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 70-3.120 - Limitations on Payment of Out-of-State Nonemergency Medical Services

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment adds services provided via
				  Telemedicine and Developmental Disabilities waiver Assistive Technology to the
				  list of services that are exempt from the requirement for prior authorization
				  of nonemergency MO HealthNet-covered services for out of state providers. This
				  amendment also changes the expiration of out-of-state nonemergency prior
				  authorizations for transplant services from one hundred eighty (180) days to
				  three hundred sixty-five (365) days from the date the out-of-state transplant
				  services are approved.
(1) All
				nonemergency, MO HealthNet-covered services, except for those services exempted
				in section (6) of this rule, which are to be performed or furnished
				out-of-state for eligible MO HealthNet participants and for which MO HealthNet
				is to be billed, must be prior authorized in accordance with policies and
				procedures established by the MO HealthNet Division before the services are
				provided.
(2) Nonemergency
				services, for the purpose of the prior authorization requirement, are those
				services which do not meet the definition of emergency. Emergency services are
				defined as those services provided in a hospital, clinic, office, or other
				facility that is equipped to furnish the required care, after sudden onset of a
				medical condition manifesting itself by acute symptoms of sufficient severity
				(including severe pain) that the absence of immediate medical attention could
				reasonably be expected to result in a) placing the patient's health in serious
				jeopardy, b) serious impairment to bodily functions, or c) serious dysfunction
				of any bodily organ or part.
(3)
				Out-of-state is defined as not within the physical boundaries of Missouri.
				Border-state providers of services (those providers located in Arkansas,
				Illinois, Iowa, Kansas, Kentucky, Nebraska, Oklahoma, and Tennessee) will be
				considered as being on the same MO HealthNet participation basis as providers
				of services located within Missouri for purposes of administration of this
				rule, except providers as defined in sections
				198.006(14) and
				(23), RSMo.
(4) The out-of-state provider of services
				must meet the requirements for participation in the MO HealthNet program and
				have a state-approved participation agreement in effect in order to receive
				reimbursement for any covered service, emergency or nonemergency.
(5) The patient's attending physician is
				responsible for obtaining prior authorization of the services s/he believes to
				be medically necessary.
(A) Failure to obtain
				prior authorization for the services shall result in no payment by the MO
				HealthNet program.
(B) All prior
				authorization requests must be submitted in accordance with policies and
				procedures established by the MO HealthNet Division as stated in the respective
				MO HealthNet Provider Manual which is 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/
,
				January 7, 2022. This rule does not incorporate any subsequent amendments or
				additions.
(C) Prior authorization
				by the MO Health-Net agency shall approve the medical necessity of the covered
				services to be performed only. It shall not guarantee payment as the
				participant must be eligible on the date the service was provided.
(D) Prior authorization expires one hundred
				eighty (180) days from the date a specific service was approved by the state,
				except transplant services. Prior authorization for transplant services will
				expire three hundred sixty-five (365) days from the date the services were
				approved by the state.
(E) All
				requests for prior authorization must be submitted to the Participant Services
				Unit of the MO HealthNet Division. The physician who is referring the patient
				for the nonemergency services must call or write the MO HealthNet Division for
				authorization.
(F) Telephone prior
				authorizations may be granted.