Long-Acting Reversible Contraception (LARC) Devices for Dual Eligible Participants

The MO HealthNet Division (MHD) reimburses providers for long-acting reversible contraception (LARC) devices for dual eligible participants even if their Medicare benefit does not cover it. The MHD currently has a Fiscal Edit in place to prevent duplicate billing of non-oral contraceptive products. Providers are responsible for checking criteria to confirm their patient’s eligibility for a LARC device prior to billing MHD.

Proper Billing for Drugs Billed to MO HealthNet

MO HealthNet Division (MHD) will begin desk audits of providers to ensure proper billing units are used for drugs billed to MO HealthNet. Providers are responsible for proper billing of claims as outlined in Section 15 of the Pharmacy Provider Manual (http://manuals.momed.com/collections/collection_pha/print.pdf). Billing a claim with the incorrect unit of measure may result in greater compensation than entitled.

COVID-19: COVID Testing and Specimen Collection Codes

COVID-19: COVID Testing and Specimen Collection Codes – Updated

The MO HealthNet Division (MHD) continues to monitor Centers for Medicare & Medicaid Services (CMS) guidance related to COVID-19 testing and specimen collection. The tables below lists the COVID-19 testing and specimen collection procedure codes MHD currently covers as well as who can bill each code, effective dates, max units, and rates.

COVID-19: Oral Antiviral Treatment

On December 22, 2021, the FDA issued an emergency use authorization (EUA) for Pfizer’s COVID-19 treatment, Paxlovid. Paxlovid is indicated for the treatment of mild-to-moderate coronavirus disease (COVID-19) in adults and pediatric patients (12 years of age and older weighing at least 40 kilograms) with positive results of direct SARS-CoV-2 testing and who are at high risk for progression to severe COVID-19, including hospitalization or death.

COVID-19: At-Home COVID Test Coverage

Effective November 1, 2021, MO HealthNet will cover at-home COVID-19 tests through the Fee-for-Service Pharmacy Benefit. MO HealthNet will reimburse the lesser of the MAC rate plus a dispensing fee or the Usual & Customary submitted by the provider. At-home tests must be prescribed by a MO HealthNet provider. MO HealthNet will monitor the use of at-home tests to prevent potential waste. Below are the covered at-home tests, including the MAC price per unit.

RSV Prophylaxis – Update #3

The MO HealthNet Division (MHD) is aware of the sustained increased positivity of RSV virology in the State of Missouri outside of the regular RSV season. MHD has considered RSV prophylaxis requests starting in July 2021. Effective September 28th: participants who meet the clinical edit requirements, including age restrictions, may receive approval for up to 6 doses. This includes 1 dose for October and up to 5 doses during the regular Missouri RSV season (November thru April). Previously approved doses given from July through September are not considered to be part of the 6 doses.

RSV Prophylaxis – Update #2

The MO HealthNet Division (MHD) is aware of the sustained increased positivity of RSV virology in the State of Missouri. MHD will consider RSV prophylaxis prior authorization requests during July, August & September. For participants who meet the clinical edit requirements, approval will include up to three doses.

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