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· Services were PRIOR AUTHORIZED by the Missouri State consultant**Services which routinely require prior authorization or have other limitations continue to require priorauthorization and are subject to established limitation, policies and procedures applicable to the MOHEALTHNET programs.If your claim DOES NOT meet one of the specific conditions listed above, the participant is responsible for thecharges, and you DO NOT need to enroll as a MO HealthNet provider. If you determine your claim(s) meets oneof the specific conditions listed above, you must request a paper application. All services must meet timely filingrequirements. ENROLLMENT DOES NOT GUARANTEE PAYMENT.It is your responsibility to verify the participant eligibility for dates of service provided. If the participant is enrolledwith a Missouri Managed Care Health Plan, you must contact the Managed Care Health Plan concerningservices provided, MO HealthNet is not responsible for those services. It is not necessary that you enroll withMO HealthNet unless you have provided services to participants who ARE NOT enrolled with a Managed CareHealth Plan.Air Ambulance (80)Above Out of State rules also apply . Submit a copy of the Helicopter Service license and a copy of the FAA AirCarrier Certificate to operate a helicopter service. Separate enrollment records are created for Air and GroundAmbulances. Each air ambulance provider must enroll and bill separately.Ambulatory Surgery Center (ASC) (50)Required documentation must be submitted with the original signed agreement. Out of state (non-bordering)providers cannot enroll. Individual practitioners practicing at the ASC must enroll individually. The ASC andindividual applications cannot be faxed as one transmission; each application and its required attachments mustbe faxed separately. Each ASC provider must enroll and bill separately.Must be licensed by the Department of Health & Senior Services and Medicare certified as an ASC. Must submita copy of the license and Medicare ASC approval letter.Assistant Behavior Analyst (73)Must submit a copy of the current permanent license. A specialty code of “LA” will be assigned.Audiologist/Hearing Instrument Specialist (33)Required documentation must be submitted with the original signed agreement. Out of state (non-bordering)providers cannot enroll. Each provider must enroll separately.Must have a current permanent license and submit a copy of the license and a copy of Medicare letter showingthe individual provider name and Medicare number if enrolled with Medicare. If licensed as both an Audiologistand Hearing Instrument Specialist, submit a copy of both licenses.Autism Clinic (50)To be assigned a specialty code of “AC”, the clinic must have at least two MO HealthNet enrolled LicensedBehavior Analysts on staff.Behavior Analyst (73)Must submit a copy of the current permanent license. A specialty code of “LB” will be assigned.Behavior Analyst, Assistant Behavior Analyst (73), Applied Behavior Analysis (ABA) Providers (73, 49,50)Each Behavior Analyst, Assistant Behavior Analyst, and Psychologist must enroll and bill individually. Requireddocumentation must be submitted with the completed enrollment application. Out of state (non-bordering)providers cannot enroll.Case Management (HCY)(18)Must be in compliance according to 13.56 of the physician manual. This type of provider number can only beissued if there is not an active clinic/group enrollment record to add the case management specialty. Out of state(non-bordering) providers cannot enroll.

Chiropractor (23)MO HealthNet Division (MHD) is implementing statewide complementary and alternative therapy services forchronic pain, effective for dates of service on or after April 01, 2019, for participants 21 years of age and olderwho have evidence of chronic pain. Eligible participants will receive complementary and/or alternative therapyservices as deemed medically necessary.Specialty 35 –Chiropractor Chiropractic services will require a Smart prior authorization (PA) for participants 21years of age and older.For participants to be eligible for complementary and alternative therapy services the individual must meet thefollowing criteria:Be currently enrolled in MO HealthNet, andBe 21 years of age or older, andHave chronic pain , andHave diagnosis within the chronic pain list provided in the MO HealthNet Provider’s Manual for thisprogram.Chiropractors currently can enroll as a Qualified Medicare Beneficiary (QMB) provider type 75 and specialty 35.However, if Chiropractors wish to enroll under the new, alternative therapy provider type they will need to do oneof the following:Dis-enroll their currently enrolled number,Enroll with a new National Provider Identifier (NPI),Enroll with a taxonomy code to keep the same NPI for both the 75-provider type and the new provider type.This will allow chiropractors to provide services under the Complementary and Alternative Therapies for ChronicPain Management program and future chiropractic programs.Clinic/Group (50)Required documentation must be submitted with the original signed agreement. Out of state (non-bordering)providers cannot enroll. Each clinic/group provider must enroll and bill separately unless one or more locationsare covered under the same clinic/group Medicare number.A clinic/group is one or more individuals designated by Medicare as a clinic/group, or one or more individualsdesignated by MO HealthNet as a clinic/group.If the clinic/group has a Medicare number, submit a copy of the clinic/group Medicare letter showing theclinic/group provider name, clinic/group Medicare number, and individual members of the clinic/group with themembers Medicare numbers. All individual providers practicing at the clinic/group must be enrolled individually.If submitting individual applications at the same time as the clinic/group, attach a cover letter referencing theindividual provider applications submitted. If the individual providers are already enrolled, attach a list of theirnames and NPI numbers. The clinic/group and individual applications cannot be faxed as one transmission; eachapplication and its required attachments must be faxed separately.Community Based MR (85)Must be prior approved by the Department of Mental Health (DMH) and enroll with MO HealthNet as enrolledwith DMH. Contact DMH if you are interested in providing services; the Provider Enrollment Unit cannot forwardthese forms to you. Out of state providers cannot enroll.Community Mental Health Center (CMHC) (56)Required documentation must be submitted with the original signed agreement. Out of state (non-bordering)providers cannot enroll.Must be Medicare certified as a CMHC and submit a copy of Medicare certification as a CMHC. Must also beapproved by Department of Mental Health as a CMHC. All individual providers practicing in the clinic must enrollindividually. Attach a cover letter referencing individual provider applications submitted. If the individual providers

are already enrolled, attach a list of their names and NPI numbers. The CMHC and individual applicationscannot be faxed as one transmission; each application and its required attachments must be faxed separately.Community Psychiatric Rehabilitation Center (87)Required documentation must be submitted with the completed enrollment application. Out of state providerscannot enroll.Must be currently certified by the Department of Mental Health (DMH) as a community psychiatric rehabilitationcenter, submit a copy of the current Certification from DMH, and enroll with MO HealthNet as certified by DMH.Comprehensive Day Rehabilitation (76)Required documentation must be submitted with the completed enrollment application. Out of state (nonbordering) providers cannot enroll.Must be currently accredited by CARF and submit a copy of current CARF Accreditation.CRNA (Certified Registered Nurse Anesthetist) (91)Required documentation must be submitted with the original signed agreement. Out of state (non-bordering)providers cannot enroll. Graduates cannot enroll.Must have a current permanent RN license and Document of Recognition as a CRNA. Must submit a copy of thecurrent permanent license, Document of Recognition, and a copy of Medicare letter showing the individualprovider name and Medicare number if enrolled with Medicare. If applicant is located in a bordering state, a copyof the permanent RN license and current CCNA certification must be submitted. All CRNAs must enrollindividually.C-STAR (86)Required documentation must be submitted with the completed enrollment application. Out of state providerscannot enroll.Must be currently certified by the Department of Mental Health and submit a copy of the current Certification andenroll with Medicaid as certified by DMH.Dental Hygienist (74)Required documentation must be submitted with the original signed agreement.Out of state (non-bordering) providers cannot enroll.Dental Hygienist services are for patients 20 and under ONLY.A Dental Hygienist must be licensed for at least 3 years and employed by a public health department, RuralHealth Clinic, or FQHC.The Dental Hygienist must enroll using the payment name and tax ID of the public health entity, payment is notmade directly to the dental hygienist. Each Dental Hygienist must enroll individually, bill under their individual NPInumber, and must apply for a separate provider enrollment record for each public health entity at which they areemployed. Each application with its required attachments must be submitted separately.Dentist (40)Required documentation must be submitted with the original signed agreement. Out of state (non-bordering)providers cannot enroll.Must have a current permanent license and submit a copy of the license. If enrolled with Medicare, must submita copy of Medicare letter showing the individual provider name and Medicare number. If a CORP dentist, submita copy of CORP Dentist orders and a copy of the current permanent license from the home state.Only dental providers selecting a specialty of general anesthesia (DS), parenteral conscious sedation (PC) orenteral conscious sedation (EC) must have a current certificate/permit to perform DS, PC or EC and a copy of

the certificate/permit must be submitted.Dialysis Center (50)Required documentation must be submitted with the original signed agreement. Out of state (non-bordering)providers cannot enroll.Must be currently certified by Medicare as a Dialysis Center. Must submit a copy of the Dialysis Center Medicarecertification approval letter. The medical director must be enrolled. Attach a cover letter stating the medicaldirector's name. Each dialysis center that is Medicare certified must enroll and bill separately. The dialysis centerand physician application cannot be faxed as one transmission; each application and its required attachmentsmust be faxed separately.Disease Management (35)Required documentation must be submitted with the original signed agreement.Within the Disease Management program is Diabetes Self-Management Training Services and Disease StateManagement Training Services. Please make sure you submit the appropriate documentation for the serviceyou will be providing as indicated below.Diabetes Self-Management Training ServicesCDE applicants:Must submit a copy of current certification by the National Certification Board for Diabetes Educators (NCBDE)for CDEs through the American Association of Diabetes Educators;If CDE is a nurse or physician:Submit a copy of current RN or physician license, and a copy of a current certification listed above.Licensed Dietitian applicants:Must submit a copy of your current license as a Licensed Dietitian (LD).Pharmacist applicants:Must submit a copy of current Pharmacist license AND a copy of appropriate certification from: the NationalCommunity Pharmacists Association (NCPA) "Diabetes Care Certification Program", OR the AmericanPharmaceutical Association (APhA)/American Association of Diabetes Educators (AADE) certification program"Pharmaceutical Care for Patients With Diabetes", OR completed the Drake University, College of Pharmacy andHealth Sciences, certification program "Developing Skills for Diabetes Care".Bordering state CDE, LD, or RPh applicants must be licensed by their state and/or certified by the abovementioned certifying boards. Out of state (non-bordering) providers cannot enroll.Disease State Management Training ServicesPhysician applicants:Must submit a copy of current physician license and a copy of your signed Disease State Management TrainingAgreement form.Pharmacist applicants:Must submit a copy of current pharmacist license and a copy of your signed Disease State Management TrainingAgreement form.Out of State applicants are not eligible to enroll for this service.Asthma Education Provider Applicants: (Provider type 35AE)· All asthma education providers must submit a copy of current national or Missouri State Certification.· If the certified asthma educator holds a current license as a nurse, physician, or respiratory therapist a currentcopy of the license must be submitted in addition to a copy of the asthma education certificate.· If the certified asthma educator holds a current professional license or certificate a copy of the professionallicense or certificate must be submitted with the asthma education certificate.· Out of State applicants are not eligible to enroll for this service.In-Home Environmental Assessor Applicants: (Provider type 35AH)

· All asthma in-home environmental assessment providers must submit a copy of current NationalEnvironmental Health Association (NEHA) Healthy Home Specialist Certification, a NEHA Health HomeEvaluator Micro-Credential certification, or Missouri state certification.· If the certified asthma educator holds a current license as a nurse, physician, or respiratory therapist a currentcopy of the license must be submitted in addition to a copy of the asthma education certificate.· If the certified asthma educator holds a current professional license or certificate a copy of the professionallicense or certificate must be submitted with the asthma education certificate.· Out of State applicants are not eligible to enroll for this service.DME (Durable Medical Equipment) (62)Required documentation must be submitted with the completed enrollment application. Each DME supplier whohas a Medicare number must enroll and bill separately. Representatives of the DME supplier are not eligible toenroll.Out of state non-bordering applicants are not permitted to enroll unless pre-approved by MMAC. Beforeenrollment forms are sent, you must indicate the recipient name, DCN, and date of service that has beenprovided.MO HealthNet participants are required to obtain services from Missouri or bordering state providers. MOHealthNet considers enrollment of an out of state (non-bordering) provider only if Medicare coinsurance and/ordeductible amounts on covered services are provided to patients who have both MO HealthNet and Medicare, orthe item needed is NOT available in Missouri or a bordering state of Missouri. If prior authorization is approvedand reimbursement is made for equipment, supplies, or services for a Missouri Medicaid patient who is notMedicare eligible, or for services that are available in Missouri or a bordering state, reimbursement may berecouped on any amounts paid.Must submit a copy of the Medicare approval letter for the location completed on the enrollment forms, a copy ofthe current Certificate of Incorporation (if a corporation), and a copy of the pharmacy permit if also registered asa pharmacy. DME providers must enroll with the same name and address as their Medicare number is issued.Environmental Lead Inspector (39)Required documentation must be submitted with the original signed agreement. Out of state (non-bordering)providers cannot enroll.Must have a current permanent license as a Lead Inspector or Lead Risk Assessor and submit a copy of thecurrent permanent license and a copy of Medicare letter showing the individual provider name and Medicarenumber if enrolled with Medicare. Each inspector must enroll individually.FQHC (Federally Qualified Health Center) (50)Required documentation must be submitted with the original signed agreement. Out of state (non-bordering)providers cannot enroll. Each individual practicing at the FQHC must be enrolled. Attach a cover letter stating theindividual provider names practicing at the FQHC. Each FQHC that is Medicare certified must enroll and billseparately. The FQHC and individual applications cannot be faxed as one transmission; each application and itsrequired attachments must be faxed separately.For purposes of providing covered services under MO HealthNet, an FQHC must:· receive a grant under Section 329, 330 or 340 of the Public Health Services Act or the Secretary of Health andHuman Services (HHS) may determine that the health center qualifies by meeting other requirements OR· must be Medicare certified as a FQHC.FQHC COVERED SERVICESMO HealthNet covered FQHC services include core services, defined generally in Section 1861 (aa) (1)(A)-(C) of the Social Security Act and any other ambulatory services provided for under the Missouri State Plan,which are furnished by the FQHC. FQHC services are subject to benefit limitations as described in the applicableMedicaid program manuals and bulletins. Reimbursement methods for these services are described in 13 CSR70-26.010.Covered services include, but are not limited to:

physician services;services and supplies incident to physician services (including drugs and biologicals that cannot be selfadministered);pneumococcal vaccine and its administration and influenza vaccine and its administration;physician assistant services (cannot enroll individually);nurse practitioner services;clinical psychologist services;clinical social worker services;services and supplies incident to clinical psychologist and clinical social worker services as would otherwisebe covered if furnished by or incident to physician services; andpart-time or intermittent nursing care and related medical supplies to a homebound individual when the FQHCis located in an area designated by HCFA as a home health agency shortage area.While dental, podiatry, optical and audiology services may be included as covered services in the FQHC, theseservices must be billed using the individual NPI number and using procedure codes specifically approved for thatprogram, as opposed to billing with the clinic number. These providers are all subject to the co-paymentrequirement, which mandates that their services not be billed under a clinic number.FQHC BILLING PROCEDURESPlease refer to the appropriate Provider Manual and Training Booklet for the FQHC Billing Procedures. The linkto the Provider Manual and the Training Booklet can be found on the MHD website on the Provider Participationpage.The link to the Provider Participation page is:http://dss.mo.gov/mhd/providers/index.htmFQHC RECORD KEEPING REQUIREMENTSHealth Center records must be sufficient to allow completion and audit of the Medicare FFHC(HCFA 242) cost report and supplemental Missouri FQHC reporting forms. The supplemental Missouri formsinclude an income statement, a summary of MO HealthNet, Medicare and total charges by program, and astatistical schedule of MO HealthNet, Medicare and total encounters. A uniform charge structure must beestablished to ensure charges for MO HealthNet participants are the same as charges assessed to all otherrecipients for similar services. Failure to maintain adequate accounting records results in recovery of all fundspaid in excess of the established fee schedules. All providers are further required to maintain adequate fiscaland Medical records for a period of five years, to fully disclose services rendered to Title XIX Medicaidparticipants.Home Health Agency (58)Required documentation must be submitted with the c

priority. When the provider enrollment is finalized, an e-mail stating the provider's name, address, NPI number and . another state agency such as the Department of Health & Senior Services, Department of Mental Health, or Medicare, that agency must approve the changes prior to Provider Enrollm