Adult Brain Injury Program Provider Manual

Credit claims will be processed in the following circumstances:

• Duplicate payments;
• Insurance payments;
• MO HealthNet payments;
• Payments made in error
• Overpayments.

The credit/recoupment will be reflected on the next payment and voucher processed to the Provider. Refunds should not be sent unless requested from the Department of Health and Senior Services (DHSS).

Correspondence

Any correspondence or payment sent by the DHSS will be sent to the address shown on the Provider Participation Agreement. It is the responsibility of the Provider to notify SHCN if the contact person, address or county coverage changes. Organizational charts or employee listing should be provided to the ABI Program Manager upon request.

Monitoring

Providers must maintain accurate participant claims files. DHSS has the authority to review participant records and Provider billings. Program Staff will monitor all providers periodically.

Provider Appeal Process

Special Health Care Needs (SHCN) enrolled providers have the right to appeal decisions regarding denial of payment for services. To appeal a decision made by SHCN, the provider must submit the following documentation to the ABI Program Manager within thirty (30) calendar days of the SHCN warrant/voucher date:

• A letter describing the reason for the appeal;
• Documentation to support overturning the denial; and
• A copy of the claim being appealed.

The ABI Program Manager will review the documentation and render a written decision to the provider within thirty (30) business days of the receipt of the appeal. If the decision is unsatisfactory, the provider may submit a second appeal letter addressed to the Bureau Chief. The appeal and supporting documentation must be received by SHCN within thirty (30) calendar days of the ABI Program Manager’s written decision date. The Bureau Chief will review the documentation and render a written decision to the provider within thirty (30) business days of the receipt of the appeal. If the decision is unsatisfactory, the provider may submit a final appeal letter to the Department Director, or designee. The appeal and supporting documentation must be received by SHCN within thirty (30) calendar days of the Bureau Chief’s written decision date. The Department Director will make a final decision based on the evidence and documentation submitted with the appeal. A letter outlining the Director’s decision will be mailed to the provider within thirty (30) business days of the receipt of the appeal.