final authority to approve payment on a request made to the
				exception process. These decisions will be made with appropriate medical or
				pharmaceutical advice and consultation.
(2) Requirements for consideration and
				provision of a service as an exception to the normal limitations of Medicaid
				coverage are as follows:
(A) A physician,
				resident, intern, extern, nurse clinician, nurse practitioner or registered
				nurse (RN) acting on the behalf of the physician must certify that medical
				treatment or items of service which are covered under the Medicaid Program and
				which, under accepted standards of medical practice, are indicated as
				appropriate to the treatment of the illness or condition, have been used and
				found to be medically ineffective in the treatment of the recipient for whom
				the exception is being requested or inappropriate for that specific
				recipient;
(B) All third-party
				resource benefits must be exhausted before the Medicaid program will pay for
				any treatment or service;
(C) Any
				drug requested has been approved by the Food and Drug Administration (FDA) and
				is being prescribed for an FDA-approved indication and route of administration
				or medical literature must exist justifying the effectiveness of the drug or
				that specific diagnosis or for that specific route of administration;
(D) Any medical, surgical, or diagnostic
				service requested which is provided by a physician must be listed in the most
				recent publication of the Physicians' Current Procedural Terminology;
(E) Any individual for whom an exception
				request is made must be eligible for Medicaid on the date(s) the item or
				services are provided or in the case of retroactive eligibility approval can be
				granted if requested;
(F) The
				provider of the service must be an enrolled provider in the Medicaid program on
				the date(s) the item or services are provided;
(G) The item or services for which an
				exception is requested must be of a type and nature which falls within the
				broad scope of a medical discipline included in the Medicaid program and which
				does not represent a departure from the accepted standards and precepts of good
				medical practice;
(H) Requests must
				be made and approval granted before the requested item or services are
				provided, or not more than one (1) state working day following the provision of
				the service. Retroactive approval of coverage may be granted in cases in which
				the recipient's eligibility for Medicaid is established;
(I) All requests for exception consideration
				must be initiated by the attending physician the resident, intern, extern,
				nurse clinician, nurse practitioner or RN acting in the physician's behalf for
				an eligible recipient and must be submitted as prescribed in policy of the
				DMS;
(J) Requests for exception
				consideration, by whatever means received, must support and demonstrate that
				one (1) or more of the following conditions are met:
1. The item or service is required to sustain
				the recipient's life;
2. The item
				or service would substantially improve the quality of life for a terminally ill
				patient;
3. The item or service is
				necessary as a replacement due to an act occasioned by violence of nature
				without human interference, such as a tornado or flood; or
4. The item or service is necessary to
				prevent a higher level of care;
(K) All exception requests must represent
				cost-effective utilization of Medicaid funds. When an exception item or service
				is presented as an alternative, lesser level-of-care than the level otherwise
				necessary, the exception must be less program costly; and
(L) Reimbursement of services and items
				approved under this exception procedure shall be made in accordance with the
				Medicaid-established fee schedules or rates for the same or comparable
				services. For those services for which no Medicaid-established fee schedule or
				rate is applicable, reimbursement will be determined by the state agency
				considering costs and charges.