The fee schedules are updated each quarter. Pricing files are used by all MO HealthNet Providers. A code may not be appropriate for your claim even though it is listed in the pricing file. This is especially true for the categories entitled EPSDT, Medical, and Other Medical. Please refer to your program specific manual and bulletins for correct coding.
MO HealthNet providers are categorized by the service(s) they perform for the MO HealthNet eligible participants. The service by which providers are classified will determine the procedures for which they receive MO HealthNet reimbursement. However, some Current Procedural Terminology codes may be billed by multiple provider types.
For programs not paid via a fee schedule, procedure codes will show as covered with a fee listed. If you are paid by percentage, per diem rate, etc., you will continue to be paid in that manner. Again, please refer to the program specific manual and bulletins for limitations and restrictions.
Independent Rural Health Clinic Medicare/Medicaid Interim Rate List
The Independent Rural Health Clinic (IRHC) Medicaid Interim Rate List contains the interim rate per visit that the MO HealthNet Division (MHD) will reimburse IRHCs for services provided to MO HealthNet participants. IRHCs are reimbursed on an interim basis at the rate noted on this report and a final cost settlement is determined on the facility's annual cost report. MHD reimburses IRHCs on an interim basis at the Medicare Maximum Interim IRHC Rate, unless a provider requests a lower rate. The IRHC Rate List is updated at the beginning of each calendar year to reflect the new Medicare Maximum Rate effective January 1st and is updated if needed to reflect new or terminating facilities and rate changes.
This report is for informational purposes only and MHD is not responsible for how outside parties utilize the information. The general program policies governing the MO HealthNet IRHC program are set forth in 13 CSR 70-94.010 Independent Rural Health Clinic Program. If you have any questions regarding this report or the MO HealthNet IRHC program, please contact the Clinic Policy & Reimbursement Manager of the Institutional Reimbursement Unit at 573-751-5663.
IRHCs that are contracted with a health plan to provide managed care services to MO HealthNet participants. According to the terms of the Managed Care Health Plan Contract, health plans are to reimburse IRHCs one hundred percent (100%) of the interim rate per visit noted in this report. For further information on managed care, please visit https://mydss.mo.gov/mhd/managed-care-health-plans. If you have any questions regarding the managed care program for IRHCs, please contact 573-526-4274.
Nursing Facility Rate List
This report is for informational purposes only and MHD is not responsible for how outside parties use the information. Anyone using this report should be aware of the general program policies. The policies and procedures governing the MHD nursing facility program, are set forth in the Prospective Reimbursement Plan for Nursing Facility Services. This regulation, as well as other applicable nursing facility regulations, may be accessed on the Missouri Secretary of State website.
The Nursing Facility Rate List contains information on nursing facilities participating in the MO HealthNet program. The information in this report is current as of the date on the report and is true and accurate to the best of the MO HealthNet Division's (MHD) knowledge. This report is updated when global per diem rate adjustments applicable to all nursing facilities are implemented by MHD. The effective dates in the column headings correspond to changes in the nursing facility regulations that resulted in global, industry-wide per diem rate changes. This report contains the rates MHD has reimbursed, or is currently reimbursing nursing facilities for services provided to MO HealthNet participants. However, there may be circumstances for individual facilities where the effective date of the rate may not correspond to the date in the column such as for new nursing facilities or facilities that had their prospective rate established. The legend explains the rate type, entity code, and the other notations included in the report. Please note, payments to facilities based on rates that are not final (i.e., rate is under appeal or facility is operating under an interim rate) may be subject to retroactive settlement, including recoupment. MHD will make any retroactive settlements to the provider of record, regardless of the provider for the applicable dates of service.
Hospice providers that furnish services to MHD participants in a nursing facility will be reimbursed 95% of the nursing facility’s per diem rate for room and board. Hospice providers operating in nursing facilities without a final rate are also subject to retroactive settlement. The general policies and procedures governing the MHD hospice program is set forth in Hospice Services Program and may be accessed on the Missouri Secretary of States website.
If you have questions regarding this report or the Nursing Facility Program, please contact the Nursing Facility Policy & Reimbursement Manager of the Institutional Reimbursement Unit at 573-751-5663.