Social Security Number Removal Initiative

The Medicare Access and CHIP Reauthorization Act (MACRA) requires CMS to remove Social Security Numbers (SSNs) from the current SSN-based Health Insurance Claim Number (HICN) and issue a new Medicare card with a Medicare Beneficiary Identification (MBI) number.

CMS has finalized mailing the new Medicare Beneficiary ID cards with the new MBI numbers to participants. Therefore, all Missouri Dual eligible Medicaid and Medicare participant have received their new cards.

Changes to Remittance Advice

Effective with the 4/19/19 Health Care Claim Payment/Advice (835), MO HealthNet implemented a required system change to correct what is reported as the submitted line item charge on the 835 for crossover claims. This will affect 837I (Institutional; Outpatient, Nursing Home, Inpatient, etc.) and 837P Professional (Medical, Dental) claim types.

Third Party Vendor Requesting Drug Prior Authorization

MO HealthNet does not accept drug prior authorization requests from third party vendors including, but not limited to, CoverMyMeds and ZAPPRX. All requests must originate from the prescriber’s office or pharmacy. Additionally MO HealthNet will not provide any participant or claims information to third party vendors nor accept information or documentation from a third party vendor. Providers may contact Pharmacy Administration at (573) 751-6963 if they have questions.

NADAC Pricing Inquiries

Providers may contact the NADAC Help Desk for support of the NADAC survey, to request review of a NADAC rate, or to provide notification of recent drug price changes not reflected in posted NADAC files.

he NADAC Help Desk may be contacted through the following means:

Participants with Other Insurance Coverage

When you verify eligibility for a MO HealthNet participant, you may be surprised to learn the participant has commercial insurance, which includes Medicare Part C plans, in addition to MO HealthNet benefits. Individuals who have commercial health insurance may still be eligible for MO HealthNet benefits. Commercial insurance will always be the first source of payment as MO HealthNet is the payor of last resort.

Reimbursement Issues – Pricing Inquiry Process

MO HealthNet providers billing pharmacy claims with reimbursement issues must contact Pharmacy and Clinical Services at (573) 751-6963 prior to dispensing. Reimbursement will be reviewed and if MO HealthNet determines a pricing update is needed, it will be made effective the date of review. If additional review is necessary, the provider must submit the MAC Pricing Inquiry Worksheet. The worksheet may only be submitted when instructed by MO HealthNet and only for the drug(s) specified.

Immunizations for Dual Eligible Participants

MO HealthNet providers billing vaccines for dual eligible participants shall bill Medicare for all vaccines. Vaccine coverage under Medicare Part B includes the pneumococcal, influenza, and Hepatitis B vaccines for individuals at high or intermediate risk, and vaccines directly related to the treatment of an injury or direct exposure to a disease or condition. Other vaccines not covered by Part B are covered by Medicare Part D (pharmacy benefit). When a provider cannot bill the Part D plan directly, the vaccine should be dispensed at a pharmacy.

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