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.