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 70-3.180 - Medical Pre-Certification Process

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment adds clarifying language,
				  updates material incorporated by reference, and updates outdated
				  terms.
PURPOSE: This rule establishes the medical
				  pre-certification process of the MO HealthNet Program for certain covered
				  diagnostic and ancillary procedures and services prior to provision of the
				  procedure or service as a condition of reimbursement. The medical
				  precertification process serves as a utilization management tool, allowing
				  payment for services that are medically necessary, appropriate, and
				  cost-effective without compromising the quality of care provided to MO
				  HealthNet participants.
(1)
				Providers are required to obtain pre-certification for certain specified
				services as outlined in the provider manuals before delivery of services. This
				rule shall apply to diagnostic and ancillary procedures and services outlined
				in the provider manuals and provider bulletins when ordered by a healthcare
				provider, unless provided in an inpatient hospital or emergency room setting.
				This pre-certification process shall not include primary services performed
				directly by the provider. In addition to services and procedures that are
				available through the traditional MO HealthNet program, expanded services are
				available to children twenty (20) years of age and under through the Healthy
				Children and Youth (HCY) Program. Some expanded services also require
				pre-certification. Certain services require pre-certification only when
				provided in a specific place or when they exceed certain limits. These
				limitations are explained in detail in the respective MO HealthNet provider
				manuals, which are incorporated by reference and made a part of this rule as
				published by the Department of Social Services, MO HealthNet Division, 615
				Howerton Court, Jefferson City, MO 65109, and at its website at
http://manuals.momed.com/manuals/
,
				October 12, 2022. The rule does not incorporate any subsequent amendments or
				additions. This rule shall only apply to those diagnostic and ancillary
				procedures or services that are listed in the provider manuals, which are
				incorporated by reference and made a part of this rule.
(2) All requests for pre-certification must
				be initiated by an enrolled medical assistance provider and approved by the MO
				HealthNet Division. A covered service for which pre-certification is required
				must meet medical criteria established by the MO HealthNet Division's medical
				consultants or medical advisory groups in order to be approved.
(3) An approved pre-certification request
				does not guarantee payment. The provider must be enrolled and verify
				participant eligibility on the date of service.
(4) Approved services/procedures must be
				initiated or dispensed within six (6) months of the date the precertification
				approval is issued. Services/procedures initiated or dispensed after the six-
				(6-) month approval period will be void and payment denied.
(5) The pre-certification for a specific
				service is time and patient status and/or diagnosis sensitive. A denial at any
				given time shall not prejudice or impact the decision to grant a future request
				for the same or similar service.
(6) Pre-certifications for exactly the same
				service may be granted to allow provision over an extended period of time and
				may be granted for a term of not more than one (1) year.
(7) If a pre-certification request is denied,
				the MO HealthNet participant will receive a letter that outlines the reason for
				the denial and the procedure for appeal. The MO HealthNet participant must
				contact the MO HealthNet Division's Participant Services Unit within ninety
				(90) days of the date of the denial letter to request a hearing. After ninety
				(90) days, a request to appeal the pre-certification decision is
				denied.
*Original authority: 208.153, RSMo 1967, amended 1973,
					 1989, 1990, 1991, 2007 and 208.201, RSMo 1987, amended
					 2007.