PURPOSE: This rule establishes a regulatory basis for implementation of prior authorization on all out-of-state nonemergency MO HealthNet-covered services.

PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

1. (1) All nonemergency, MO HealthNet-covered services, except for those services exempted in section (6) of this rule, which are to be performed or furnished out-of-state for eligible MO HealthNet participants and for which MO HealthNet is to be billed, must be prior authorized in accordance with policies and procedures established by the MO HealthNet Division before the services are provided.
2. (2) Nonemergency services, for the purpose of the prior authorization requirement, are those services which do not meet the definition of emergency. Emergency services are defined as those services provided in a hospital, clinic, office, or other facility that is equipped to furnish the required care, after sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in a) placing the patient’s health in serious jeopardy, b) serious impairment to bodily functions, or c) serious dysfunction of any bodily organ or part.
3. (3) Out-of-state is defined as not within the physical boundaries of Missouri nor within the boundaries of any state which physically borders on the Missouri boundaries. Borderstate providers of services (those providers located in Arkansas, Illinois, Iowa, Kansas, Kentucky, Nebraska, Oklahoma, Tennessee) will be considered as being on the same MO HealthNet participation basis as providers of services located within Missouri for purposes of administration of this rule.
4. (4) The out-of-state provider of services must meet the requirements for participation in the MO HealthNet program and have a stateapproved participation agreement in effect in order to receive reimbursement for any covered service, emergency or nonemergency.

5. (5) The patient’s attending physician is responsible for obtaining prior authorization of the services s/he believes to be medically necessary.

   1. (A) Failure to obtain prior authorization for the services shall result in no payment by the MO HealthNet program.
   2. (B) All prior authorization requests must be submitted in accordance with policies and procedures established by the MO HealthNet Division as stated in the respective MO HealthNet Provider Manual and provider bulletins which are 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 www.dss.mo.gov/mhd, June 15, 2009. This rule does not incorporate any subsequent amendments or additions.
   3. (C) Prior authorization by the MO Health- Net agency shall approve the medical necessity of the covered services to be performed only. It shall not guarantee payment as the participant must be eligible on the date the service was provided.
   4. (D) Prior authorization expires one hundred eighty (180) days from the date a specific service was approved by the state.
   5. (E) All requests for prior authorization must be submitted to the Participant Services Unit of the MO HealthNet Division. The physician who is referring the patient for the nonemergency services must call or write the MO HealthNet Division for authorization.
   6. (F) Telephone prior authorizations may be granted.

6. (6) The following are exempt from the requirement for prior authorization of nonemergency MO HealthNet-covered services for out-of-state providers:

   1. (A) All services provided individuals having both Medicare and MO HealthNet coverage for which Medicare does provide coverage and is the primary payer (crossover claims);
   2. (B) All border state providers as defined in section (3) of this rule;
   3. (C) All foster care children living outside Missouri. Nonemergency services which routinely require prior authorization will continue to require prior authorization by out-ofstate providers even though the service was provided to a foster care child. Foster care 13 CSR 70-3

children are identified on the MO HealthNet ID card with a Type of Assistance (TOA) indicator of “D” or “Z”; and

1. (D) All independent laboratory and emergency ambulance services.

1. (7) All other policies and procedures applicable to the MO HealthNet program will be in effect for services provided by out-of-state providers.

AUTHORITY: sections 208.153 and 208.201, RSMo Supp. 2008.* This rule was previously filed as 13 CSR 40-81.190. Emergency rule filed Sept. 18, 1981, effective Sept. 28, 1981, expired Jan. 13, 1982. Original rule filed Sept. 18, 1981, effective Jan. 14, 1982. Amended: Filed Oct. 21, 1994, effective June 30, 1995. Amended: Filed May 14, 2009, effective Nov. 30, 2009.

*Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007 and 208.201, RSMo 1987, amended 2007.