Providers

Missouri Care Health Plan was developed to ensure the provision of high quality, cost effective, outcomes-oriented care to Missouri MO HealthNet managed care members. We realize that the successful pursuit of these goals requires the active participation of a committed provider network.

Missouri Care provider responsibilities include, but are not limited to, the following:

• Verifying member eligibility on the date of service
• Referring members to participating network providers and facilities
• Abiding by Missouri Care policies for prior authorization (Click here for prior authorization information)
• Notifying us upon receipt of an NPI
• Notifying us in advance of any changes in address, phone number, TIN, etc.
• Notifying us in advance of any provider additions or termination
• Not balance billing members

A convenient and secure login is available for Missouri Care providers to:

• Submit and verify prior authorizations
• Verify enrollment
• Look up claims status
• Find a provider or specialist
• Get information on covered health care services
• Access and print member panel rosters

During the registration process, Missouri Care providers are asked to assign a Primary Representative from their office. A provider's office has only one Primary Representative. If necessary, the primary representative is allowed to add authorized representatives within their office to their account.

To register, click here.
If you are already registered and would like to login to the secure site, please click here.

For more information on how to use the secure web portal, please click here for navigation guide.

Electronic Fund Transfer
Missouri Care, Incorporated offers electronic payments through electronic funds transfer (“EFT”), which offers a fast, easy and convenient way to have Missouri Care payments deposited directly into providers’ bank accounts upon completion of the EFT authorization process. A properly completed EFT Authorization Form and a copy of a voided check for bank verification are required to complete the EFT authorization process. This documentation must be sent to the attention of the Missouri Care Provider Relations Department at the address listed below or faxed to 1-866-946-1105.

Missouri Care Incorporated
Attn: Provider Relations
2404 Forum Boulevard
Columbia, MO 65203

Pharmacy Program Changes
Effective October 1, 2009, Missouri Care and all other MO HealthNet managed care plans will carve out coverage for all medications and pharmaceuticals administered on an outpatient basis (with the exception of observation cases). This change will impact reimbursement for any outpatient medications or pharmaceuticals dispensed in the physician’s office, outpatient department of a hospital, or other outpatient facilities.

• Any service provided in these settings will no longer be reimbursed by Missouri Care. Instead, these services should be billed to the State of Missouri’s MO HealthNet Fee-For-Service program, using the appropriate NDC codes.
• Outpatient medications should be billed to MO HealthNet on a pharmacy claim form using the product’s exact NDC, with the exception of claims for drugs dispensed in the outpatient hospital setting.
• Outpatient hospitals may bill claims using either an electronic Professional or Institutional ASC X12N 837 Health Care claim transaction, or a pharmacy claim form. NDCs will be required for only the "Top 20" multiple source physician-administered drugs for outpatient hospitals.
• Any services related to these outpatient medications and pharmaceuticals, such as office visits or administration fees, should continue to be billed to and reimbursed by Missouri Care.

Since claims for medications and pharmaceuticals will be billed to the MO HealthNet Fee-For-Service program, you must be a MO HealthNet provider in order to be directly reimbursed for these services. If you are not a MO HealthNet provider, please go to http://www.dss.mo.gov/mhd/providers/index.htm and click on “Provider Enrollment Application” to complete the enrollment process.

Please visit the Missouri Department of Social Services, Pharmacy Program Web site for pharmacy program Clinical Edit and Preferred Drug List criteria.

Also effective October 1, 2009, Missouri Care members will have access to the statewide Fee-For-Service pharmacy network instead of the current Missouri Care pharmacy network. This network should continue to provide your Missouri Care patients the same service that they have always had and should have minimal impact on them. Those patients may call MO HealthNet Participant Services at 1-800-392-2161 or 573-751-6527 for any assistance with this transition.

New: HIPAA 5010 transaction set upgrade
On January 16, 2009, the Department of Health and Human Services (HHS) released updated standards for electronic health care and pharmacy transactions as part of the Administrative Simplification Provision of Health Insurance Portability and Accountability Act (HIPAA).

The Electronic Data Interchange (EDI) HIPAA 5010 (ASC X12 5010) transaction set will help facilitate a nationwide conversion to an electronic health care environment. HIPAA 5010 is effective January 1, 2012.

Health care providers, health plans and health care clearinghouses must comply with the changes to transaction set standards.

Resources

Frequently Asked Questions

Training

Centers for Medicare and Medicaid Services (CMS):

Standards for Electronic Transactions - New Versions, New Standard and New Code Set - Final Rules

Versions 5010 and D.0 Educational Resources