Missouri Administrative Code

HealthNet Pharmacy Program (Rescinded January 30, 2019) . . . . . . . . . . . 4

Treatment of Acquired Immunodeficiency Syndrome (AIDS) (Rescinded September 30, 2018) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Required (Rescinded May 30, 2019) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

(Rescinded January 30, 2019) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 13 CSR 70-20.042 Automatic Refill Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

(2) Prescriptions that are exempt from the thirty-one- (31-) day supply limit and therefore may be dispensed in quantities PURPOSE: This rule establishes the regulatory basis to prohibit exceeding a thirty-one- (31-) day supply are made available automatic refill of prescriptions…

MO HealthNet Division . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 13 CSR 70-20.047 Ninety-Day Supply Requirement for Select Prescriptions . . . . . . . . . . . . . . 5 13 CSR 70-20.050 Return of Drugs . . . . . . . . . . . . . . . . .…

plus an adjustment to account for the costs of the Missouri PURPOSE: This rule establishes that pharmacies must give the MO Pharmacy Reimbursement Allowance attributable to Medicaid- HealthNet Division credit for any unused portion of the drug that reimbursed prescriptions; is re…

(C) Indicate, as prescribed by the MO HealthNet Division, on PURPOSE: The MO HealthNet Division establishes the amount of each claim that the prescription was provided in packaging 6 CODE OF STATE REGULATIONS (4/30/25) Denny Hoskins Secretary of State 13 CSR 70-20—DEPARTMENT OF S…

effective Dec. 11, 1981. Emergency amendment filed Oct. 19, 1987, PURPOSE: This rule establishes the basis and the method for effective Oct. 29, 1987, expired Feb. 25, 1988. Amended: Filed Dec. pricing all drug claims in Missouri under the Title XIX Medicaid 1, 1987, effective Fe…

on Reimbursement (Rescinded September 30, 2018) . . . . . . . . . . . . . . . . . . 7 13 CSR 70-20.075 340B Drug Pricing Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Denny Hoskins (12/31/25) CODE OF STATE REGULATIONS 1 Secretary of Sta…

(Rescinded September 30, 1991) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Acquired Immunodeficiency Syndrome (AIDS) (Rescinded September 30, 1991) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

(Rescinded June 29, 1989) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 13 CSR 70-20.200 Prescription Prior Authorization Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 13 CSR 70-20.250 Prior Authorization of New Drug E…

after all recommendations have been reviewed. All pertinent PURPOSE: This rule establishes the MO HealthNet Division (MHD) information relating to the edit implementation schedule process by which drugs may be restricted under Section 4401 of and the edit criteria shall be made a…

(5) MHD shall post the tentative meeting agenda on the MHD or New Drug Dosage Form website (https://mydss.mo.gov/mhd/pharmacy-committees) at least seven (7) days before the meeting, and the agenda will PURPOSE: This rule outlines how new drugs or new drug dosage include the thera…

PURPOSE: This rule establishes the MO HealthNet Division (MHD) (10) The DUR Board shall advise MHD regarding all activities process by which the Drug Utilization Review Board is established associated with the DUR process, including identifying types as required by Section 4401 o…

Patient Counseling document for each MHD patient’s prescription uniformly whether the offer to counsel was accepted or refused by the PURPOSE: This rule establishes provisions for prospective drug use patient or the patient’s agent. review and patient counseling for MO HealthNet …

correct, unless the pharmacy files a protest in accordance with PURPOSE: This rule establishes a Pharmacy Federal Reimbursement subsection (2)(D) of this regulation. Allowance and the methodologies to determine the formula for the amount of allowance each pharmacy is required to …

Program (B) Providing medication education; (C) Providing self-care education for specific chronic PURPOSE: This rule establishes the regulatory basis for the conditions; administration of the MO HealthNet Medication Therapy (D) Contacting physicians to schedule diagnostic testin…

PURPOSE: This rule implements the National Drug Code (NDC) requirement for all medications administered in the clinic or outpatient hospital setting. The Deficit Reduction Act of 2005 (DRA) requires states to collect rebates for certain physician- administered drugs. (1) Drug cha…

tion available to eligible participants. The components of the PURPOSE: This rule complies with Federal Law and rules relating general physical examination shall include a comprehensive to abortions and maintains compliance with the requirements of health and developmental histor…

Program Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Certain Physicians in Calendar Years 2013 and 2014 (Rescinded September 30, 2018) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 13 CSR 70-25.130 Diabetes Prevention Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1…

one hundred twenty-five (125) mg/dl; or PURPOSE: The purpose of this rule is to establish the Department 3. Two (2) hour plasma glucose of one hundred forty (140) of Social Services’ MO HealthNet Division guidelines regarding to one hundred ninety-nine (199) mg/dl after the seven…

Youth and Adults of BMI values as expressed in percentiles for age and gender as plotted on the pediatric BMI chart. PURPOSE: This rule establishes the MO HealthNet payment policy B. “Pediatric Body Mass Index (BMI) Chart” means a for the biopsychosocial treatment of obesity for …

Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 13 CSR 70-25.160 Doula Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Denny Hoskins (5/31/26…

program and be deemed competent to provide doula services. PURPOSE: This rule establishes the Department of Social Ser- Certification is attained after evaluation by a birth professional vices’ MO HealthNet Division guidelines regarding coverage and or trainer; reimbursement for …

Center Services................................................................................3 JOHN R. ASHCROFT (4/30/19) CODE OF STATE REGULATIONS 1 Secretary of State Chapter 26—Federally-Qualified Health Center Services 13 CSR 70-26 Title 13—DEPARTMENT OF Net charges shall i…

(Rescinded March 30, 2022) at which the service was rendered, unless the services were provided in the participant’s home, via a mobile unit, or AUTHORITY: sections 208.159, 208.164, and 210.924, RSMo 2000 other circumstance that would require the records be kept at and sections …

Claims for MO HealthNet Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

in Recovering Third-Party Payments (Rescinded November 30, 2018) . . . 9

(Rescinded February 28, 2022) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

(Rescinded August 11, 1988) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 13 CSR 70-3.100 Filing of Claims, MO HealthNet Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 13 CSR 70-3.105 Timely Payment of MO HealthNet Claims . .…

Operations (Rescinded June 30, 2011) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

(Rescinded April 30, 2019) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 13 CSR 70-3.140 Direct Deposit of Provider Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . 13 13 CSR 70-3.150 Authorization To Receive Payment for Med…

effective March 30, 2022. PURPOSE: This rule requires the direct deposit of MO HealthNet *Original authority: 208.201, RSMo 1987, amended 2007, and 660.017, RSMo 1993, provider payments and describes the procedure by which those amended 1995. payments will be made. PUBLISHER’S NO…

Remittance Advices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Denny Hoskins (1/29/26) CODE OF STATE REGULATIONS 1 Secretary of State…

(Rescinded November 30, 2021) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 13 CSR 70-3.180 Medical Pre-Certification Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 13 CSR 70-3.190 Telehealth Services (Rescinded Janua…

PURPOSE: This rule establishes the medical pre-certification (6) Pre-certifications for exactly the same service may be process of the MO HealthNet Program for certain covered diagnostic granted to allow provision over an extended period of time and and ancillary procedures and s…

in paragraph (1)(A)5. (Rescinded January 30, 2019) A. Exceptions. AUTHORITY: section 208.201, RSMo Supp. 2008. Original rule filed (I) For emergency ambulance providers without Jan. 2, 2008, effective Aug. 30, 2008. Amended: Filed Feb. 17, 2009, reported data, emergency transport…

Allowance (b) Emergency transport mileage shall be individually summed and divided by the total emergency PURPOSE: This rule establishes the formula for determining ambulance transports in the quartile to yield an average per the Ambulance Service Reimbursement Allowance each gro…

written notice of the final determination of its ambulance service reimbursement allowance, may file a protest with the PURPOSE: This rule advises MO HealthNet providers of the director of the department setting forth the grounds on which opportunity to store records on an electr…

(I) Their individual Medicaid patient encounters as a PURPOSE: The Health Information Technology and Clinical Health percentage of their total individual encounters; or Act (HITECH) offers incentive payments to encourage eligible (II) The practice’s total Medicaid encounters as a…

Conditions the occurrence of HCACs based on the POA indicator, and calculate the payment recoupments based on the facts of each PURPOSE: This rule establishes the MO HealthNet payment policy HCAC, for hospitals reimbursed on a per diem. for services provided by acute care hospita…

(E) It must utilize an interoperable patient registry to input PURPOSE: This rule establishes the MO HealthNet Primary Care annual metabolic screening results, track and measure care of Health Home program for MO HealthNet participants with individuals, automate care reminders, a…