The MO 886 0858 form is a critical document issued by the Missouri Department of Social Services for the MO HealthNet Division, facilitating the process of obtaining prior authorization for certain medical services, equipment, or procedures. It is designed to verify the medical necessity of the requested service but does not stand as a guarantee for payment or reimbursement levels. Individuals seeking approval must ensure that the participant is MO HealthNet eligible on the intended date of service. For a smooth submission process, it's paramount to follow the detailed instructions provided, ensuring all sections are completed accurately.
For assistance or more information on how to accurately complete and submit the MO 886 0858 form, please click the button below.
The Missouri Department of Social Services' MO 886 0858 form plays a crucial role in the MO HealthNet Division, facilitating the prior authorization request process for medical services, equipment, or prostheses needed by participants. This document ensures that the medical necessity of requested services is reviewed and authorized before delivery. However, it's important to note that authorization granted through this form does not guarantee payment to the service provider or confirm that the billed amount will match the reimbursed amount. For services or items to be eligible for reimbursement, the participant must be eligible for MO HealthNet on the date of service or receipt of the equipment or prosthesis. The form is comprehensive, requiring detailed information about the participant, including their MO HealthNet identification number, diagnosis, and prognosis, along with specifics about the requested service or item, such as description, quantity, and medical necessity. It also includes sections for provider information and, if applicable, prescribing or performing practitioner details. Providers must ensure accuracy and completeness when filling out the form, as this facilitates the review process. Additionally, the form outlines instructions for its completion, emphasizing the need for a detailed medical necessity explanation and proper identification of service requests, which may require a separate plan of care depending on the nature of the service or the provider's specifications.
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return to: infocrossing healthcare services, inc.
mo healthnet division
po box 5700
PRIOR AUTHORIzATION REQUEST
Jefferson city, mo 65102
authorization approves the medical necessity of the requested service only. it does not guarantee payment, nor does it guarantee that the
amount billed will be the amount reimbursed. the participant must be mo healthnet eligible on the date of service or date the equipment or
prosthesis is received by the participant. SEE REVERSE SIDE FOR INSTRUCTIONS.
I. GENERAL INFORMATION
2. name (last, first, m.i.)
3. date of birth
1.
4. address (street, city, state, zip code)
5. mo healthnet number
6. prognosis
7. diagnosis code
8. diagnosis description
9. name and address of facility where services are to be rendered if other than home or office
II. HCY (EPSDT) SERVICE REQUEST (MAY REQUIRE PLAN OF CARE)
partial
10. date of hcy screen
11. screening
full
interperiodic
12. type of partial hcy screen
13. screening provider name
14. provider identifier
15. telephone number
III. SERVICE INFORMATION
19.
20.
21.
22.
23.
16.
17.
18.
description of service/item
appr. denied
amount allowed if
ref.
procedure
modifiers
from
through
qty. or
amount to
no
code
units
be charged
priced by report
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
24. detailed explanation of medical necessity for services/equipment/procedure/prosthesis (attach additional pages if necessary)
IV. PROVIDER
V. PRESCRIBING/PERFORMING PRACTITIONER
25. provider name
29. name
30. telephone
26. address
31. address
32. date disability began
33. period of medical need in months
fax number
34. npi
taxonomy
i certify the information given in sections i and iii of this form is true, accurate, and
27. npi
complete.
PRESCRIBING PHYSICIAN/PRACTITIONER
28. signature
date
35. signature of
VI. FOR STATE OFFICE USE ONLY
denial reason(s): refer to field 16 above by reference numbers (ref. no.)
IF APPROVED: services authorized to begin
mo 886-0858 (3-15)
reviewed by signature4
mo 8809
INSTRUCTIONS FOR COMPLETION
I. GENERAL INFORMATION - To be completed by the provider requesting the prior authorization. 1. leave blank
2. participant’s name - enter the participant’s name as it appears on the mo healthnet id card. enter the participant’s current address.
3. date of birth - enter the participant’s date of birth.
4. address - enter the participant’s address, city, state, and zip.
5. mo healthnet number - enter the participant’s 8-digit mo healthnet identification number as shown on the mo healthnet identification card or county letter of eligibility.
6. prognosis - enter the participant’s prognosis.
7. diagnosis code - enter the diagnosis code(s).
8. diagnosis description - enter the diagnosis description. if there is more than one diagnosis, enter all descriptions appropriate to the services being requested.
9. name and address of the facility where services are to be rendered if service is to be provided other than home or office.
II. HCY SERVICE REQUEST (Plan of care may be required, see your provider manual) 10. date of hcy screen - enter the date the hcy screen was done.
11. screening - check whether the screening performed was full, interperiodic, or partial.
12. type of partial hcy screen - enter the type of partial hcy screen that was performed. (e.g., vision, hearing, etc.)
13. screening provider name - enter the provider’s name who performed the screening.
14. provider identifier - enter the provider’s npi number who performed the screening.
15. telephone number - enter the screening provider’s telephone number including the area code.
16. ref. no. - (reference number) a unique designator (1-12) identifying each separate line on the request.
17. procedure code - enter the procedure code(s) for the services being requested.
18. modifier - enter the appropriate modifier(s) for the services being requested.
19. from - enter the from date that services will begin if authorization is approved (mm/dd/yy format).
20. through - enter the through date the services will terminate if authorization is approved (mm/dd/yy format).
21. description of service/item - enter a specific description of the service/item being requested.
22. quantity or units - enter the quantity or units of service/item being requested.
23. amount to be charged - enter the amount to be charged for the service.
24. detailed explanation of medical necessity of the service, equipment/procedure/prosthesis, etc. attach additional page(s) as necessary.
Do not use another Prior Authorization Form.
IV. PROVIDER REQUESTING PRIOR AUTHORIzATION
25. provider name - enter the requested provider’s information. if a clinic or group practice, also complete section v.
26. address - enter the complete mailing address in this field.
27. npi - enter the provider’s npi and taxonomy code (if applicable).
28. signature/date - the provider of services should sign the request and indicate the date the form was completed. (check your provider manual to determine if this field is required.)
this section must be completed for services which require a prescription such as durable medical equipment, physical therapy, or for services which will be prescribed by a physician/practitioner that require prior authorization, or when the provider in section iv is a clinic or group practice. check your provider manual for additional instructions.
29. name - enter the name of the prescribing/performing practitioner.
30. telephone number - enter the prescribing/performing practitioner telephone number including area code.
31. address - enter the address, city, state, and zip code.
32. date disability began - enter the date the disability began. for example, if a disability originated at birth, enter date of birth.
33. period of medical need in months - enter the estimated number of months the participant will need the equipment/services.
34. npi - enter the provider’s npi and taxonomy code (if applicable).
35. signature of prescribing/performing practitioner - the prescribing physician/practitioner must sign and indicate the date signed in mm/dd/yy format. (Signature stamps are not acceptable)
approval or denial for each line will be indicated in the box to the right of section iii. also in this box the consultant will indicate allowed amount if procedure requires manual pricing.
at the bottom, the consultant may explain denials or make notations referencing the specific procedure code and description by number (1 thru 12). the consultant will sign or initial the form.
After you've gathered all the necessary information to submit a prior authorization request for MO HealthNet participants, it's crucial to correctly fill out the MO 886-0858 form. This guide will break down the steps you need to follow, ensuring your request is processed efficiently and effectively. Remember, completing this form accurately is key to facilitating the approval process for the medical services, equipment, or procedures needed.
Once you’ve completed these steps and carefully reviewed the form for accuracy, submit it to the address listed at the top. The MO HealthNet Division’s review process will begin, and they will reach out should they need further information or to communicate their determination. By following these directions closely, you help streamline the approval process, bringing the services or items needed one step closer to the participant.
The MO 886 0858 form is designed for providers to request prior authorization from the Missouri Department of Social Services, specifically the MO HealthNet Division. The main purpose of this form is to establish the medical necessity of specific services, equipment, procedures, or prostheses for participants of MO HealthNet before the services are rendered. It is essential to understand that obtaining authorization through this form verifies that the requested service is necessary; however, it does not guarantee payment nor the amount that will be reimbursed. Additionally, it is crucial that the participant be eligible for MO HealthNet on the date the service is provided or the equipment is received.
To correctly fill out the General Information section of the form, providers must follow these steps:
In the Service Information section of the form, a detailed breakdown of the requested services or items is required. The following information must be provided for each request:
If the requested service requires a prescription, such as for durable medical equipment, or if the service will be performed by a practitioner other than the one filling out the form, Section V should be completed thoroughly. This includes providing the name, telephone number, address, and the National Provider Identifier (NPI) and taxonomy code of the prescribing or performing practitioner. Additionally, it is necessary to sign and date the form, underscoring the commitment that all provided information is accurate and complete. It's important to remember that using a signature stamp is not permissible for this documentation.
Once the MO 886 0858 form is submitted, the MO HealthNet Division reviews the request in detail. Approval or denial for each line of requested service or item is indicated in the section designated for state office use only. This section also contains space for the consultant to note the allowed amount if the procedure requires manual pricing. Furthermore, consultants may provide explanations for denials or additional notations referencing specific procedure codes and descriptions. The consultant's signature or initials signify the completion of the review process. It is pivotal for providers to await this decision before proceeding with the service, as it affects reimbursement eligibility.
Filling out the MO 886-0858 form, also known as the Prior Authorization Request form for the Missouri Department of Social Services, demands attention to detail. Common mistakes can lead to delays or denial of authorization. Below are eight common errors to avoid:
Not double-checking the participant's MO HealthNet number: Incorrect MO HealthNet identification numbers can lead to processing delays or outright denials.
Overlooking the diagnosis code and description fields: Omitting or inaccurately filling out the diagnosis code(s) and description(s) reduces the clarity of the medical necessity for the requested service.
Skipping the prognosis section can lead to incomplete submissions, as this information is crucial for understanding the participant's current health status and anticipated needs.
Incorrect service dates: Providing incorrect 'from' and 'through' dates in the service information section can affect the validity of the authorization.
Failing to attach additional pages when a detailed explanation of the medical necessity for services, equipment, procedure, or prosthesis is needed, limits the reviewer's understanding of the request.
Forgetting to sign and date the form: The lack of a signature and date from the provider requesting prior authorization or the prescribing/performing practitioner invalidates the form.
Not specifying the type of HCY (Health, Childhood, and Youth) screen performed, whether it was full, interperiodic, or partial, neglects to inform on the extent of care and screenings the participant has undergone.
Leaving procedural and modifier codes blank or incorrect in the service information section fails to specify the requested services, leading to confusion or denial of the request.
Avoiding these mistakes requires careful review and completion of the MO 886-0858 form. Ensuring accuracy and completeness in every section supports a smoother authorization process, helping participants receive the necessary services without undue delays.
When navigating the complexities of submitting the MO 886-0858 form, which requests prior authorization for medical services or equipment under Missouri's Medicaid Program (MO HealthNet), one must be well-informed about the accompanying documentation that can significantly impact the authorization process. This form is crucial for healthcare providers as it seeks approval for the medical necessity of services or equipment, a step that is essential before rendering services to ensure coverage. Yet, this form is often just the tip of the iceberg. There are several other documents and forms that typically accompany or are closely related to the MO 886-0858 form, each serving its unique role in ensuring a smooth process.
The process of obtaining prior authorization is a collaborative effort involving detailed documentation to support the request. Each supporting document plays a vital role in substantiating the need and eligibility for the services or equipment requested. With a comprehensive understanding and careful preparation of these documents, providers can navigate the prior authorization process more efficiently, helping ensure that their patients receive the necessary care without undue delay.
The Mo 886 0858 form, issued by the Missouri Department of Social Services, is designed for the purpose of Prior Authorization Requests within the MO HealthNet Division. This form shares similarities with other healthcare documents aimed at streamlining medical service requests, ensuring that patients receive the necessary care while also aligning with the protocols for insurance coverage and service eligibility verification.
One such document is the Centers for Medicare & Medicaid Services (CMS) 855I form. This form is utilized by individual healthcare providers to enroll in the Medicare program. Both the Mo 886 0858 and CMS 855I forms require detailed provider information, including the provider’s National Provider Identifier (NPI), the practice location, and specifics about the services provided. They play a crucial role in verifying the eligibility of providers to offer services under respective health programs and ensure that the details about the care or service to be provided are clearly documented for authorization or enrollment purposes. However, while Mo 886 0858 focuses on prior authorization for specific services or equipment, CMS 855I is more about establishing or maintaining a provider’s status within the Medicare system.
Another document with similarities is the Health Insurance Claim Form, also known as the CMS-1500. This form is widely used by healthcare providers to submit insurance claims for services rendered to patients. Like the Mo 886 0858 form, the CMS-1500 collects detailed information about the patient (such as name, date of birth, and insurance details), the provider (including NPI and taxonomy codes), as well as specifics about the diagnosis and procedure codes relating to the service provided. Both forms are integral to the healthcare billing process, ensuring that services are appropriately documented and billed to the correct payer. However, the Mo 886 0858 form is specifically designed for the MO HealthNet system to request prior authorization, while the CMS-1500 form spans a broader range of healthcare insurance billing across various payers.
Filling out the MO 886 0858 form for the Missouri Department of Social Services requires attention to detail and adherence to specific instructions. To ensure accuracy and improve the likelihood of approval, here are some dos and don'ts to consider:
Taking the time to carefully complete the MO 886 0858 form will help ensure that the request is processed efficiently and effectively, minimizing the risk of delays or denials due to administrative issues.
Understanding the MO 886 0858 form, commonly required for prior authorization by the Missouri Department of Social Services, is crucial for healthcare providers and participants. However, several misconceptions surround its use and requirements. It's important to clarify these to ensure the process goes smoothly for all involved.
Misconception #1: Approval guarantees payment. The authorization only approves the medical necessity of the requested service; it does not ensure payment nor confirm the reimbursed amount.
Misconception #2: The participant’s MO HealthNet eligibility is not required on the date of service. The truth is, eligibility on the date of service or when the equipment or prostheses are received is mandatory.
Misconception #3: Any section of the form can be left blank if deemed irrelevant. Actually, certain sections must be completed fully, even if they seem unnecessary; for example, the participant’s MO HealthNet number must always be included.
Misconception #4: A detailed medical necessity explanation isn’t crucial if the service is clearly essential. Regardless of perceived clarity, a detailed explanation is always required to justify the medical necessity.
Misconception #5: Prior Authorization forms can be used to submit additional information. If more space is needed, additional pages should be attached rather than using another form.
Misconception #6: Digital signatures are acceptable for all submission types. The form specifically requires a handwritten signature; digital signatures or signature stamps are not acceptable.
Misconception #7: The provider’s section is only for individual practitioners. If the service is provided by a clinic or group practice, their information must also be included in the relevant section.
Misconception #8: The form is only for services provided at a hospital or doctor’s office. Services rendered at home or other locations require the name and address of the facility where they will be provided.
Misconception #9: All sections of the form are reviewed by the same professional. The review process might involve different departments or professionals, especially in determining medical necessity and eligibility.
Clarifying these misconceptions ensures that the MO 886 0858 form is completed accurately, thereby facilitating a smoother prior authorization process. It's always recommended to review the instructions provided and consult with a professional if uncertainties remain.
Filling out and using the MO 886 0858 form, a Prior Authorization Request for the Missouri Department of Social Services MO HealthNet Division, requires careful attention to detail and an understanding of the form's requirements. Below are key takeaways to guide you through the process:
In conclusion, thoroughness, accuracy, and adherence to guidelines are essential when completing the MO 886 0858 form to request prior authorization for services under the MO HealthNet program. Understanding these key takeaways can facilitate a smoother process for both providers and participants, ultimately enabling timely and necessary care.
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