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.
The following review categories form the basis for the requirements for the
services performed for the MO Healthnet division.
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 (CON) Review:
Certification of Need reviews 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:
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MHD uses the following
definition of an Augmentative Communication Device (ACD). |
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(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 Review of Medical Assistance and Consultations:
Health Care Excel provides a broad base of physicians to review medical
records of special cases and to make recommendations. Health Care Excel
also, at the request of the state, conducts focused studies of MO HealthNet
service delivery and utilization in areas identified by the state agency on
an as-needed basis.
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 MO HealthNet eligible children.
| Prior Authorization Toll-Free : (800) 766-0686 Facsimile: (573) 634-4262 |
