Children and Youth with Special Health Care Needs (CYSHCN) Program Reimbursement Rates
Children and Youth with Special Health Care Needs Program Provider Manual
Children and Youth with Special Health Care Needs (CYSHCN) Program Reimbursement Rates
| SERVICES | PRIOR AUTHORIZATION REQUIREMENTS | REIMBURSEMENT RATE |
|---|---|---|
| Audiological Procedures | Required through PM regardless of cost for service plan entry | 80% UCR |
| Dental (Up to 2 routine dental check-ups annually) | Not required | 80% UCR |
| Dental (Orthodontic/Prosthodontic Procedures including Extractions) | Required through PM regardless of cost | 80% UCR |
| Durable Medical Equipment Includes: | ||
General DME | Required if greater than $300 | 80% of UCR |
Repair | Required regardless of cost | 80% of UCR |
Rental | Required regardless of cost | Negotiated through Prior Authorization (up to purchase price when applicable) |
Orthotic & Prosthetic Devices | Required if greater than $300 | 80% of UCR |
Augmentative Communication Evaluation & Device | Required through PM regardless of cost | 80% of UCR |
Disposable Supplies (Diapers, etc.) | Required if greater than $300 | 80% of UCR |
Hearing Aids | Required through PM regardless of cost | Wholesale cost plus 10% |
Cochlear Implants, FM Systems & Magnifiers | Required through PM regardless of cost | 80% of UCR |
Ear Molds | Required for service plan entry | 80% of UCR |
Hearing Aid Accessories | Required if greater than $300 | 80% of UCR |
Hearing Aid Repair | Required regardless of cost | 80% of UCR |
| Emergency Care Centers | Notification required within three (3) business days for service plan entry | 80% of UCR up to MO HealthNet Inpatient per diem rate |
| Emergency Transportation | Not required | 80% UCR |
| Hemophilia Factor | Required for service plan entry | Average Wholesale Price – 10.43% + Dispensing Fee |
| Inpatient Hospitalization Includes: | Required through PM regardless of cost: | |
Evaluation & Treatment for Eligible Condition including Surgery & Special Procedures | Required for service plan entry | 80% of UCR up to MO HealthNet Inpatient per diem rate |
| Interpreter Fees Includes: | ||
In-home | Required for service plan entry | $12.00/unit (1 unit equals 15 minutes) with a 2 hour minimum |
Telephone | Required for service plan entry | $8.00/unit (1 unit equals 15 minutes) |
| Medical Nutritional Services | Required through PM regardless of cost | $16.50/unit (1 unit equals 15 minutes) |
| Office/Outpatient Clinic Visit (New & Established Patient) | Not required | Varies by level of service |
| Office Visit Procedures | Required for service plan entry | 80% of UCR up to MO HealthNet Inpatient per diem rate |
| Outpatient Procedures & Surgery Includes: | Required through PM regardless of cost: | |
Emergency | Notification required within three (3) business days for service plan entry | 80% of UCR up to MO HealthNet Inpatient per diem rate |
Non-Emergency | Required for service plan entry | 80% of UCR up to MO HealthNet Inpatient per diem rate |
| Professional Fees – Inpatient/Outpatient (Ambulatory Surgical Centers, Anesthesiology, Consultation, Emergency, Pathology, Radiology & Special Procedures) | Not required | Up to $100 paid in full. Balance of $100 or more, paid at 54% with a maximum reimbursement of $800 a day |
| Pharmacy Services Includes: | ||
Prescription Medications | Required for service plan entry | 90% of UCR |
Compounded Medications | Required through PM regardless of cost | 90% of UCR |
Formula (Specialized) | Required through PM regardless of cost | 90% of UCR |
Pharmacy, Physician’s Office & Treatment Center | Required for service plan entry | 90% of UCR |
| Therapies/Evaluations Includes: | ||
Auditory Therapy | Required through PM regardless of cost | $16.50/unit (1 unit equals 15 minutes) |
Occupational Therapy | Required through PM regardless of cost | $16.50/unit (1 unit equals 15 minutes) |
Physical Therapy | Required through PM regardless of cost | $16.50/unit (1 unit equals 15 minutes) |
Respiratory Therapy | Required through PM regardless of cost | $16.50/unit (1 unit equals 15 minutes) |
Speech Therapy | Required through PM regardless of cost | $16.50/unit (1 unit equals 15 minutes) |
Evaluations/Re-Evaluations | Not required | $60 |
* Services must be medically necessary and directly related to the participant’s eligible condition(s) for CYSHCN to consider payment.
** If not otherwise specified above, any service exceeding $300 annually requires prior authorization from the CYSHCN Service Coordinator and any service exceeding $2,500 annually requires prior authorization through the CYSHCN Program Manager (PM).
CYSHCN will consider limited funding up to $25,000 annually per participant.
Rates are subject to change.
Current CYSHCN Claims Submission Guidelines.