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Handling Suspended Personal Care Claims

If your claim for personal care services enters a "Suspended" status, the most important thing to do first is wait. A suspended status is a normal part of the processing cycle. In most cases, the system is simply verifying data, and the claim will resolve itself within a few business days—moving automatically to either "To Be Paid" or "To Be Denied."

If a claim remains suspended or is denied, use the following tips to identify and correct the issue.

Check Your Units in Fusion

Before you resubmit your claim, ensure you aren't billing for more than what is authorized.

  • The Rule: Check Fusion to see how many units the participant has left for the month in their current care plan. If you bill for 100 units but only 90 are authorized, the claim will suspend and eventually deny.
  • The Fix: If denied for units, use the “Copy Claim Original” feature in eMOMED to adjust the units so they match the authorized amount.

Ensure Information Matches (EVV vs. eMOMED)

The information in your Electronic Visit Verification (EVV) system must be an exact match to what is entered in eMOMED. If there is a mismatch, the claim will likely stay suspended or be denied. Double-check these details in both systems:

  • National Provider Identifier (NPI) and Taxonomy Code
  • MO HealthNet Participant ID (DCN)
  • Procedure Codes and Modifiers
  • Total Units billed
  • Units

If you notice a mismatch between the EVV system and eMOMED, correct the issue in the appropriate system and then resubmit the claim.

Confirm Verification (EAS)

Before you submit a claim, make sure the visit is actually ready in the EVV Aggregator Solution (EAS).

  • Even if a visit shows up in your EVV system, it must be successfully uploaded to the EAS and show a "Verified" status.
  • Wait until you see that "Verified" status in the EAS before submitting your claim to avoid unnecessary suspensions.

Summary: When to Take Action

  • Day 1–3: Be patient. The system is likely processing your claim.
  • If Denied: Determine the error, correct in the appropriate system (EVV system or eMOMED), and resubmit the claim.

Review the Mastering EVV Compliance and Claims Validation on the EVV provider page or contact Provider Communications via eMOMED or at (833) 222-7916.