PURPOSE: This rule implements the requirement that claims for reimbursement by the Missouri Medical Assistance Program (Medicaid) be submitted electronically.

1. (1) “Electronic claim” means a claim that is submitted via electronic media.

2. (2) Electronic submission of Medicaid claims for services rendered under the Medicaid program is required. A Missouri Medicaid claim may be paid only if submitted as an electronic claim for processing by the Medicaid Management Information System.

   1. (A) To utilize the Internet for electronic claim submissions the provider must apply online via the Application for Missouri Medicaid Internet Access Account link.
   2. (B) Each user is required to complete this online application to obtain a user ID and password.
   3. (C) The enrolled Medicaid provider shall be solely responsible for the accuracy and authenticity of said electronic media claims submitted, whether submitted directly or by an agent.
   4. (D) The enrolled Medicaid provider shall agree that services described on the electronic media claim are true, accurate, and complete.
   5. (E) The enrolled Medicaid provider certifies that services described on the electronic media claim are personally rendered by the provider.

3. (3) State required supporting documentation (paper attachments) must be maintained at the place of service for auditing purposes.

   1. (A) The failure of the enrolled Medicaid provider to keep or furnish, or both, such information shall constitute grounds for the disallowance and recoupment of all applicable charges or payments.
   2. (B) The enrolled Medicaid provider shall be responsible for refund of any payments that result from claims being paid inappropriately or inaccurately.
   3. (C) The records shall be maintained for five (5) years, unless the records are the subject of an audit or litigation. Records that are the subject of an audit or litigation shall be maintained until the conclusion of the audit or litigation.

4. (4) Medical record documentation shall support the medical necessity of the service being provided as well as the frequency of the service. The provider shall establish and maintain a record containing the signature of each recipient of service furnished by the Medicaid enrolled provider or, when applicable, the signature of a responsible person made on behalf of the recipient. Clinical laboratories, radiologists, and pathologists are exempt from the requirement that a Medicaid enrolled provider establish and maintain a record containing the signature of each recipient of service. A physician’s order shall be documented in the medical record. Clinical laboratories, radiologists, and pathologists shall maintain a record of the ordering physician for a Medicaid service for which they request reimbursement.

   1. (A) The failure of the enrolled Medicaid provider to keep or furnish, or both, such information shall constitute grounds for the disallowance and recoupment of all applicable charges or payments.
   2. (B) The enrolled Medicaid provider shall be responsible for refund of any payments that result from claims being paid inappropriately or inaccurately.
   3. (C) The records shall be maintained for five (5) years, unless the records are the subject of an audit or litigation. Records that are the subject of an audit or litigation shall be maintained until the conclusion of the audit or litigation.

5. (5) The provider shall keep such records, including original source documents, as are necessary to disclose fully the nature and extent of services provided to recipients under the Missouri Medical Assistance (Medicaid) Plan and to furnish information regarding any payment of claims for providing such services as the Division of Medical Services, or its designee, may request. The enrolled Medicaid provider agrees that the service was medically necessary for the treatment of the condition as indicated by the diagnosis and shall maintain records, including source documents, to verify such.

   1. (A) The failure of the enrolled Medicaid provider to keep or furnish, or both, such information shall constitute grounds for the disallowance and recoupment of all applicable charges or payments.
   2. (B) The enrolled Medicaid provider shall be responsible for refund of any payments that result from claims being paid inappropriately or inaccurately.
   3. (C) The records shall be maintained for five (5) years, unless the records are the subject of an audit or litigation. Records that are the subject of an audit or litigation shall be maintained until the conclusion of the audit or litigation.
6. (6) The enrolled Medicaid provider must identify and bill third party insurance and Medicare coverage prior to billing Medicaid.
7. (7) Sufficient security procedures must be in place to ensure that all transmissions of documents are authorized and protect recipient specific data from improper access.
8. (8) The provider is responsible for assuring that electronic billing software purchased from any vendor or used by a billing agent complies with billing requirements of the and Procedure of General Applicability

Medicaid program and shall be responsible for modifications necessary to meet electronic billing standards.

1. (9) The enrolled Medicaid provider agrees to accept as payment in full the amount paid by Medicaid for the electronic media claims submitted for payment.

2. (10) The submission of an electronic media claim is a claim for Medicaid payment.

   1. (A) Any person who, with intent to defraud or deceive, makes, causes to be made, or assists in the preparation of any false statement, misrepresentation or omission of a material fact in any claim or application for any claim, regardless of amount, knowing the same to be false, is subject to civil or criminal sanctions or both under all applicable state and federal statutes.

AUTHORITY: sections 208.153 and 208.201, RSMo 2000. Original rule filed April 29, 2005, effective Nov. 30, 2005.*

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