Mo. Code Regs. tit. 13 § 70-70.010
Current through Register Vol. 49, No. 18, September 16, 2024
Section 13 CSR 70-70.010 - Adjustments to the Distribution of St Louis County Cigarette Tax Funds Pursuant to the Federal Decennial CensusPURPOSE: This proposed amendment will allow the provision of speech, occupational, and physical therapy services by licensed and enrolled speech, occupational, and physical therapy assistants. The proposed amendment will also allow occupational therapists to provide medically necessary covered behavioral health services within the scope of their practice to MO HealthNet participants.
(1) Administration. The MO HealthNet therapy program shall be administered by the Department of Social Services, MO HealthNet Division. The therapy services covered and not covered, the limitations under which services are covered, and the maximum allowable fees for all covered services shall be determined by the MO HealthNet Division and shall be included in the Therapy Provider Manual, which is incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at http://manuals.momed.com/collections/collection_the/print. pdf, January 31, 2023. This rule does not incorporate any subsequent amendments or additions. Therapy services shall include only those which are clearly shown to be medically necessary as determined by the physician, advanced practice registered nurse, or other practitioner of the healing arts. The division reserves the right to effect changes in services, limitations, and fees with notification to therapy providers by amending this rule.(2) Participants Eligible. Medically necessary therapy services as determined by the physician, advanced practice registered nurse, or other practitioner of the healing arts are covered for individuals under the age of twenty-one (21). The Healthy Children and Youth (HCY) Program (also known as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)) ensures a comprehensive, preventive health care program for MO HealthNet eligible children under the age of twenty-one (21) years. The Omnibus Budget Reconciliation Act of 1989 (OBRA-89) mandated that MO HealthNet-covered services be provided, based on medical necessity as identified in a HCY (EPSDT) well-visit and interperiodic screening. These services include physical, occupational, and speech/language therapy services. The participant must be eligible on the date the service is furnished. Participants may have specific limitations to therapy program services according to the type of assistance for which they have been determined eligible. It is the provider's responsibility to determine the coverage benefits for a participant based on their type of assistance as outlined in the Therapy Provider Manual. The provider shall ascertain the patient's MO HealthNet status before any service is performed. The participant's eligibility shall be verified in accordance with methodology outlined in the therapy provider program manual.(3) Provider Participation. (A) To be eligible for participation in the MO HealthNet therapy program, a provider must meet the criteria specified for his or her profession as outlined in the therapy provider program manual and be an enrolled MO HealthNet provider.(B) To be eligible for participation in the MO HealthNet therapy program as a therapy assistant, a provider must be licensed according to state law and provide services under the direction of a qualified therapist.(C) The enrolled MOHealthNet provider shall agree to- 1. Keep any records necessary to disclose the extent of services the provider furnishes to participants; and2. On request furnish to the Department of Social Services or state Medicaid Fraud Control Unit any information regarding payments claimed by the provider for furnishing services under the plan.(4) Covered Services. The participant shall have a referral for speech therapy services from a MO HealthNet-enrolled physician, advanced practice registered nurse, or other practitioner of the healing arts. The participant shall have a prescription for occupational and physical therapy services from a MO HealthNet-enrolled physician, advanced practice registered nurse, or other practitioner of the healing arts.(5) Reimbursement. Payment will be made in accordance with the established fee as defined and determined by the MO HealthNet Division. Providers must bill their usual and customary charge for therapy services. Reimbursement will not exceed the lesser of the maximum allowed amount determined by the MO HealthNet Division or the provider's billed charges. Physical, occupational, and speech therapy services are only payable to the enrolled, eligible, participating provider. The MO HealthNet program cannot reimburse for services performed by non-enrolled persons.(6) Documentation. For physical, occupational, and speech therapy services, the MO HealthNet Division requires compliance with 13 CSR 70-3.030 and that the following documentation be included in the participant's record: (A) First name, last name, and either middle initial or date of birth of the MO Health-Net participant;(B) Date the service was provided (month/day/year);(C) An accurate, complete, and legible description of each service(s) provided for the participant (more than "treatment given") on the specific date of service;(D) Individual or group therapy (the provider must document the type of therapy given);(E) The actual begin and end time taken to deliver the service must be clearly documented in the client record (e.g., 4:00-4:15 p.m.); providers cannot bill for charting time, only the time they spend doing the therapy;(F) The signature of the enrolled therapist or enrolled therapy assistant who provided the service;(G) The official Individual Education Plan (IEP) or Individual Family Services Plan (IFSP) which must be in the record when billing therapy with a WQ modifier;(H) The setting in which the service was rendered; and(I) The plan of treatment, evaluation(s), test(s), findings, results, and prescription(s) as necessary.(7) Records Retention. Sanctions may be imposed by the Department of Social Services against a provider for failing to make available, and disclosing to the Department of Social Services or its authorized agents, all records relating to services provided to MO HealthNet participants or records relating to MO HealthNet payments, whether or not the records are commingled with non-Title XIX (Medicaid) records in compliance with 13 CSR 70-3.030. These records must be retained for six (6) years from the date of service. Fiscal and medical records coincide with and fully document services billed to the MO HealthNet agency. Providers must furnish or make the records available for inspection or audit by the Department of Social Services or its representative upon request. Failure to furnish, reveal, or retain adequate documentation for services billed to the MO HealthNet program, as specified above, is a violation of this regulation. AUTHORITY: sections 208.153 and 208.201, RSMo Supp. 2013.* Original rule filed Nov. 1, 2002, effective May 30, 2003. Amended: Filed June 1, 2006, effective Dec. 30, 2006. Amended: Filed Oct. 15, 2008, effective May 30, 2009. Amended: Filed Sept. 26, 2013, effective March 30, 2014. Amended by Missouri Register January 3, 2022/Volume 47, Number 1, effective 2/28/2022Amended by Missouri Register September 15, 2023/Volume 48, Number 18, effective 10/31/2023*Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007 and 208.201, RSMo 1987, amended 2007.