MO HealthNet Utilization Review

Health Care Excel (HCE) was again selected as the Prior Authorization and Utilization Review contractor with the State of Missouri's MO HealthNet Division (MHD) and has now served as the UR agent since 2001. The MHD is part of the Department of Social Services (DSS). The categories of reviews are Inpatient Hospital Prior Authorization and Utilization, Certification of Need, Augmentative Communication Devices, Specialty Pediatric Hospital Post-Payment Reviews, and General Medical Assistance and Consultation.

Inpatient Hospital Prior Authorization and Utilization Review:

Health Care Excel's objectives are to serve as a utilization management measure allowing payment only for those inpatient days that are medically necessary, reduce over-utilization, and identify concerns in the level of care or quality of covered services that are funded by MO HealthNet.

Certification of Need Review:

Certification of Need reviews (CON) are post-payment desk audits of inpatient admissions to psychiatric facilities. HCE monitors compliance with federal and state requirements for inpatient psychiatric services provided to MO HealthNet eligible individuals under the age of 21 years. The review includes an audit for medical necessity, documentation compliance, and quality of care issues.

Augmentative Communication Devices Review:

MHD uses the following definition of an Augmentative Communication Device (ACD).

Augmentative Communication Devices are speech prosthesis and are regarded as durable medical equipment. ACDs are alternative and supplemental communication equipment used to overcome or ameliorate an individual's inability to communicate due to a disease or medical condition that precludes or significantly interferes with participation in activities of daily living.

(MO HealthNet Provider Bulletin dated November 18, 1999)

ACD reviews are conducted to determine the medical necessity of a device and related training for participants and their families.

General Medical Assistance and Consultations:

HCE provides general medical assistance and consultation services for the State Agency on an as-needed basis. Such services entail specialist reviews and focused studies.

Specialty Pediatric Hospital Post-Payment Reviews

Specialty Pediatric Hospital Post-Payment reviews are desk audits of inpatient admissions to specialized pediatrics hospitals. HCE monitors compliance with state requirements for inpatient pediatric services provided to Medicaid eligible children.

Prior Authorization
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