Adult Brain Injury Program Provider Manual

Provider Application Process

Individuals, Agencies, or Rehabilitation Organizations may apply to be Providers for the ABI Program.

Provider qualifications vary for each service, and are listed on each service description page and summarized on the ABI Program Provider qualifications section of the Provider Manual. Contact the Provider Services Representative at (573)751-6246 for an application packet, visit the Adult Brain Injury Program Provider website [NEEDS LINK], or email shcnproviders@health.mo.gov.

The Provider Application Process is as follows:

Provider Responsibility

• Complete and return Provider Application (CC-35), Participation Agreement (DH-74A), Vendor Input /ACH-EFT Application. See instructions for assistance in completion. Send only one per agency, not one per service;
• Submit copies of current certification/licensure and educational transcripts;
• Maintain complete and current information. Inaccuracies in information submitted will jeopardize application or continuation of the Provider Participation Agreement and payment of claims;
• Assure that qualified individuals are hired and trained following the guidelines for each service for which approved.
• Note: The Provider must notify the Provider Service Representative if:
  • Business name, payment/mailing address, or county coverage changes; or
  • Tax ID Number changes
  • Financial/banking information

Provider Approval Process

The Provider Service Representative will process the Provider Application (CC-35), Participation Agreement (DH-74A) and Vendor Input/ ACH-EFT Application in the following manner:

• The Provider Service Representative will evaluate the information submitted against requirements for service(s) for which the Provider is requesting approval;
• Any questions or incomplete information remaining upon review of material submitted will be summarized in writing within two weeks of the date received to the Provider for a response. If possible, minor questions may be handled with a phone call;
• A signed copy of the Participation Agreement (DH-74A) and approval letter will be forwarded to the Provider when the approval process has been completed;
• Providers should allow approximately four weeks for the approval process to be completed, assuming all application forms and documentation are in order; and
• No claims will be reimbursed for services provided before the date the Provider is officially approved (date Participation Agreement is fully executed).
• Renewal of Participation Agreements must follow guidelines as documented on the most current Participation Agreement (DH-74A) form.