- TO:
- ALL COUNTY OFFICES
- FROM:
- ALYSON CAMPBELL, DIRECTOR
- SUBJECT:
- REQUEST FOR PARTICIPANT MO HEALTHNET REIMBURSEMENT FORM (IM-64) REVISED
- FORMS MANUAL REVISION #10
DISCUSSION:
The purpose of this memorandum is to introduce the revised Request for Participant MO HealthNet Reimbursement form (IM-64) and instructions. The IM-64 is updated to use current terminology and to allow reimbursement requests based on monthly spend down eligibility rather than quarters. This form is used to notify the MO HealthNet Division when a claimant is requesting reimbursement for incorrectly denied medical expenses that were paid by the claimant. The IM-64 should be completed when:
- The medical provider has not and will not reimburse the individual who paid for services.
- The Services were received during a period that the individual is later determined eligible for MO HealthNet coverage because of a:
- hearing decision, or
- decision by an eligibility specialist (ES) and ES supervisor that benefits were incorrectly denied.
The revisions include:
- Medicaid is changed to MO HealthNet.
- Spend down quarters is replaced with months.
- Recipient is changed to participant.
- Recipient Services is now Participant Services.
- Caseworker is updated to eligibility specialist.
- Division of Medical Services (DMS) is now MO HealthNet Division (MHD).
- Spenddown is changed to spend down.
NECESSARY ACTION:
- Review this memorandum with appropriate staff.
- Immediately begin using the revised Request for Participant MO HealthNet Reimbursement form (IM-64) with the 2/13 revision date.
AC/KS/VB