Policy: To provide tuberculosis evaluation services for those who have been identified as infected with or suspected of having tuberculosis and are without health insurance or are underinsured.

Purpose: To control and eliminate tuberculosis through a comprehensive system of diagnostic evaluation, appropriate and effective treatment, consultation, technical assistance, and education.

Procedure:

1. The patient is identified by the Local Public Health Agency (LPHA) as being tuberculin skin test positive, and is not covered by health insurance, or is underinsured, preventing the patient from accessing diagnostic medical evaluation for tuberculosis.
   1. The Missouri Department of Health and Senior Services (DHSS) TB Elimination Program determines eligibility at the request of the LPHA, as funding allows.
2. The LPHA chooses a physician from the Diagnostic Services Providers list located in the TB Manual; Appendices/Other Resources
3. The LPHA completes the Diagnostic Services Eligibility/Authorization Form and sends the form to the DHSS TB Elimination Program for authorization.
   1. The LPHA should indicate the services requested for the patient, prior to faxing the form to the program, only if they are requesting services other than an initial office visit (OV), chest x-ray (CXR), and interpretation of the CXR.
4. The Diagnostic Services Program Manager assigns a prior-authorization number, indicates which services are approved and faxes the signed form and billing instructions for the provider back to the LPHA.
5. The LPHA schedules an appointment for the patient, faxes a copy of the approved authorization form to the provider(s), and ensures that appropriate follow-up takes place.
6. If TB medications are prescribed for the patient, the physician sends a copy of the prescription for the entire prescribed course of medications to the LPHA.
7. The LPHA sends the prescriptions to the DHSS TB Elimination Program State TB nurse for authorization of medications to be provided by the TB Elimination Program.
8. Upon receipt of the State TB nurse’s authorization of the medication request, the LPHA faxes the prescription and authorization form to the contract pharmacy.
   1. The LPHA provides the medications and routine patient monitoring on a monthly basis.
      
      For more information see the TB Manual; Case Management; Disease/Obtaining Medications
9. All bills for services provided through the DSP program are to be submitted to the Missouri Department of Health and Senior Services, TB Elimination Program, not to the LPHA, or patient.
10. All clinical specimens for diagnostic tests are to be sent to the State Public Health Laboratory (SPHL)/TB Unit so that there will be no costs incurred by either the participating physician or the patient.

Program Guidelines

An increased demand for outpatient services for tuberculosis has been experienced by the Local Public Health Agencies (LPHA). One of the shortcomings of public health is the difficulty in accessing care. With the help of the Diagnostic Services Program (DSP), uninsured and underinsured patients can seek the diagnosis and treatment they need.

General Program Guidelines:

1. The rate of reimbursement shall be the established rate listed under the service description at the end of this section.
2. Prior to providing program services, providers shall assure that the client has been authorized to receive services from the Missouri Department of Health and Senior Services (DHSS) TB Elimination Program. DHSS will not reimburse providers for services that are provided prior to authorization.
3. Prior to the LPHA making an appointment with a DSP provider, the LPHA must request authorization from the DHSS TB Elimination Program. The LPHA provides the following information in the request:
   1. Patient’s name
   2. Date of birth
   3. Social Security Number
   4. Telephone number
   5. Address

4. All providers may submit bills on any standard invoice or billing form. The procedure codes and pre-authorization number listed on the Diagnostic Services Eligibility/Authorization form must be included. Providers shall not submit results of the lab work, progress notes, or any other type of medical information. Bills should be submitted in an encrypted email to: TBProgram@health.mo.gov or faxed to (573) 526-0234. Bills may also be mailed to:

   Missouri Department of Health and Senior Services
   TB Elimination Program
   P.O. Box 570
   Jefferson City, MO 65102

5. The DHSS will not make payment for any items or services to the extent that payment has been made, or can reasonably be expected to be made, under any state compensation program, including Medicaid or Medicare, any insurance policy, any federal or state health benefits program, or by an entity that provides health services on a prepaid basis. DHSS is unable to pay the co-pay portion or deductible portion of any public or private compensation programs in which the patient is enrolled.
6. DHSS has the authority to review patient records and provider billings to assure that program guidelines as written herewith are followed.
7. The program shall be conducted in accordance with all state and federal nondiscrimination requirements. The standards for eligibility and participation in this program shall be the same for all regardless of race, creed, color, national origin, handicap, sexual orientation, or gender.
8. DHSS reserves the right to limit or deny services to clients in order to adhere to budgetary limitations of the program.

Eligibility Requirements

Purpose: To ensure proper identification of patients who are eligible for services under the Diagnostic Services Program (DSP).

Procedure: The Missouri Department of Health and Senior Services (DHSS) TB Elimination Program determines eligibility at the request of the local public health agency (LPHA).

• The patient is identified by the Local Public Health Agency (LPHA) as being tuberculin skin test positive, and is uninsured or underinsured by health insurance, preventing the patient from accessing diagnostic medical evaluation for tuberculosis.

1. The LPHA shall complete a Diagnostic Services Eligibility/Authorization Form and send it to the TB Program email account at TBProgram@health.mo.gov prior to scheduling any services for the patient.
   1. All requests for DSP services must be in writing, verbal authorization will not be provided.
2. All requests for DSP services must be in writing, verbal authorization will not be provided.
   1. The patient must not have the ability to obtain the services from any other public or private health insurance program.
   2. This program will not cover the deductible portion of any insurance program.
   3. Services are not available to residents of penal institutions, however, services are available to eligible parolees and those who have completed their sentence.
   4. Confidentiality of names and identifying characteristics will be carefully guarded and only given to the provider of services.

Health Services

Services provided under the DSP, as funding allows, include office visits, clinical procedures, chest x-rays, and chest x-ray interpretation.

1. Office Visits and Diagnostic Services
   1. Participating medical providers must hold a current license with the Missouri Board of Healing Arts and must have a current participation agreement with the Missouri Department of Health and Senior Services.
   2. Reimbursement amounts for diagnostic tests will be the established state rate:
      1. Initial Office Visit - $100
      2. Subsequent office visit (SOV) - $70 per visit (maximum of eight SOV)
      3. Chest x-ray (CXR) - $75
      4. Chest x-ray interpretation - $36
      5. Induced sputum collections - $10.83 per collection (maximum of six collections)
   3. Authorizations for diagnostic tests are made under the procedure codes listed on the last page of this subsection. Invoices should be submitted using the specific code for the test.
   4. The total allowable amount per patient will be $836:

      1. Service	Maximum allowed	Price per unit of service	Total
         Initial office visit	1	$100	$100
         Subsequent office visit	8	$70	$560
         Chest x-ray	1	$75	$75
         X-ray interpretation	1	$36	$36
         Induced sputum collection	6	$10.83	$65
         Total allowable per patient			$836

      2. Subsequent office visits (SOVs) will be authorized after initial office visit and physician determines the need for follow up.
      3. SOVs will be authorized in increments of two visits per request, until the maximum allowable eight visits have been used.
      4. Participating physicians must be willing to provide office visits for diagnosis of tuberculosis, and must have prior arrangements for patient chest x-rays.
      5. Physicians must also be willing to order induced sputum collection for patients who cannot produce sputum on their own, and clinical proof of sputum conversion is needed.
         
         Diagnostic Services Program Provider Listing is located in the TB Manual; Appendices/Sample Forms at: Tuberculosis Case Management Manual | Health & Senior Services.
2. Physician Ordered Treatments
   
   Treatment of tuberculosis and tuberculosis infection in adults and children is to be in accordance with the American Thoracic Society (ATS), the Centers for Disease Control and Prevention (CDC) and Infection Disease Society of America (IDSA) recommended regiments as endorsed by the Missouri Department of Health and Senior Services, TB Elimination Program.

Billing Instructions for DSP Providers

Patients may not be charged a co-payment for authorized services

1. Prior Authorizations
   1. Upon identification of a patient that may qualify for assistance through the Diagnostic Services Program (DSP), the LPHA will send the completed Diagnostic Services Eligibility/Authorization form in an encrypted email to the TB Elimination Program at: TBProgram@health.mo.gov or fax to (573) 526-0234. The DSP manager will assign a prior-authorization number, indicate which services are authorized, and return the signed authorization form and provider billing instructions to the LPHA in an encrypted email.
   2. Providers will not be reimbursed for services that were provided to a client prior to receiving authorization for the service from the DSP.
   3. Prior authorization will list services authorized per client. The initial authorization will be for one chest x-ray, one interpretation, and the initial office visit. A second authorization is required prior to provision of subsequent TB diagnostic services.
   4. Prior authorization questions should be addressed to the DSP Manager at (573) 526- 5832.
2. Invoice Forms
   1. Invoice(s) may be submitted on any facility standard bill form. Include patient’s name(s), procedure code, amount for the procedure, and the authorization number.
   2. Invoices must show the specific date of service and number of services delivered on that date.
   3. All invoices for services provided to DSP approved patients must be submitted no later than 60 days following the date of service.
      Invoices can be submitted in one of three ways.
      1. Mail to:
         Missouri Department of Health and Senior Services (DHSS)
         TB Elimination Program
         PO Box 570
         Jefferson City, MO 65102
         or
      2. Encrypted email:
         Attach the invoice in an encrypted email and send to: TBProgram@health.mo.gov
         or
      3. Fax to (573) 526-0234
   4. Final invoices for services must be submitted no later than January 31, of the following year.
   5. Questions regarding how to submit invoices should be directed to the DSP Manager at (573) 526-5832.
3. Denial of Payment
   1. Services will be paid only if prior authorization for the services has been authorized by the DSP.
   2. The decision to pay an invoice is based on information taken from the written prior authorization. If a service is denied for payment, completely or partially, a denial letter will be sent to the provider.
   3. Failure to invoice within 60 days following the date of service may result in denial of payment.
   4. Questions regarding authorization or billing may be addressed to the DSP Manager at (573) 526-5832.

Participation Agreement for Diagnostic Services Provider

All participating providers must have a current Diagnostic Services Program (DSP) agreement with the Missouri Department of Health and Senior Services (DHSS).

The provider’s printed name, name of authorized representative, signature of provider or representative with date, social security or federal tax identification number, payment mailing address, state license number, telephone number, and primary contact person’s email address must be completed on all participation agreements. In addition, providers who are not already registered as a vendor should register in the MissouriBUYS system. Failure to complete the registration process may result in delay of payment for invoices received from unregistered vendors.

1. Log on to the MissouriBUYS webpage
   1. Under the Registration Help tab, locate the vendor registration checklist and ensure all required information is readily available to complete the registration process.
   2. Vendor registration instructions are also available under the Registration Help tab.
   3. Questions regarding technical difficulties with the webpage should be directed to the helpdesk listed under the Contacts tab.
   4. Complete the Vendor Input/ACH-EFT application, and fax it to (573) 526-9813 or mail to:
      Office of Administration/Accounting
      PO Box 809
      Jefferson City, MO 65102

All copies of the signed participation agreement should be submitted to the DSP Manager either by faxing the signed agreement to (573) 526-0234 or mailing it to:

Missouri Department of Health and Senior Services
TB Elimination Program
PO Box 570
Jefferson City, MO 65102-0570

After approval by DHSS, a copy of the fully executed agreement will be sent to the provider.

Provider Monitoring

The DSP has the right to monitor providers with current DSP agreements. The provider will be contacted by phone in order to schedule a date for a review. A list of client records that will be reviewed will be included with a follow up letter which will be mailed within 5 business days of the scheduling phone call.

Follow up visits may be indicated if problems are identified that require corrective action. Questions regarding provider monitoring reviews may be addressed to the DSP manager.

Records will be reviewed for:

1. Prior authorization of services;
2. Physician orders, when indicated;
3. Services were delivered within the date range stated on the prior authorization;
4. Billed services match delivery dates of services;
5. Services delivered coincide with services billed.

Health Procedure Codes and Rates