Outpatient Hospital Billing Tips for 340B Providers

The submission of a National Drug Code (NDC) is not required for 340B providers on outpatient hospital claims; however, MO HealthNet prefers claims be submitted with a valid Healthcare Common Procedure Coding System (HCPCS) procedure code and a valid NDC. A valid NDC and/or a valid HCPCS procedure code (not a dump code) must be billed for each medication for MO HealthNet to identify drugs dispensed. For drugs without a valid HCPCS procedure code, revenue code 0250 "General Classification: Pharmacy” should be used with the appropriate NDC.

Outpatient Hospital Facility Charges

It is important to remember when it is appropriate to bill MO HealthNet an outpatient hospital facility charge. Inappropriate billing of facility charges will result in recoupment of payments. The following information can be found in the MO HealthNet hospital provider manual which is available at http://manuals.momed.com/manuals/. Please refer to sections 13.38, 15.20, 15.21 and 15.23 for more information regarding outpatient facility charges.

Inpatient Hospital: Validation Review

Inpatient hospital admissions must be pre-certified as medically necessary by the MO HealthNet Division (MHD) review authority, Xerox Care and Quality Solutions. In addition to precertification of inpatient stays, Xerox's responsibilities include validation reviews described in 13 CSR 70-15.020(9) and in Section 13.29.F(5) of the MO HealthNet hospital provider manual available at: http://manuals.momed.com/manuals/.

Reconstructive Breast Surgery

Reconstructive breast surgery is considered a MO HealthNet covered service, if necessary to restore symmetry as recommended by the oncologist or primary care physician for the patient incident to mastectomy, as well as other documented medical necessity deemed appropriate via MO HealthNet physician consultant review.

Subscribe to Hospital