by ANGELA WILSON – Pharmacy Program Manager, MO HealthNet & ERICA MAHN, PharmD, BC-ADM – Executive Director of Community Pharmacy Services at Alps Pharmacy
Presumptive Eligibility (PE) makes it possible for eligible individuals to gain immediate access to medical services temporarily while they submit an application to the Family Support Division for ongoing MO HealthNet coverage. Participants benefit from PE because they can start on the medications they need instead of waiting for the Family Support Division to process their application. These medications include mental and behavioral health medications, heart failure treatments, and prenatal vitamins for pregnant moms, among many other medications.
PE programs include Temporary MO HealthNet during Pregnancy (TEMP), PE for children ages 0-18, Show-Me Healthy Babies-PE (SMHB-PE), and PE for Parents/Caretaker Relatives and Former Foster Care Youth. These groups receive MO HealthNet pharmacy coverage for a temporary period of time under PE. The PE form will list the participant’s case number (DCN) for claim processing. This 8 or 10-digit number will remain the participant’s processing information for MO HealthNet services for life, so once this information is received, the pharmacy can build insurance coverage into the pharmacy system for processing. Potentially, the claim will not process immediately, but the information can be used for reprocessing the claim in the coming days.
PE ensures reimbursement to MO HealthNet pharmacy providers for any covered medication dispensed to the patient. If a patient presents a pharmacy provider with a PE-3 or PE-3 TEMP, the pharmacy can bill for covered medications provided to the patient. Make sure to only dispense a 30-day supply and attempt to identify medications consistent with MO HealthNet’s preferred drug lists (PDL) when possible.
These can be found at: https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm
A searchable database for MO HealthNet’s Preferred Drug List is also available at: https://mopdl.gainwelltechnologies.com/
PE eligibility is not immediately entered into the MO HealthNet system and is not directly available in eMOMED® or the point-of-sale pharmacy system. The forms, however, are valid once issued and guarantee eligibility after the date on the form. When billing MO HealthNet for services provided to PE patients, pharmacy providers should make a copy of the PE-3 and PE3TEMP forms and maintain a copy in the pharmacy files for documentation of eligibility. As long as the date you provide a service is after the date on the PE-3 and PE-3 TEMP forms, MO HealthNet will guarantee reimbursement for any covered medication dispensed, including medications that generally require prior authorization.
Once the DCN is active you should reprocess any unpaid claims for the individual from the date range on the PE forms. If a denial occurs when reprocessing call or submit a backdate request to MO HealthNet Pharmacy Administration. By establishing a process for this participant group at your pharmacy, participants will be able to receive necessary care during the transition period.
If you have questions or your pharmacy has difficulty processing claims for individuals with PE, contact MO HealthNet Pharmacy Administration at (573) 751-6963 or MHD.PharmacyAdmin@dss.mo.gov.
**A quick reference table similar to the one below would be helpful to share with staff along with sample PE form **
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Be sure to: |
| Train staff on how to recognize the document and best assist the participant |
| Keep a copy of the PE document presented at the pharmacy counter. |
| Review the MO HealthNet PDL resources https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm https://mopdl.gainwelltechnologies.com/ |
| Only process a 30-day supply |
Establish a process for transmitting claims and reprocessing when the participant is not currently active. One example could include:
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| Have the MO HealthNet Pharmacy Administration phone number readily available for follow-up. (573) 751-6963 |