PURPOSE: This rule states the function and general organization of the Division of Medical Services to comply with the requirements of section 536.023, RSMo.

1. (1) General Authority and Purpose.

   1. (A) The Missouri Division of Medical Services was created within the Department of Social Services by executive order of the governor on February 27, 1985. The Missouri General Assembly granted statutory authority to the division by adding section 208.201, RSMo effective September 28, 1987. The Division of Medical Services operates under the provisions of Chapter 208, RSMo and Title XIX of the federal Social Security Act.
   2. (B) The Division of Medical Services is responsible for the administration of the medical assistance program in Missouri except for the determination of recipient eligibility for the program, which shall be the responsibility of the Division of Family Services.

2. (2) Organization and Operations. The Division of Medical Services is located in Jefferson City at 615 Howerton Court. Contact can be made by writing to the division at P.O. Box 6500, Jefferson City, MO 65102-6500. The Division of Medical Services is divided into six (6) major organizational components—administration and five (5) sections— institutional reimbursement, management services, operations, planning and budget, and policy.

   1. (A) The director is in charge of the administration of the division. The director employs the necessary personnel and designates the subdivisions needed to perform the duties and responsibilities of the division. In addition to providing the overall direction of the agency, Administration is responsible for overseeing the filing of all state plan amendments and regulations, all aspects of personnel-related issues and directing of the Managed Care Program.
   2. (B) The Institutional Reimbursement section is responsible for the administration of payments to hospitals, nursing facilities, and rural and federally qualified health clinics.
   3. (C) The Management Services section is responsible for the administration and monitoring of consultant and professional services contracts. Other management services activities include third-party liability identification and recovery, claims adjustments and cash control. Management Services is also responsible for administering the payment of Medicare Part B premiums (Medicare Buy-In), the Qualified Medicare Beneficiary (QMB) program and the Health Insurance Premium Payment (HIPP) program.
   4. (D) Operations is organized into six (6) units: Medicaid Management Information Systems (MMIS), Surveillance and Utilization Reviews, Provider Enrollment, Provider Education, Provider Communications, and Recipient Services. The operations section is responsible for monitoring the state’s contract with the fiscal agent, investigation of over utilization or noncompliance with Medicaid policies and regulations, reviewing compliance of hospitals’ utilization review plans, initiating administrative sanctions of providers due to disciplinary action by a professional licensing board, Medicare exclusion, repeated patterns of abuse or fraud against the Medicaid program, claims processing and maintaining reporting systems. Operations is also responsible for the program relations functions.
   5. (E) The Planning and Budget section is responsible for preparation of the annual budget, preparation of fiscal note estimates for proposed legislation, and forecasting and monitoring Medicaid expenditures throughout the fiscal year.
   6. (F) The Policy section is responsible for researching, developing implementing and monitoring programs that are the responsibility of the Medicaid agency.

AUTHORITY: section 208.201, RSMo Supp. 1987.* This rule was previously filed as 13 CSR 40-81.005. Emergency rule filed Sept. 15, 1987, effective Sept. 28, 1987, expired Jan. 25, 1988. Original rule filed Oct. 1, 1987, effective Jan. 29, 1988. Amended: Filed July 2, 1992, effective Feb. 26, 1993.

*Original authority: 208.201, RSMo 1987.