MEMORANDUM

DISCUSSION:

The purpose of this memo is to introduce the new MO HealthNet Spend Down Provider Form. If providers complete the form, the participants do not have to wait to receive an official bill to prove incurred medical expenses. Use of the form may allow more timely determination of the participant’s MO HealthNet coverage start date.

This memorandum discusses the following:

• USE OF MO HEALTHNET SPEND DOWN PROVIDER FORM
• REQUIRED INFORMATION ON MO HEALTHNET SPEND DOWN PROVIDER FORM
• NOTICES

USE OF MO HEALTHNET SPEND DOWN PROVIDER FORM

The MO HealthNet Spend Down Provider Form can be used when:

• A provider is unable to generate an official bill that includes the date of service, type of service, third party payment and patient responsibility; or
• A provider is able to generate an official bill with the date of service, type of service, third party payment, and patient responsibility, but is unable to provide this at the time the service is provided.

REQUIRED INFORMATION ON THE MO HEALTHNET SPEND DOWN PROVIDER FORM

When the MO HealthNet Spend Down Provider Form is received in the local FSD office, the ES must review the form to ensure it includes the following:

• Name and MO HealthNet Number (this is the same as the Department Client Number (DCN));
• Date of service, type of service, name of liable third party (if applicable), total amount of charge, amount of third party responsibility, amount of patient responsibility; and
• Name of person completing the form, title, agency name, and the signature of the person completing the form.

NOTICES

When the form is received with all of the required information and the participant meets spend down with the expenses listed on the form, or with a combination of the expenses listed on the form and other submitted expenses, the ES authorizes the spend down coverage and notifies the participant using the Spend Down Notification (IM-29 (SPND)) form.

When the form is received with none or only part of the required information, send the IM-29 (SPDN) form to the participant listing the date on the Provider Form, the provider information, and explaining the reason it was not applied to the spend down liability.

When the form is received with incurred medical expenses that are not allowable expenses to meet spend down, send the IM-29 (SPND) form to the participant listing the bills that were not used to meet spend down with the reason it was not applied to the spend down liability.

NECESSARY ACTION:

• Review this memorandum with appropriate staff.
• Provide the form to participants and to providers who request a copy of the form.
• Effective immediately, accept a completed MO HealthNet Spend Down Provider Form as documentation of incurred medical expenses to meet spend down.

ATTACHMENTS:

• MO HEALTHNET SPEND DOWN PROVIDER FORM

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