Electronic Submission of MO HealthNet Claims and Electronic Remittance Advices

PURPOSE: This rule implements the requirement that claims for reimbursement by the MO HealthNet program be submitted electronically and remittance advices be retrieved electronically. (1) “Electronic claim” means a claim that is submitted via electronic media. (2) Electronic submission of MO HealthNet claims for services rendered under the MO HealthNet program is required. A MO HealthNet claim may be paid only if submitted as an electronic claim for processing by the Medicaid Management Information System. (A) To utilize the Internet for electronic claim submissions, the provider must apply online via the Application for MO HealthNet Internet Access Account link. (B) Each user is required to complete this online application to obtain a user ID and password. (C) The enrolled MO HealthNet provider shall be solely responsible for the accuracy and authenticity of said electronic media claims submitted, whether submitted directly or by an agent. (D) The enrolled MO HealthNet provider shall agree that services described on the electronic media claim are true, accurate, and complete. (E) The enrolled MO HealthNet provider certifies that services described on the electronic media claim are personally rendered by the provider. (3) State-required supporting documentation (paper attachments) must be maintained at the place of service for auditing purposes. (A) The failure of the enrolled MO HealthNet provider to keep or furnish, or both, such information shall constitute grounds for the disallowance and recoupment of all applicable charges or payments. (B) The enrolled MO HealthNet provider shall be responsible for refund of any payments that result from claims being paid inappropriately or inaccurately. (C) The records shall be maintained for five (5) years, unless the records are the subject of an audit or litigation. Records that are the subject of an audit or litigation shall be maintained until the conclusion of the audit or litigation. (4) Medical record documentation shall support the medical necessity of the service being provided as well as the frequency of the service. The provider shall establish and maintain a record containing the signature of each participant of service furnished by the MO HealthNet enrolled provider or, when applicable, the signature of a responsible person made on behalf of the participant. Clinical laboratories, radiologists, and pathologists are exempt from the requirement that a MO HealthNet enrolled provider establish and maintain a record containing the signature of each participant of service. A physician’s order shall be documented in the medical record. Clinical laboratories, radiologists, and pathologists shall maintain a record of the ordering physician for a MO HealthNet service for which they request reimbursement. (A) The failure of the enrolled MO HealthNet provider to keep or furnish, or both, such information shall constitute grounds for the disallowance and recoupment of all applicable charges or payments. (B) The enrolled MO HealthNet provider shall be responsible for refund of any payments that result from claims being paid inappropriately or inaccurately. (C) The records shall be maintained for five (5) years, unless the records are the subject of an audit or litigation. Records that are the subject of an audit or litigation shall be maintained until the conclusion of the audit or litigation. (5) The provider shall keep such records, including original source documents, as are necessary to disclose fully the nature and extent of services provided to participants under the MO HealthNet program and to furnish information regarding any payment of claims for providing such services as the MO HealthNet Division, or its designee, may request. The enrolled MO HealthNet provider agrees that the service was medically necessary for the treatment of the condition as indicated by the diagnosis and shall maintain records, including source documents, to verify such. (A) The failure of the enrolled MO HealthNet provider to keep or furnish, or both, such information shall constitute grounds for the disallowance and recoupment of all applicable charges or payments. (B) The enrolled MO HealthNet provider shall be responsible for refund of any payments that result from claims being paid inappropriately or inaccurately. (C) The records shall be maintained for five (5) years, unless the records are the subject of an audit or litigation. Records that are the subject of an audit or litigation shall be maintained until the conclusion of the audit or litigation. (6) The enrolled MO HealthNet provider must identify and bill third party insurance and Medicare coverage prior to billing MO HealthNet. (7) Sufficient security procedures must be in place to ensure that all transmissions of documents are authorized and protect participant specific data from improper access. (8) The provider is responsible for assuring that electronic billing software purchased from any vendor or used by a billing agent complies with billing requirements of the MO HealthNet program and shall be responsible for modifications necessary to meet electronic billing standards. (9) The enrolled MO HealthNet provider agrees to accept as payment in full the amount paid by MO HealthNet for the electronic media claims submitted for payment. (10) The submission of an electronic media claim is a claim for MO HealthNet payment. (A) Any person who, with intent to defraud or deceive, makes, causes to be made, or assists in the preparation of any false statement, misrepresentation, or omission of a material fact in any claim or application for any claim, regardless of amount, knowing the same to be false, is subject to civil or criminal sanctions, or both, under all applicable state and federal statutes. (11) “Electronic remittance advice” means a remittance that is retrieved via electronic media. (12) The enrolled MO HealthNet provider agrees to retrieve his/ her remittance advice via electronic media. (A) To utilize the Internet for electronic remittance advice retrieval, the provider must apply online via the Application for MO HealthNet Internet Access Account link. (B) Each user is required to complete this online application to obtain a user ID and password. (C) Sufficient security procedures must be in place to ensure that all transmissions of documents are authorized and protect participant specific data from improper access. AUTHORITY: sections 208.153 and 208.201, RSMo Supp. 2009.* Original rule filed April 29, 2005, effective Nov. 30, 2005. Amended: Filed June 1, 2010, effective Dec. 30, 2010. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007 and 208.201, RSMo 1987, amended 2007.