Inpatient Certification FAQs
Inpatient hospital admissions must be certified as medically necessary and appropriate before the MO HealthNet Division (MHD) reimburses for inpatient services. All MO HealthNet enrolled hospitals in Missouri and bordering states are subject to this admission certification requirement. The state has given authority for Conduent to receive all the appropriate information necessary to review admissions subject to admission certification.
For additional information, review the Hospital Provider Manual and the MHD Hospital Program page.
- What services are exempt from admission certification?
Some inpatient stays are exempt from Conduent review. These exemptions can have certain pregnancy-related, delivery or newborn diagnosis codes. When the stay is exempt, the maximum number of days allowed will be identified by the exempt diagnosis code on the Inpatient Stay Exemption By Diagnosis Code Table. If the inpatient stay is within the number of days allowed for the exempt diagnosis, the provider is not required to obtain a precertification. However, if the stay exceeds the permitted number of days, the provider must obtain a precertification for the entire inpatient stay; otherwise, payment will only be made for the allowed number of days listed for the exempt diagnosis table.
- How does a provider request an admission certification if a participant is enrolled in a MO HealthNet Managed Care health plan?
The Managed Care health plan certifies the hospital admission for Managed Care participants. Providers may contact the Managed Care health plans using the following information:
Home State Health
855-694-4663
ManagedCareContracting@centene.comShow Me Healthy Kids
877-236-1020
ManagedCareContracting@centene.com- How does a provider submit an inpatient certification request for a Fee For Service participant?
Providers may submit inpatient certification requests at CyberAccess. Submission via CyberAccess is the preferred method. CyberAccess is available 24 hours a day, seven days a week, or admission certification before admission, on the day of admission, before discharge, or within 14 calendar days after discharge for continued stay reviews. Other methods of submission include:
Conduent
PO Box 105110
3425 West Truman Blvd
Jefferson City, MO 65110Phone: 800-766-0686
Fax: 866-629-0737The phones are staffed from 8:00 am to 4:30 pm, Monday – Friday, excluding holidays. Providers may leave a message, and a call will be returned by the next business day.
- Can medical records be sent on a CD?
Yes, a copy of medical records may be sent in a PDF format via a CD to the following address:
Conduent
PO Box 105110
3425 West Truman Blvd
Jefferson City, MO 65110- What criteria are used when reviewing an admission certification?
Conduent utilizes the Milliman Care Guidelines screening criteria to establish a benchmark length of stay for all inpatient hospitalizations. Screening criteria are not a standard of care; failure to meet any particular screen does not mean that the participant does not require an acute hospital level of care but rather that the case requires review by a physician.
Certification review is performed via CyberAccess within Conduent’s Inpatient Certification Management System (ICMS), which uses the review criteria Milliman Care Guidelines®. The review is based on pertinent medical information received from the attending physician or hospital regarding the patient's condition and planned services.
For additional information, review Section 2.27 in the Hospital Provider Manual.
- How does a provider know if the admission certification is approved?
For certifications meeting criteria, Conduent expects to certify the admission at the time of the initial request when made via CyberAccess or by phone at (800) 766-0686. Certifications meeting criteria when submitted by written or fax request will be made by the end of the next working day.
All admission certification decisions are available through CyberAccess. Written notification of approved certifications will not be sent to providers.
- What happens if Conduent needs additional information after a provider has submitted an admission certification?
Certification requests submitted via CyberAccess, fax, or mail must have all information necessary for Conduent to review and complete the certification of the inpatient stay. If Conduent does not receive all the required information, the certification request will be closed, and the physician and hospital will receive a letter requesting all medically necessary information to complete the certification. This is not a denial of the certification. The certification request will be considered “closed,” so the reconsideration and appeal rights awarded to each certification remain intact. The provider must then resubmit all information about the inpatient stay. Conduent will review the information again to determine a benchmark length of stay and issue a certification number if the stay is approved. If the original request was submitted prior to discharge but did not contain sufficient information and a new complete request is not received by Conduent prior to discharge, the request will be considered retrospective and restricted to the retrospective certification guidelines.
For additional information, review Section 2.27 in the Hospital Provider Manual.
- Can a provider request reconsideration of a denied certification request?
An attending physician, hospital, or participant dissatisfied with a Conduent initial denial determination is entitled to reconsideration by Conduent. The reconsideration may be requested before or after discharge. However, the request must be made within three working days of receipt of a denial letter if the participant is still inpatient or within 60 calendar days of receipt of the denial letter if the participant has already been discharged. Requests must be mailed using the Inpatient Certification Request and all pertinent medical documentation.
The reconsideration is conducted by a Conduent physician reviewer who has had no previous involvement in the case. The physician is board certified or board eligible in the specialty that matches the care under review except in cases where meeting this requirement compromises the efficiency and effectiveness of the review. The reconsideration process consists of reviewing all medical records including information used to make the initial determination. Conduent also considers any additional information submitted by a party to the reconsideration. Conduent reconsideration is the final level of review.
For additional information, review Section 2.27 in the Hospital Provider Manual
- Can a provider request an expedited request to reconsider a denied certification request?
To request an expedited reconsideration for a patient before admission or for a patient still in the hospital, the provider should call Conduent at (800) 766-0686. To expedite the process, the provider must indicate that this is a request for reconsideration. Conduent will complete the reconsideration review and issue a determination within one working day of Conduent receipt of the request and all pertinent information. Pertinent information is any information the attending physician, hospital, or participant feels may justify or qualify the hospitalization.
- Can a provider request a review of a denied admission certification after the patient has been discharged from the hospital?
A retrospective review is a request for certification after the participant has been discharged from the hospital. Retrospective certification requests are only accepted when the participant has retroactive eligibility, or the hospital provider has a retroactive enrollment date. All other retrospective certifications will only be accepted on a case-by-case basis. The Inpatient Certification Request must be faxed to 866-629-0737 or mailed to the address below, along with a copy of the patient’s medical record for days of the inpatient stay requiring review.
Inpatient Certification Program
PO Box 105110
Jefferson City, MO 65110For Retrospective review questions, please call the Utilization Review (UR) Assistant line at 800-766-0686, Opt. 0.
Refer to Section 2.27 of the Hospital Provider Manual for more information on certification reviews.
- How will concurrent days be added to a certification?
A Continued Stay request can be submitted through the application, and any additional days will be reviewed based on Milliman criteria. When additional days are required, the continued stay requested will have the same certification number through the application.
- How does a provider let Conduent know that a certification is complete and can be closed?
Conduent will provide a daily report by facility on CyberAccess reflecting all approved certifications scheduled to expire or have already expired that do not contain a discharge date. This is called the Daily Discharge/Expired Certification Report. Each facility will access the report under the Case Management link in CyberAccess. The facility must then add the discharge date to the report and save it. This lets Conduent know the certification is complete and can be closed.
- Must the Daily Discharge/Expired Certification report be faxed back to Conduent daily or can we save them up and fax all back at the end of the week or whenever it is convenient for our staff?
The necessary information concerning a discharge date or additional information to complete a concurrent review should be submitted to Conduent via CyberAccess by phone 800-766-0686 or by fax 866-629-0737 as soon as the information is available. This will help close out certifications with discharge dates and eliminate repeated information in the next day’s report. This will also facilitate the timeliness of concurrent reviews. If multiple areas of the hospital (i.e., psych and acute care) should receive this information, please provide the correct contact information (person’s name and fax number) to Conduent.
- Adding all dual-eligible (Medicare/Medicaid) participants to the Daily Discharge/Expired Certification report in addition to the discharge information on each patient is quite labor intensive. Is this information required? What is its purpose? Will it affect our payment if we do not add the dual eligible to the report?
At this point, the information is not required but is requested. This information will help MO HealthNet assist providers in improving patient care during and after discharge. The information does not affect your reimbursement in any way.
Revised August 2024