General Provider and Claim FAQs

How do providers stay current on MO HealthNet policy and other changes?

Providers receive updates by subscribing to MO HealthNet News. Once subscribed, providers are notified by e-mail as updates occur. If you would like to receive updates by email, you can subscribe.

Providers can also visit MO HealthNet News and search by date, program or keyword to locate updates posted over the last ten years. 

Who should a provider contact for MO HealthNet assistance?

For inquiries, concerns, or questions regarding proper claim filing instructions, claims resolution/disposition, and participant eligibility, providers may contact Provider Communications at the Interactive Voice Response System (IVR) by calling 573-751-2896.

Providers may also contact Provider Communications by using the secure direct messaging option in eMOMED.  Once logged into eMOMED, click on Provider Communications Management button to submit your inquiry. Your response will appear in the same place within 24-72 hours. Providers should send one inquiry on each submission.

For more information regarding Provider Communications, review Section 3.3 of the General Sections Provider Manual.

For additional MO HealthNet contact information, review the Provider Resource Guide. 
Should providers need training on navigating provider resources, proper billing methods and procedures for claim filing via eMOMED, contact MHD Education and Training at MHD.Education@dss.mo.gov or by calling 573-751-6683.

How do I get access to eMOMED, the MO HealthNet billing and eligibility portal?

Each user can apply for a user identification (ID) and password by selecting the “Not Registered? Register Now!” link on eMOMED. Once the application is completed, you will be assigned a user ID and password. After you receive your user ID and password, you can immediately log onto eMOMED and begin using the site. You may contact the Provider Technical Help Desk for assistance at 573-635-3559 (option 1).

How can providers get information on the status of a claim?

To retrieve information regarding the status of a claim, providers have three options:

•    Contact Provider Communications by calling the Interactive Voice Response (IVR) System at 573-751-2896, Option 3.

•    Providers may also contact Provider Communications by using the secure direct messaging option in eMOMED.  Once logged into eMOMED, click on Provider Communications Management button to submit your inquiry. A response will appear in the same place within 24-72 hours. Providers should send one inquiry on each submission.

•    Providers may also access 2 months of Remittance Advice (RA) and Claim Confirmation documents using the File Management option on eMOMED. Providers can also request aged RAs for up to three years.

How does a provider determine why a claim was denied?

All claims processed by MO HealthNet are listed on the provider’s Remittance Advice (RA). The RA lists the Claim Adjustment Reason Codes and Remittance Remark Codes which assist providers with identifying the reason for a claim adjustment or denial.

•    For questions regarding a claim denial, contact Provider Communications at the Interactive Voice Response System (IVR) by calling 573-751-2896.

•    Providers may also contact Provider Communications by using the secure direct messaging option in eMOMED.  Once logged into eMOMED, click on Provider Communications Management button to submit your inquiry. Your response will appear in the same place within 24-72 hours. Providers should send one inquiry on each submission.

Should providers need training on how to navigate provider resources, proper billing methods and procedures for claim filing on eMOMED, contact MHD Education and Training at MHD.Education@dss.mo.gov or by calling 573-751-6683.

Is there a way to retrieve and modify a previously submitted claim?

Most denied claims can be reprocessed without re-keying the claim through eMOMED. eMOMED has the capability to retrieve a previously submitted claim. After the claim is retrieved, providers can modify the original claim by using the “Copy Claim Original” option on eMOMED. The provider can then submit the claim again for processing. This function is available for most claims submitted electronically or on paper. There are some exceptions to claims that can be retrieved and resubmitted.

eMOMED has many other helpful functions to assist you with reprocessing and researching claims. Reach out to Provider Communications or Education and Training using the contacts below for assistance and training.  

•    For questions regarding this process, contact Provider Communications at the Interactive Voice Response System (IVR) by calling 573-751-2896.

•    Providers may also contact Provider Communications by using the secure direct messaging option in eMOMED.  Once logged into eMOMED, click on Provider Communications Management button to submit your inquiry. Your response will appear in the same place within 24-72 hours. Providers should send one inquiry on each submission.

•    Should providers need training on how to navigate provider resources, proper billing methods and procedures for claim filing on eMOMED, contact MHD Education and Training at MHD.Education@dss.mo.gov or by calling 573-751-6683.

What is MO HealthNet’s timely filing policy?

For information regarding MO HealthNet Division’s policy on timely filing for MO HealthNet claims, Medicare/MO HealthNet crossover claims, claims with Third Party Liability, and more, review Section 4 of the General Sections Manual. 

What information can be found on the MO HealthNet identification card?

The Department of Social Services issues a permanent MO HealthNet identification card for each MO HealthNet participant.

Every MO HealthNet card contains the participant’s name, date of birth and MO HealthNet ID number. The reverse side of the card contains basic information and the Participant Inquiries and Fraud and Abuse phone numbers.

A MO HealthNet ID card does not guarantee benefits. It is important that the provider always check eligibility and the MO HealthNet/Managed Care Medical Eligibility (ME) code on file for the date of service in eMOMED.

For more information on MO HealthNet and Managed Care ID cards, review Section 1.2 of the General Sections Provider Manual. 

For questions regarding eligibility, contact Provider Communications at the Interactive Active Voice Response System (IVR) by calling 573-751-2896. Providers may also contact Provider Communications by using the secure direct messaging option in eMOMED.  Once logged into eMOMED, click on Provider Communications Management button to submit your inquiry. Your response will appear in the same place within 24-72 hours. Providers should send one inquiry on each submission.

What is a Medical Eligibility (ME) code and why is this information important?

Medical Eligibility (ME) codes indicate the eligibility group or category of assistance under which an individual is eligible for MO HealthNet benefits. Some eligibility groups or categories of assistance have benefit restrictions.

For a description of the ME Codes refer to Section 1.1 of the General Section Provider Manual, or the Provider Resource Guide. For more information on coverage and benefit restrictions for each ME code, refer to the Benefit Tables.

Should providers need training on how to navigate provider resources, proper billing methods and procedures for claim filing on eMOMED, contact MHD Education and Training at MHD.Education@dss.mo.gov or by calling 573-751-6683.

What should a provider do if Medicare denied a claim and they want to file the claim with the MO HealthNet Division?

Some benefits that are covered by Medicare may be subject to certain limitations. The provider will receive a Medicare Remittance Advice (RA) that indicates if Medicare has denied a service. The provider may then submit a claim to the MO HealthNet Division (MHD), using the proper claim form for consideration of reimbursement.

Providers can submit claims that require a Third Party Liability (TPL) or Medicare denial RA through eMOMED or with the 837 transaction. If the 837 transaction is chosen, please refer to the eMOMED Information document for assistance.

Refer to the Medicaid/Medicare Claims Processing Provider Manual for instructions.

For questions regarding claim entry, contact Provider Communications at the Interactive Voice Response System (IVR) by calling 573-751-2896. Providers may also contact Provider Communications by sending and receiving secure e-mails through eMOMED. After logging in to eMOMED, click on Provider Communications Management to send a direct message. Providers should send one inquiry per e-mail.

Should providers need training on how to navigate provider resources, proper billing methods and procedures for claim filing on eMOMED, contact MHD Education and Training at MHD.Education@dss.mo.gov or by calling 573-751-6683.

What is a crossover claim and what should a provider do if their Medicare crossover claim isn’t crossing over?

Some participants qualify for both Medicare and MO HealthNet (Medicaid). For these participants, Medicare claims will crossover to MO HealthNet. When MO HealthNet providers submit claims to Medicare for payment, Medicare will pay the claim, apply a deductible/coinsurance or co-pay amount and then automatically forward the claim to MO HealthNet for review of payment. This is referred to as a crossover claim.

Some crossover claims do not crossover due to the following reasons:

  • The Medicare contractor does not send crossover claims to MO HealthNet.
  • The provider did not indicate on their claim to Medicare that the beneficiary was eligible for MO HealthNet.
  • The MO HealthNet participant information on the crossover claim does not match the MO HealthNet participant file The provider’s Medicare identification number is not on file in MHDs provider file.
  • The provider’s National Provider Identifier (NPI) number is not on file in the MHD provider files. When this occurs, providers should contact Missouri Medicaid Audit and Compliance (MMAC) Provider Enrollment Unit at MMAC.ProviderEnrollment@dss.mo.gov.

MO HealthNet no longer accepts paper crossover claims. Providers must bill crossover claims that do not cross automatically from Medicare to MO HealthNet through eMOMED or through the 837 electronic claims transaction. Providers should wait 30 days from the date of Medicare payment to file an electronic crossover claim.

For educational resources describing how to file cross over claims, refer to the Claim Filing presentations on MHD Education and Training.

For questions regarding claim entry, contact Provider Communications at the Interactive Active Voice Response System (IVR) by calling 573-751-2896. Providers may also contact Provider Communications by using the secure direct messaging option in eMOMED.  Once logged into eMOMED, click on Provider Communications Management button to submit your inquiry. Your response will appear in the same place within 24-72 hours. Providers should send one inquiry on each submission.

Should providers need training on how to navigate provider resources, proper billing methods and procedures for claim filing on eMOMED, contact MHD Education and Training at MHD.Education@dss.mo.gov or by calling 573-751-6683.

Can MHD pharmacy staff reverse a pharmacy claim?

If a provider cannot reverse a claim through their POS system, it may also be reversed in eMOMED in real time. If a provider requests MHD reverse a claim on behalf of the provider, the reversal will take an overnight update to process.

Please contact Pharmacy Administration at MHD.PharmacyAdmin@dss.mo.gov or call 573-751-6963 for more information.

For more information on adjustments, refer to Section 6 of the General Sections Provider Manual.

How does insurance information on the participant’s eligibility file get updated to show a change or termination date?

If a provider learns of a change in insurance information or a change in the third party liability (TPL) information prior to the MO HealthNet Division (MHD), they should submit the information to MHD by completing the Insurance Resource Report (TPL-4). MHD will verify and update the information on the participant’s eligibility file.

For more information, refer to Section 5.8 of the General Sections Provider Manual. 

Do outpatient hospital services require pre-certification?

Providers are required to seek per-certification for certain diagnostic and ancillary procedures and services ordered by a healthcare provider unless provided in an inpatient hospital or emergency room setting. Services requiring pre-certification can be found in the Hospital Provider Manual.  

Do inpatient hospital admissions require pre-certification?

Inpatient hospital admissions must be certified by Conduent. Providers may submit inpatient certification requests at CyberAccess. CyberAccess is available 24 hours a day, seven days a week for admission certification prior to admission, on the day of admission, prior to discharge or within 14 days calendar days after discharge for continued stay reviews.

Refer to Section 2.27 of the Hospital Provider Manual for more information on inpatient pre-certifications. 

What are the requirements for a participant to receive voluntary sterilization?

In  all  situations  involving  voluntary  sterilization,  it  is  mandatory  that  the  (Sterilization) Consent Form be attached to each paper claim or be submitted via eMOMED.   Any claim for a sterilization procedure performed that does not have a signed, Missouri-approved (Sterilization) Consent Form is denied in accordance with mandated regulations set forth by the Centers for Medicare & Medicaid Services (CMS).

The MO HealthNet participant must: 
•    Be at least 21 years of age at the time the consent is obtained and 
•    Not be a mentally incompetent individual or an institutionalized individual
•    Have voluntarily given informed consent, in accordance with mandated regulations set forth by CMS and requirements by the Department of Social Services (DSS).

Refer to Section 2.15 of the Hospital Provider Manual for additional information regarding sterilization, including required timeframes and definitions.

How does a provider determine the status of a non-drug prior authorization request?

Below are ways providers may check the status of their Prior Authorization Requests:
•    Selecting the Prior Authorization Status option in eMOMED
•    Contacting Provider Communications at the Interactive Voice Response System (IVR) by calling 573-751-2896 
•    Providers may also contact Provider Communications by using the secure direct messaging option in eMOMED.  Once logged into eMOMED, click on Provider Communications Management button to submit your inquiry. Your response will appear in the same place within 24-72 hours. Providers should send one inquiry on each submission.

An approved authorization approves only the medical necessity of the service and does not guarantee payment. Claim information must still be complete and correct, and the provider and the participant must both be eligible at the time the service is rendered or item delivered. Program restrictions such as age, category of assistance, managed care, etc., that limit or restrict coverage still apply and restricted services provided to participants are not reimbursed.

Payment is not made for services initiated before the approval date on the prior authorization request or after the authorization deadline. For services to continue after the expiration date of an existing prior authorization request, a new prior authorization request must be completed and mailed.

Refer to Section 8 of the General Sections Provider Manual for more information regarding prior authorizations. Refer to the Benefits and Limitations and Special Documentation Requirements Sections of the applicable Provider Manuals for program-specific information regarding prior authorization.

What attachments are required on Durable Medical Equipment (DME) procedures?

The MO HealthNet Division (MHD) may require the Certificate of Medical Necessity and/or the supplier’s invoice of cost for each covered procedure code.

For a complete list of the MO HealthNet covered DME procedure codes and the required attachment(s), please refer to Section 5 of the Durable Medical Equipment Provider Manual or to the MHD Fee Schedule.

Revised August 2024