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Missouri Provider Questions & Answers

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Pharmacy Questions



General Questions

  • Is a written referral required in order for a member to see a specialist?
    Children's Mercy Family Health Partners does not require written referrals. PCPs may verbally refer a member to a specialist and document in the member's chart that this has been done.
  • What is CMFHP's timely filing requirement?
    By contract, participating providers with CMFHP must file a claim within 90 days from the initial date of service. CMFHP has currently extended this time frame to 180 days. If the claim is received after 180 days, the claim will be denied and the provider must write off any applicable charges. The member cannot be billed.
  • How may timely filing denials be appealed?
    In order for timely filing denials to be reconsidered for payment, the provider must have proof that this claim was originally filed within the 180 days and have been followed-up on within the same 180-day time period.

    If it is a coordination of benefit claim, the 180 days starts from the date of the primary explanation of benefits. However, the provider must have filed timely with the primary carrier.
  • What is a formulary medical exception?
    The medical exception process is designed to ensure that nonformulary medications are available to members when medically necessary. The medical exception review policy permits coverage of nonformulary drugs when at least one of the following criteria is met:

    • Documented allergic/adverse reaction to a formulary agent
    • Documented failure of formulary agents
    • Documented stability/control issues in patients with concomitant drug/disease states where a fomulary agent is contraindicated or a change in therapy is not available.
  • What process should be followed when a formulary drug requires prior authorization?
    A drug that requires prior authorization cannot be dispensed by the pharmacy without the prior authorization number. The pharmacist will contact the provider's office and instruct them to contact Caremark at 888-413-2723. Be prepared to answer the following questions:

    • Patient name, ID number and date of birth
    • Physician name, address and phone number
    • Drug name, strength and directions
    • Diagnosis and clinical information


    Caremark will then determine whether or not the patient meets the set criteria for the drug in question. Caremark staff will be responsible for notifying the provider regarding the approval/denial of a prior authorization request.

    The criteria used for each drug follows the FDA-approved label indications and standards of providers' practice. These criteria can change based on newly approved indications and/or at least two peer-reviewed studies showing effectiveness.
  • What does it mean if a drug is listed in the formulary as a "step therapy"?
    Step therapy requires the use of one or more prerequisite drugs that meet specific conditions prior to the use of another drug or drugs. Medications that require step therapy are on the formulary, but will not be considered by Caremark unless qualifying medications are found in the members' medication claims history. Sample medication and prescriptions obtained by coupons are not considered for the qualification requirement. If the patient was previously with another MC+ plan or fee for service Medicaid we will not have the claims history.
  • Does Children's Mercy Family Health Partners cover infertility treatment?
    Infertility treatment is not a covered benefit under the MC+ program. If these services are provided, they will be denied and the member will be responsible for these charges.
  • Can we bill newborn charges under the temporary identification number?
    Claims cannot be paid under the temporary identification number. If you bill with the temporary number, the claim(s) will be denied. Once notified, it takes the State 30 days to add members to the plan and issue and identification number. Please checkwith the State of CMFHP for the valid identification number under which claims need to be billed.
  • How long does it take Children's Mercy Family Health Partners to process a "clean-claim"?
    If the claim is submitted to Children's Mercy Family Health Partners electronically and we require no additional information, a claim will be paid within the State-defined statutory requirement for payment of a clean-claim. Paper claims that require no additional information are paid within 30 days.
  • Where should we direct Children's Mercy Family Health Partners' diabetic members for monitors and test strips for those members where this is a covered benefit?
    Children's Mercy Family Health Partners has a contract with Egepark Surgical, Inc. (800-321-0591) for diabetic supplies. Through our arrangement, they will provide free glucose monitors for diabetic members and send test strips directly to the members' home. They also have a diabetic program available that notifies Children's Mercy Family Health Partners of any potential compliance issues our members may experience.
  • How does Children's Mercy Family Health Partners determine if the member has other insurance information?
    Since Children's Mercy Family Health Partners is the payer of last resort (except for EPSDTs and OB services), we first look for other payment resources. We are provided information from the State concerning COB information (verified every six months for accuracy by CMFHP). We also get information from providers when an EOB is submitted with their claim. If you have other insurance information without an EOB, include the information on the HCFA. COB information should be available on the website within the next few months.
  • How do I use the website to look up claims for my practice?
    Follow the easy steps below to check your claims status:
    • Login using your assigned user id and password.
    • Go to the Office Manager menu item and then:
      • Claims
      • Inquiry (Click)
    • Member Information
      • Fill in the fields with the appropriate information, member name or id number.
    • Claim Information
      • Claim Type, you'll need to select the appropriate claim your searching for either encounters, institutional, or pre-logged claims.
      • From and To dates, enter a date range
    • Search for Claims

    To look up another claim, click on Inquiry as you did before and follow the same steps.
  • How frequently is eligibility information updated on the website?
    Eligibility information is updated daily.
  • How do I find out who my provider representative is?
    Call CMFHP Provider Relations at (816) 855-1813.
  • How can MC+ recipients switch to Children's Mercy Family Health Partners?
    MC+ recipients may only switch health plans during open enrollment or in cases of medical necessity. Open enrollment dates and additional information may be obtained by calling the MC+ Help Line at (800) 348-6627.
  • What is MC+ for Kids?
    MC+ for Kids, part of the Children's Health Insurance Program, is a health insurance program for uninsured children of low-income families who do not have access to affordable health insurance.
  • What does MC+ for Kids do?
    • Expands the availability of affordable health insurance for uninsured children.
    • Provides children with a Primary Care Provider (PCP), someone to coordinate all aspects of their health care and preventive services; and
    • Increases efficient delivery of health care services and controls costs.
  • Who is covered?
    Uninsured children, ages birth to 19, whose family's gross income is up to 300% of the federal poverty level are eligible. Pregnant women whose family's gross income is under 185% of the federal poverty level can apply. Insured children with lower family income may also be eligible.
  • What does it cost members?
    Based on income, some members will be required to pay monthly premiums for professional services and prescriptions.

    Families will pay no more than 5% of their annual income for premiums in a year. If out-of-pocket expenses reach the 5% limit, the family will not have to pay the premium for the rest of the year.
  • What does it cover?
    Some benefits are limited based on your eligibility group or age. Call Children's Mercy Family Health Partners at 816-855-1888 or 1-800-347-9363 for information about your health benefits.
    • Adult day health care
    • Ambulance
    • Ambulatory surgical center, birthing center
    • Comprehensive day rehabilitation, services to help you recover from a serious health injury
    • Dental
    • Diabetic supplies, equipment, education, and self-management training
    • Durable Medical Equipment (DME), such as oxygen, wheelchairs, walkers, and other things your PCP says you need for medical support
    • Early Periodic Screening, Diagnosis and Treatment (EPSDT) or Healthy Children and Youth (HCY) services for children
    • Emergency room
    • Family planning
    • Hearing aids and related services
    • Home health care
    • Hospice, if you are in the last six months of your life
    • Hospital, when an overnight stay is required
    • Laboratory tests and x-rays
    • Maternity benefits, including certified nurse midwife
    • Mental health and substance abuse
    • Outpatient, when an overnight stay is not required
    • Personal care
    • Podiatry, medical services
    • Pharmacy
    • PCP services
    • Specialty care and PCP referral
    • Transplant related services
    • Transportation to medical appointments
    • Vision
    Children's Mercy Family Health Partners will notify you of changes in your benefits, services or service delivery office/site in writing.
  • How are services delivered?
    Eligible children will be enrolled through MC+ for Kids, Missouri's health insurance program for children. Families in certain areas of the State, will choose coverage through a MC+ managed care health plan; others will receive services from MC+ approved providers.
  • How do I enroll?
    • Call your local Family Support Division office to apply or go to http://www.dss.state.mo.us/mcplus/appl.htm
    • Pick-up a simple, two-page application form, available at all Family Support Division offices in each county, and at many hospitals, community centers, local public health agencies, mental health sites and schools; or
  • What do I need to enroll?
    • Verification of income (check stub, federal income tax return, or other income verification);
    • Social Security numbers of those applying for MC+ for Kids;
    • Immigration status of those applying for MC+ for Kids will be required; and
    • Children must have been uninsured for at least six months (some exceptions apply).
  • What is a Primary Care Provider (PCP)?
    A PCP is a physician or a provider who specializes in the delivery of primary care services. The PCP is responsible for coordinating all of a member's healthcare needs.
  • Who is my PCP?
    Your PCP is the provider that you selected as your personal health care provider. If you did not select a provider, one was selected for you. The name and phone number of your PCP is listed on your membership card.
  • Can I change my PCP?
    You can change your Primary Care Provider twice a year. To change your PCP, select a participating PCP, then call Children's Mercy Family Health Partners Customer Service at 1-800-347-9363.
  • What is a closed panel and why can't I have that PCP?
    PCP's sometimes will have a "closed panel." That means the PCP has limited the number of Children's Mercy Family Health Partners members for whom they can provide care. Providers limit their panels to ensure their current patients are able to continue to have access to care. Providers with closed panels are indicated in the Provider Directory. If you have a question about a provider that has a closed panel, call Children's Mercy Family Health Partners Customer Service at 1-800-347-9363.
  • What providers can I use?
    All providers must be participating providers with Children's Mercy Family Health Partners. If you need care other than what your PCP can provide, you must have a referral from your PCP.
  • Are there any services that I can get without PCP approval?
    Yes. The services you can receive without a referral are:
    • Family planning or birth control
    • Mental Health care (must use participating providers)
    • Health Department Services - immunizations, lead screening, tests and treatment for sexually transmitted diseases, tuberculosis or HIV/AIDS
    • Vision services (must use participating providers)
  • How do I know if I am eligible for Children's Mercy Family Health Partners services?
    Children's Mercy Family Health Partners is contracted through the State of Missouri for a specific program. This program has specific income guidelines which determines eligibility. For more information about possible eligibility, you can call Children's Mercy Family Health Partners Customer Service at 1-800-347-9363. If you want to apply by phone call 1-877-KIDS-NOW.
  • Why was I taken off Children's Mercy Family Health Partners insurance?
    Children's Mercy Family Health Partners does not determine eligibility for MC+. If you have lost coverage, please contact your caseworker at your local Family Support Division office.
  • What do I do if I think I need to go to the Emergency Room?
    If your situation is an emergency, go directly to the nearest Emergency Room or dial 911. Be sure to call your PCP the following day and schedule follow-up care.

    If your situation is not an emergency you should call either your PCP or the Nurse Advice Line. Either your PCP or Nurse Advice can give approval for you to seek urgent care if needed. The Nurse Advice Line for CMFHP members is 1-800-347-9369.
  • How can I get mental health services?
    MC+ members can self-refer, meaning you can select a participating provider within our network and go without a referral. You may get up to four (4) visits in a year without our OK. If you need assistance in making an appointment you may call 1-800-409-2225.
  • How can I get dental services?
    Most members may see any dentist in our network. Simply select a participating dentist and call them to make an appointment. Dental services for many adults is limited. If you need any more help you may call Children's Mercy Family Health Partners Customer Service at 1-800-347-9363.
  • How can I file a grievance or appeal?
    You can file a grievance or appeal by calling Customer Service and request the Quality Management Nurse in charge of appeals at 816-855-1888 or 1-800-347-9363.
  • How can I find out if I have Medicaid or MC+ coverage?
    You should have received a red plastic insurance card from Medicaid and a white card from Children's Mercy Family Health Partners.

    To find out if your coverage is active you can contact Children's Mercy Family Health Partners Customer Service at 816-855-1885 or 1-800-347-9363.

    You can also call your local Family Support Division or call the Medicaid and MC+ Recipient Services Unit at 1-800-392-2161 or 573-751-6527.

    If you have a touch tone telephone the 800 number can be used to find out if you are eligible by choosing option 1 and entering your eight digit Medicaid or MC+ number.
  • What should I do if I receive a bill or if there is a charge on my credit report?
    You should first ask the provider to bill Children's Mercy Family Health Partners. It is your duty to be sure the provider knows you have Medicaid or MC+. If they billed Medicaid and still billed you, send the bill or a copy of the bill to Children's Mercy Family Health Partners, PO Box 411806, Kansas City, Mo. 64141-1806. Include a note with the patient name and member ID number.
  • What should I do if I lose my Medicaid or MC+ card?
    To report a loss of your Children's Mercy Family Health Partners ID card, call Customer Service at 816-855-1885 or 1-800-347-9363.

    To report a loss of your Red MC+ card, you should contact your local Family Support Division office in the county where you live. Check your telephone book under the name of your county or the FSD Web site for a list of Family Support offices.
  • Can I use my Medicaid or MC+ if I travel out of state?
    Services outside the United States, District of Columbia, and the following territories: Northern Mariana Islands, American Samoa, Guam, Puerto Rico, and the Virgin Islands are not covered.

    Emergency: Emergency services are covered as long as the out of state treating provider agrees to enroll and accept the Missouri Medicaid amount. Emergency services are services required when there is a sudden or unforeseen situation or occurrence or a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in:
    • 1. Placing the patient's health in serious jeopardy; or
    • 2. Serious impairment to bodily functions; or
    • 3. Serious dysfunction of any bodily organ or part.

    Non-Emergency: Non-Emergency: Out of state is defined as "not within the physical boundaries of Missouri or any of the states that border Missouri." All non-emergent, Medicaid covered services that are to be obtained out of state must be approved before the services are received. To get the approval for out of state services a written request must be sent by a physician to:

    Children's Mercy Family Health Partners, PO Box 411806, Kansas City, Mo. 64141-1806 or by calling our Prior Authorization line at 1-800-691-4872.

    The written request must include a brief past medical history, services attempted in Missouri, where the services are being requested and who will provide them, and why the service cannot be done in Missouri. The out of state provider must agree to enroll and accept the Missouri Medicaid amount.
  • Can I have a private insurance plan with my Medicaid or MC+?
    You may have private insurance with your Medicaid or MC+ as long as being uninsured is not a condition of your eligibility. It is your duty to report a private insurance plan to your Family Support Division caseworker. You can also report your private insurance plan information to the Medicaid and MC+ Recipient Services Unit at 1-800-392-2161 or 573-751-6527. If you have a touch tone telephone the 800 number can be used to hear the private insurance plan listed by choosing option 2 and entering your eight digit Medicaid or MC+ number.

    The Medicaid and MC+ program may be able to help pay your private insurance plan premiums. For information about the Health Insurance Premium Payment (HIPP) program, you should contact the Third Party Liability Unit at 573-751-2005.
  • Who should I contact if I move?
    It is very important to report address changes. It is important to report an address change so you will get important notices about your eligibility or services. You should report every address change to your local Family Support Division office. You should also contact Children's Mercy Family Health Partners Customer Service at 816-855-1885 or 1-800-347-9363.

For answers to any questions you may still have, please contact your Provider Relations Representative or call Children's Mercy Family Health Partners at our toll-free telephone number, 1-800-347-9363.



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