Missouri WISEWOMAN Program Manual

WISEWOMAN billing and reimbursement guidelines for providers outlined in this section are effective September 30, 2021-September 29, 2022 and replace all other existing billing guidelines. WISEWOMAN reimbursement rates are set based on Medicare CPT Code rates and are subject to change, typically with the fiscal year. Please see the MOHSAIC section for guidelines on claim submission.

Clinical Services Reimbursement

The WISEWOMAN Program will provide reimbursement for services including; completed cardiovascular screening, laboratory tests, Risk Reduction Counseling, diagnostic and other medical follow-up. WISEWOMAN clinical services will be directly reimbursed through the provider’s annual contract, with awarded funds loaded in MOHSAIC. In order to be considered for payment, WISEWOMAN services must be entered into the MOHSAIC data system within sixty (60) days of the service being performed. If a participant has an ALERT value, claim submission must occur within seven (7) days. Providers will only be paid for cases that meet eligibility, performance and data requirements.

WISEWOMAN Reimbursement Guidelines

In Accordance with Public Law 101-354 and Its Amendments, Reimbursement Guidelines for the WISEWOMAN Program Include:

• MDHSS/WISEWOMAN must be the payer of last resort
• MDHSS reimbursements are considered payment in full
• Service providers and their subcontractors shall not charge the participant for any screening/diagnostic services reimbursable by MDHSS
• MDHSS participants shall not be charged with any administrative fees
• When services other than WISEWOMAN cardiovascular risk assessment are performed, documentation shall be provided verifying the participant was notified in advance of these services and their costs
• Grantees cannot use WISEWOMAN funds to pay for any services that are covered by a State compensation program, an insurance policy, a federal or state health benefits program or an entity that provides health services on a prepaid basis

Reimbursable WISEWOMAN Clinical Services

• Cardiovascular screening, laboratory tests and Risk Reduction Counseling services, as outlined in those respective sections of this manual
• Follow-up visit(s) with a provider for ALERT values, untreated disease-level values and uncontrolled hypertension
• Participation in lifestyle programs or Health Coaching
• Administrative procedures to ensure access to affordable medication for women who require it
• Costs associated with WISEWOMAN referrals for HBSS

Exclusions and Exceptions for Reimbursements

Use of WISEWOMAN Funds Are Not Allowed for the Following Services:

• Services provided to ineligible women
• Standards outlined in the Provider Manual, as stated in Clinical Screening Services Section, are not met
• Required data reporting forms are not submitted into MOHSAIC within 60 days of service (or 7 days for an ALERT value), with the exception of filing with participant’s insurance, which must be submitted within 30 days from receipt of the Explanation of Benefits (EOB)
• Participant’s original enrollment and office visit (paid for by SMHW)
• Laboratory tests other than those on the allowable CPT Code List
• Medication or other medical treatment or procedures for clinical conditions

Resubmission for denied service will only be considered one time. Submit questions pertaining to participant’s data reporting form for service denied/adjusted to the MDHSS by telephone toll-free at 866-726-9926 or fax 573-522-3023. Denial will be explained or reconsidered. No further resubmission will be accepted after the second denial.

Timing of Reimbursements

• Reimbursements are made at MDHSS through a warrant
• On average, warrants are run every 3 weeks, typically on Thursdays
• Reimbursement from the warrant run will be based on the completed and approved WISEWOMAN services that have met data and quality standards in MOHSAIC, as of the date of the warrant
• Reimbursement payments are produced by and electronically transferred from the MDHSS comptroller’s office
• Payment vouchers are mailed to the providers from the WISEWOMAN central office, outlining the claims and services that have been paid and the amount reimbursed with WISEWOMAN funding
• Each payment received will include a payment voucher

Tracking Budgets

• Each provider receives a funding amount to be used to provide services through the WISEWOMAN Program each fiscal year
• WISEWOMAN providers are responsible for tracking their funding amounts
• Once a provider’s total budget amount has been reached, the WISEWOMAN program may not pay for any additional expenses incurred by the provider
• When 80 percent of the provider contract total for WISEWOMAN funds are expended, the provider will be notified and they should contact the WISEWOMAN central office to request an amendment to increase funding
• Providers that are under-spent in their budgets may have funds taken back and reallocated to other providers at any time during the contract period
• WISEWOMAN staff will send each provider contract expenditures semi-annually

Overpayments

When an overpayment has occurred, please notify the WISEWOMAN staff and your RPC. A paper check for each participant will need to be sent in for the overpayment amount.

Include the following information on the check:

• Provider agency
• Participant’s full name
• Date of birth
• Date of service
• Program to return funds to

Please Make the Check Payable to Department-DA-Fee Receipts and Mail To:

MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
DIVISION OF ADMINISTRATION, FEE RECEIPTS
P.O. BOX 570
920 WILDWOOD DRIVE
JEFFERSON CITY, MO 65102-0570

Reporting Only Submission

If a WISEWOMAN participant receives cardiovascular screening services that do not meet the requirements for a valid WISEWOMAN screening, a MOHSAIC claim submission can be entered as “Reporting Only.” A Reporting Only claim will have no reimbursement cost for the provider, but will be used to track data on WISEWOMAN participants. Examples of appropriate Reporting Only claims include:

• Incomplete screening (e.g. missing labs, only one BP measure, no height/weight)
• Additional labs not covered by the WISEWOMAN Program
• Diagnostic information from an outside provider

HBSS Reimbursement Guidelines

If providers choose to sign a LOA for additional funding for HBSS, they will be reimbursed using invoice submission to the WISEWOMAN Program. Invoices can be faxed to WISEWOMAN staff at 573-522-3023. Every LSP and HBSS has a reimbursement cap per participant for the grant year. Similar to clinical service funding, providers are responsible for tracking their LOA funding. If a provider is in need of additional funding, please contact the WISEWOMAN Program Manager to request an amendment for additional funding.

LSP/HBSS Reimbursement Caps

• Fitness Club/Gym Memberships: $360.00/year, including the joining fee
• Fitness Class: $30.00 for a 4‐6 week class or a total cost of $200.00/year
• TOPS: $32.00 yearly fee and no more than $5.00 weekly fee, if necessary
• Weight Watchers: $800.00/year for membership every 3 months
• DPP: $500.00/year