| 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.
View current claims submission guidelines.