Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 3 - Conditions of Provider Participation, Reimbursement, and Procedure of General Applicability › Section 13 CSR 70-3.105 - Timely Payment of MO HealthNet Claims

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule advises MO HealthNet providers of
				  the time frames in which they can expect payment for the service(s) they
				  provide to MO HealthNet participants. This rule implements Section 1902(a)(37)
				  of the federal Social Security Act.
PUBLISHER'S NOTE: The secretary of state has
				  determined that the publication of the entire text of the material which is
				  incorporated by reference as a portion of this rule would be unduly cumbersome
				  or expensive. Therefore, the material which is so incorporated is on file with
				  the agency who filed this rule, and with the Office of the Secretary of State.
				  Any interested person may view this material at either agency's headquarters or
				  the same will be made available at the Office of the Secretary of State at a
				  cost not to exceed actual cost of copy reproduction. The entire text of the
				  rule is printed here. This note refers only to the incorporated by reference
				  material.
(1) As used in this
				rule, unless the context clearly indicates otherwise, the following terms shall
				mean:
(A) Claim A-bill submitted by a
				provider to the MO HealthNet Division for MO HealthNet reimbursement for a
				procedure, a set of procedures, or a service rendered a MO HealthNet
				participant for a given diagnosis or a set of related diagnoses;
(B) Clean claim-A claim that can be processed
				without obtaining additional information from the provider of the service or
				from a third party. It includes a claim with errors originating in the state's
				claim system. It does not include a claim from a provider who is under
				investigation for fraud or abuse, or a claim under review for medical
				necessity;
(C) Date of payment-The
				date of the check or other form of payment;
(D) Date of receipt-The date the MO HealthNet
				Division receives the claim, as indicated by its date stamp on the
				claim;
(E) Nonpractitioner
				claim-Claims for the following services: inpatient hospital, state-operated
				mental health facility, outpatient hospital, inpatient psychiatric facility for
				individuals age twenty-one (21) and under, intermediate care facility for the
				mentally retarded (ICF/MR), home health services (personal care home and
				community-based services), family planning (rendered by a hospital-inpatient or
				outpatient), sterilization (rendered by a hospital-inpatient or outpatient),
				nursing facility; and durable medical equipment; and
(F) Practitioner claim-Claims for the
				following services: physician, dental, clinic, family planning (rendered by a
				physician, clinic or other practitioner), laboratory and X-ray services,
				prescribed drugs, early and periodic screening, rural health clinic,
				sterilization services (rendered by a physician, clinic or other practitioner),
				and other (chiropractors, podiatrists, psychologists, registered or licensed
				practical nurses providing private duty nursing services, optometrists,
				physical therapists, occupational therapists, speech pathologists, audiologists
				and Christian Science practitioners).