Enrolled MO HealthNet providers often ask about certain situations that would make the MO HealthNet participant responsible for payment of medical services.
The guidelines for non-covered services are reflected in the Missouri Code of State Regulations 13 CSR 70-4.030 titled "Recipient Liability for Medical Services Not Reimbursable to the Provider by the Medicaid Agency".
In simple terms, this regulation states Enrolled MO HealthNet providers may NOT bill participants for covered services. The provider must accept MO HealthNet reimbursement as payment in full for provided services, even if MO HealthNet denies payment for a service for failure to follow rules and regulations of the program (such as Prior Authorization, Sterilization Consent Form, etc.).
The only exception is for services that are NOT covered by the participant’s MO HealthNet benefits. In that case, the participant may be billed if they have signed a written statement, prior to receiving the service, indicating their understanding that MO HealthNet does not cover the service and that the participant accepts financial responsibility for the service. The statement must include the date of service, the service for which the participant has accepted financial responsibility, the participant’s signature and the date signed. This should be maintained by the provider in the patient record.
A signed participant statement is not needed for systematically denied amounts reported on the provider remittance advice, such as ineligibility, limited benefits, copayment or spend down amounts.