Amendment number 10 to Missouri HealthNet Managed Care Eastern Region contract between the State of Missouri Office of Administration Division of Purchasing and Materials Management and Harmony Health Plan of Illinois, Inc. d/b/a Harmony Health Plan of Missouri

Contract Categories: Business Operations - Administration Agreements
EX-10.1 2 missouricontractamend10.htm AMENDMENT 10 TO MISSOURI HEALTHNET MANAGED CARE CONTRACT missouricontractamend10.htm
Back to Form 8-K    
Exhibit 10.1

 
NOTICE OF AWARD
 
State Of Missouri
Office Of Administration
Division Of Purchasing And Materials Management
PO Box 809
Jefferson City, MO 65102
www .oa.mo. gov/purch

CONTRACT NUMBER
 
C306118005
CONTRACT TITLE
 
Medicaid Managed Care – Eastern Region
 
AMENDMENT NUMBER
 
Amendment #010 Revised
CONTRACT PERIOD
 
July 1, 2008 through June 30, 2009
 
REQUISITION NUMBER
 
NR 886 ###-###-####
VENDOR NUMBER
 
3640504950 1
 
CONTRACTOR NAME AND ADDRESS
 
HARMONY HEALTH PLAN OF MISSOURI
23 PUBLIC SQUARE STE 400
BELLEVILLE IL 62220
 
STATE AGENCY’S NAME AND ADDRESS
 
Department of Social Services
MO HealthNet Division
PO Box 6500
Jefferson City MO 65102-6500
 
ACCEPTED BY THE STATE OF MISSOURI AS FOLLOWS:
 
Contract C306118005 is hereby amended pursuant to the attached Amendment #010 Revised dated 09/24/08.
 
BUYER
 
Laura Ortmeyer
 
BUYER CONTACT INFORMATION
 
E-Mail: ***@***
Phone: (573) 751-4579
 
SIGNATURE OF BUYER
 
/s/ Laura Ortmeyer
DATE
 
September 25, 2008
 
DIRECTOR OF PURCHASING AND MATERIALS MANAGEMENT
 
 
/s/ James Miluski
James Miluski
 
 
 
 
STATE OF MISSOURI
OFFICE OF ADMINISTRATION
DIVISION OF PURCHASING AND MATERIALS MANAGEMENT (DPMM)
CONTRACT AMENDMENT
 
AMENDMENT NO.:  010 Revised
REQ NO.: NR 886 ###-###-####
CONTRACT NO.:  C306118005
BUYER:  Laura Ortmeyer
TITLE:  Mo Health Net Managed Care – Eastern Region
PHONE NO.:   ###-###-####
ISSUE DATE:  09/24/08
E-MAIL:   ***@***

TO:     HARMONY HEALTH PLAN OF MISSOURI
23 PUBLIC SQUARE STE 400
BELLEVILLE IL  62220

RETURN AMENDMENT NO LATER THAN:  SEPTEMBER 25, 2008 AT 5:00 PM CENTRAL TIME
 
RETURN AMENDMENT TO:
                                         (U.S. Mail)
Div of Purchasing & Matls Mgt (DPMM)    OR
PO BOX 809
JEFFERSON CITY MO  65102-0809
                      (Courier Service)
Div of Purchasing & Matls Mgt (DPMM)
301 WEST HIGH STREET, ROOM 630
JEFFERSON CITY MO  65101-1517

OR FAX TO: (573) 526-9817 (either mail or fax, not both)

DELIVER SUPPLIES/SERVICES FOB (Free On Board) DESTINATION TO THE FOLLOWING ADDRESS:

Department of Social Services, MO HealthNet Division
Post Office Box 6500
Jefferson City MO  65102-6500

SIGNATURE REQUIRED

  DOING BUSINESS AS (DBA) NAME
 
  Harmony Health Plan of Illinois Inc., d/b/a/ Harmony Health Plan of Missouri
  
  LEGAL NAME OF ENTITY/INDIVIDUAL FILED WITH IRS FOR THIS TAX ID NO.
 
  Harmony Health Plan of Illinois, Inc
  MAILING ADDRESS
 
  23 Public Square, Suite 400
  IRS FORM 1099 MAILING ADDRESS
 
  200 West Adams Street, Suite 800
  CITY, STATE, ZIP CODE
 
  Belleville, IL 62220
  CITY, STATE, ZIP CODE
 
  Chicago, IL 60606
 
  CONTACT PERSON
 
  Ms. Tina Gallagher
  EMAIL ADDRESS
 
  ***@***
  PHONE NUMBER
 
  (800) 608-8158 Ext. 2405
  FAX NUMBER
 
  (800) 608-8157
  TAXPAYER ID NUMBER (TIN)
  36 ###-###-####
   TAXPAYER ID (TIN) TYPE (CHECK ONE)
            ___ FEIN       ___ SSN
  VENDOR NUMBER (IF KNOWN)
  3640504950 1
  VENDOR TAX FILING TYPE WITH IRS (CHECK ONE)                                                                                                                (NOTE:  LLC IS NOT A VALID TAX FILING   TYPE.)
 
 ___ Corporation         ___ Individual         ___ State/Local Government         ___ Partnership         ___ Sole Proprietor         ___Other ________________
 
  AUTHORIZED SIGNATURE
 
  /s/ Heath Schiesser
  DATE
 
  9-24-08
   PRINTED NAME
 
  Heath Schiesser 
  TITLE
 
  President and CEO
 
 
 

Contract C306118005
  
Page 2
 
AMENDMENT 010 (REVISED) TO CONTRACT C306118005

CONTRACT TITLE:
  
Mo Health net Managed Care – Eastern Region

CONTRACT PERIOD:
July 1, 2008 through June 30, 2009

The State of Missouri hereby desires to amend the above-referenced contract, as follows.

1.           Paragraph 2.4.9 is hereby amended effective July 1, 2008 as follows:

 
2.4.9
The health plan shall maintain the fee schedule for office visit services and dental services located in Attachment 14 at no lower than the MO HealthNet fee-for-service fee schedule in effect at the time of service.  The fee schedule for office visit services included in Attachment 14 is for dates of services July 1, 2006 through June 30, 2007.  The fee schedule for dental services included in Attachment 14 are for dates of service July 1, 2006 through June 30, 2008.

2.           Paragraph 2.4.9 d. and e. is hereby inserted effective July 1, 2008 as follows:

 
  2.4.9 d.
A physician fee increase will be implemented effective July 1, 2008. Physician reimbursement rates that are currently less than 62.5% of the Medicare reimbursement rate will increase to 62.5% and physician reimbursement rates currently at or above 62.5% will remain unchanged.  The MO HealthNet Online Fee-For-Service Fee Schedule is available electronically at the MO HealthNet Division's website:  http://www.dss.mo.gov/mhd/providers/pages/cptagree.htm.

 
  2.4.9 e.
Effective July 1, 2008, the MO HealthNet Managed Care health plan shall increase the rates for physician services provided to MO HealthNet Managed Care enrollees in accordance with the fee-for-service rate increases.  The MO HealthNet Managed Care health plan's capitation rates will be adjusted effective July 1, 2008 to reflect the increases for physician services.  The MO HealthNet Managed Care health plan shall request and receive proof from its health care services subcontractors that these increases have been passed on to providers beginning July 1, 2008.  Such proof shall be provided to the state agency upon request.

3.
Paragraph 2.4.9 f. is hereby inserted effective July 1, 2008 as follows:

 
  2.4.9 f.
The Missouri 94th General Assembly approved a fee increase for the MO HealthNet Optical and Dental Programs.  The reimbursement rates for certain optical and dental services will be implemented for dates of service on or after July 1, 2008.  The MO HealthNet Online Fee-For-Service Fee Schedule is available electronically at the MO HealthNet Division's website:  http://www.dss.mo.gov/mhd/providers/pages/cptagree.htm.

4.
Attachment 5 is hereby revised effective July 1, 2008.

5.
Attachment 13 is hereby revised effective July 1, 2008.

6.
Attachment 14 is hereby revised effective July 1, 2008.
 
 
 

Contract C306118005
  
Page 3

The contractor shall indicate in Column 2 on the attached Pricing Page, any changes to the firm fixed prices of the contract for performing the required services in accordance with the terms, conditions, and provisions of the contract, including the above stated changes.  The contractor's firm, fixed PMPM Net Capitation Rate for Each Category of Aid (COA) Rate subgroup must not exceed the State's Maximum Net Capitation Rate listed in Column 1.

All other terms, conditions and provisions of the contract shall remain the same and apply hereto.

The contractor shall sign and return this document, on or before the date indicated, signifying acceptance of the amendment.

 
 
 
 
5.3 East Region - Firm Fixed Net Capitation Pricing Page
 
July 1, 2008
            
    
 
Column 1
  
Column 2
Category
of Aid
  Age  Sex
 State's Maximum Net
Capitation Rate
(Per Member, Per Month)
  
 Firm Fixed Net
Capitation Rate
(Per Member, Per Month)
1
Newborn < 01
Male and Female
$
$988.79
  
$
$988.79
1
01 - 06
Male and Female
$
$147.77
  
$
$147.77
1
07 - 13
Male and Female
$
$114.64
  
$
$114.64
1
14 - 20
Female
$
$221.94
  
$
$221.94
1
14 - 20
Male
$
$138.91
  
$
$138.91
1
21 - 44
Female
$
$342.35
  
$
$342.35
1
21 - 44
Male
$
$239.74
  
$
$239.74
1
45 - 99
Male and Female
$
$528.33
  
$
$528.33
4
00 - 20
Male and Female
$
$233.48
  
$
$233.48
1&4
Delivery
  
$
$5,059.90
  
$
$5,059.90
               
5
00 - 06
Male and Female
$
$172.28
  
$
$172.28
5
07 - 13
Male and Female
$
$148.51
  
$
$148.51
5
14 - 18
Male and Female
$
$193.76
  
$
$193.76
5
Delivery
  
$
$5,059.90
  
$
$5,059.90
 
 
 

EAST REGION
  
Attachment 5
    
Family Planning and STD Treatment Providers
Jul-2008
    
         
Franklin County:
        
Name
Address
City
State
ZIP
Family Planning Clinic
920L Saint Clair Plaza Dr
St Clair
MO
63077
         
Iron County:
        
Name
Address
City
State
ZIP
East Missouri Action Agency Family Planning
606 W Russell
Ironton
MO
63650
         
Madison County:
        
Name
Address
City
State
ZIP
East Missouri Action Agency Family Planning
806 W College Ave
Fredericktown
MO
63645
         
Perry County:
        
Name
Address
City
State
ZIP
East Missouri Action Agency Family Planning
519 Old Saint Marys Road
Perryville
MO
63775
         
St. Francois County:
        
Name
Address
City
State
ZIP
East Missouri Action Agency Family Planning
107 Industrial Drive
Park Hills
MO
63601
         
St. Louis City:
        
Name
Address
City
State
ZIP
Planned Parenthood of the St Louis Region
4251 Forest Park Ave
St Louis
MO
63108
         
Warren County:
        
Name
Address
City
State
ZIP
NECAC Health Services
120 E Booneslick
Warrenton
MO
63383
         
         
Other:
        
Name
Address
City
State
ZIP
East Missouri Action Agency Family Planning
1111 Linden
Cape Girardeau
MO
63702
NECAC Family Planning Center
24 Northport Plaza
Hannibal
MO
63401
         
Some local Public Health Agencies may also provide Family Planning and STD Treatment Services.
Contact your local County Health Department for more information.
      
         
 
 
 

EAST REGION
  
Attachment 5
   
Jul-2008
Local Health Agencies
     
Crawford County Nursing Service
  
St Charles County Dept of Health
202 W Main Street
  
1650 Boonslick Road
Steelville, MO  65565
  
St Charles, MO  63301
     
Franklin County Health Services
  
St Francois County Health Dept
15 South Oak
  
1025 W Main
Union, MO  63084
  
Park Hills, MO  63601
     
Iron County Health Department
  
St Louis County Department of Health
606 W Russell
  
111 S Meramec
Ironton, MO  63650
  
Clayton, MO  63105
     
Jefferson County Health Department
  
City of St Louis Department of Health
405 Main Street
  
634 N Grand
Hillsboro, MO  63050
  
St Louis, MO  63103
     
Lincoln County Health Department
  
Ste Genevieve County Health Dept
5 Health Department Drive
  
115 Basler Drive
Troy, MO  63379
  
Ste Genevieve, MO  63670
     
Madison County Health Department
  
Warren County Health Department
806 W College Ave
  
104 W Booneslick
Fredericktown, MO  63645
  
Warrenton, MO  63383
     
Perry County Health Department
  
Washington County Health Dept
406 N Spring
  
520 Purcell Drive
Perryville, MO  63775
  
Potosi, MO  63664
     
Pike County Health Department
    
5 E Church Street
    
Bowling Green, MO  63334
    
 
 
 
EAST REGION
  
Attachment 5
  
   
 
July-2008
  
Federally Qualified Health Centers (FQHC)
Franklin County:
Name
Address
City
State
ZIP
Crider Center South (Behavioral)
416 Market Street
Washington
MO
63090
Crider Center South (Dental)
851 E 5th Street Ste 132
Washington
MO
63090
 
Iron County:
Name
Address
City
State
ZIP
Annapolis Family Clinic
Highway 49
Annapolis
MO
63620
Iron County Medical Clinic
301 N Highway 21
Pilot Knob
MO
63663
Ironton Medical Clinic
128 W Russell
Ironton
MO
63650
Viburnum Medical Clinic
#9 Viburnum Shopping Ctr
Viburnum
MO
65566
 
St. Charles County:
Name
Address
City
State
ZIP
Crider Health Center Central
1032 Crosswinds Court
Wentzville
MO
63385
Crider Health Center East
300 Water Street
St Charles
MO
63301
 
St. Francois County:
Name
Address
City
State
ZIP
Great Mines Health Center of Farmington
1101 Weber Road
Farmington
MO
63640
 
St. Louis City:
Name
Address
City
State
ZIP
Family Care Health Centers (Carondelet)
401 Holly Hills Ave
St Louis
MO
63111
Family Care Health Centers (Forest Park)
4352 Manchester Rd
St Louis
MO
63110
Florence Hill Health Center
5541 Riverview Blvd
St Louis
MO
63120
Grace Hill @ St. Patrick Health Service
800 N Tucker
St Louis
MO
  63101*
Grace Hill Murphy-O'Fallon Health Center
1717 Biddle Street
St Louis
MO
  63106*
Grace Hill Soulard-Benton Health Center
2220 Lemp
St Louis
MO
  63104*
Grace Hill South Health Center
3400 S Jefferson
St Louis
MO
  63118*
Grace Hill Water Tower Health Center
4308 N Grand
St Louis
MO
  63107*
Homer G. Phillips Health Center
2425 Whittier St
St Louis
MO
63113
Myrtle Hilliard Davis Comprehensive Health Center
5471 Martin Luther King Dr
St Louis
MO
63112
Myrtle Hilliard Davis Comprehensive Health Center II
4411 N Newstead
St Louis
MO
63115
Peoples Health Centers
5701 Delmar Blvd
St Louis
MO
63112
 
St. Louis County:
Name
Address
City
State
ZIP
Peoples Health Centers
11642 W Florissant
Florissant
MO
63033
Peoples Health Centers
7200 Manchester Rd
Maplewood
MO
63143
 
Warren County:
Name
Address
City
State
ZIP
Crider Health Center West
1428 N State Hwy 47
Warrenton
MO
63383
 
Washington County:
Name
Address
City
State
ZIP
Great Mines Health Center
600 Purcell Drive Suite B
Potosi
MO
63664
         
Other:
Name
Address
City
State
ZIP
Valley Springs Medical Clinic
County Road 814
Black
MO
63625
Cross Trails Medical Center
408 S Broadview St
Cape Girardeau
MO
63703
Ellington Family Clinic
Hwy 106 & 2nd Street
Ellington
MO
63638
Cross Trails Medical Center
109 Highway 51 N
Marble Hill
MO
63764

*St. Louis City: Grace Hill listings per Gerald Sonnenberg (Grace Hill Director of Communications) 07-10-2008.
 
 
 
EAST REGION
  
Attachment 5
    
   
Jul-2008
    
Rural Health Clinics (RHC)
Crawford County:
        
Name
Address
City
State
ZIP
Bourbon Medical Office
240 College Road
Bourbon
MO
65441
Cuba Medical Office
102 Ozark Street
Cuba
MO
65453
Healthnet Regional Center of Cuba
412 N Franklin
Cuba
MO
65453
SJC-Cuba
114 Downy Street
Cuba
MO
65453
SJC-Steelville
518 Pine Street
Steelville
MO
65565
Steelville Medical Office
510 W Main Street
Steelville
MO
65565
Riverside Medical Clinic
101 Progress Drive
Sullivan
MO
63080
Sullivan Medical Office
965 Mattox
Sullivan
MO
63080
         
Franklin County:
        
Name
Address
City
State
ZIP
St Johns Mercy Hospital Clinic
851 E 5th Street Ste 312
Washington
MO
63090
         
Iron County:
        
Name
Address
City
State
ZIP
Arcadia Valley Family Clinic
305 Maple Street
Pilot Knob
MO
63663
         
Jefferson County:
        
Name
Address
City
State
ZIP
De Soto Family Practice
12 Jefferson Square
De Soto
MO
63020
Byrnes Mill Medical Center
100 Osage Executive Circle
House Springs
MO
63051
         
Lincoln County:
        
Name
Address
City
State
ZIP
Glennon Care Pediatrics
1165A East Cherry
Troy
MO
63379
Troy Family Practice
344 S Lincoln Drive
Troy
MO
63379
Troy Surgical Clinic
900 E Cherry Street
Troy
MO
63379
         
Madison County:
        
Name
Address
City
State
ZIP
Chands Medical Office
733 W Main Street
Fredericktown
MO
63645
Community Health Care Associates
735 W Main Street
Fredericktown
MO
63645
Fredericktown Primary Care
309 Garrett Street
Fredericktown
MO
63645
Madison Medical Center RHC
611 W Main Street
Fredericktown
MO
63645
         
Perry County:
        
Name
Address
City
State
ZIP
Convenient Care Clinic
624 Old Saint Marys Road
Perryville
MO
63775
Perry Kids Pediatrics
210 Hospital Lane Ste 202
Perryville
MO
63775
Perryville Family Care Clinic
212 Hospital Lane Ste 101
Perryville
MO
63775
Perry County Womens Care
212 Hospital Lane Ste 205
Perryville
MO
63775
         
Pike County:
        
Name
Address
City
State
ZIP
Eastern Missouri Health Services
214 W Church Street
Bowling Green
MO
63334
Pike Medical Clinic Inc.
Jct 61 & 161
Bowling Green
MO
63334
Eastern Missouri Health Services
2305 W Georgia
Louisiana
MO
63353
Pike Medical Clinic Inc.
211 S Third
Louisiana
MO
63353
         
St. Francois County:
        
Name
Address
City
State
ZIP
Bonne Terre Primary Care
55 Nesbit Drive
Bonne Terre
MO
63628
Chands Medical Office
1031 Karsch Road
Farmington
MO
63640
Farmington Primary Care
1101 Weber Rd Ste 302
Farmington
MO
63640
Medical Arts Clinic
1103 West Liberty
Farmington
MO
63640
EAST REGION
  
Attachment 5
    
                                                   
Aug-2008
    
      Rural Health Clinics (RHC)
Ste. Genevieve County:
        
Name
Address
City
State
ZIP
Family Health Care - Pointe Basse
753 Pointe Basse Drive
Ste Genevieve
MO
63670
Ste Genevieve Family Health Center
930 Park Drive
Ste Genevieve
MO
63670
         
Warren County:
        
Name
Address
City
State
ZIP
Glennon Care Pediatrics at Warrenton
511 Ashland
Warrenton
MO
63383
         
Washington County:
        
Name
Address
City
State
ZIP
Heartland Medical Center
10048 Settle Mill Road
Cadet
MO
63630
Austin Plaza Primary Care
108 Frizzell Suite 5
Potosi
MO
63664
Healthway Primary Care
200 Health Way Drive
Potosi
MO
63664
Potosi Medical Clinic
1 Kwan Plaza
Potosi
MO
63664
Quality Health Care, Inc.
600 Purcell Drive Suite 1
Potosi
MO
63664
Simpelo Medical Clinic
108 Frizzell Suite 6
Potosi
MO
63664
Byrnes Mill Medical Center-Richwoods
10649 State Hwy A
Richwoods
MO
63071
         
Other:
        
Name
Address
City
State
ZIP
Barry Rural Health Clinic
868 Mortimer
Barry
IL
62312
A Womans Life Holistic Fam HC Ctr
36 Doctors Park
Cape Girardeau
MO
63703
Cape Girardeau Co Public
1121 Linden St
Cape Girardeau
MO
63702
Immediate Healthcare
1702 N Kingshighway
Cape Girardeau
MO
63701
Medstop One Inc
3065 Williams St
Cape Girardeau
MO
63703
Midtown Family Medical Center
24 N Sprigg St
Cape Girardeau
MO
63701
River City Health Clinic
224 N Frederick
Cape Girardeau
MO
63701
Advanced Community Care Clinic
Route 4 Box 4629
Ellington
MO
63638
Reynolds Co Mem Hosp-Rains Clinic
Route 4 Box 4273
Ellington
MO
63638
Hermann Medical Arts
134 W 6th Street
Hermann
MO
65041
Southwest Medical Associates
1714 Wein Street
Hermann
MO
65041
Prompt Care
2130 E Jackson Blvd
Jackson
MO
63755
Mexico Family Health Care
626 Summit Suite L
Mexico
MO
65265
Mexico Health Services
809 Medical Park Drive Suite 104
Mexico
MO
65265
Mexico Pediatric Services
625 Summit
Mexico
MO
65265
Associated Medical Arts
504 N Sturgeon
Montgomery City
MO
63361
Montgomery City Medical Clinic
240 N Pickering
Montgomery City
MO
63361
Wilbers Family Care Clinic
111 E First Street
Montgomery City
MO
63361
Medical Clinic of Owensville
303 N First Street
Owensville
MO
65066
Perry Medical Clinic
1223 Main Street
Perry
MO
63462
Piedmont Family Clinic
1 Hals Plaza Drive
Piedmont
MO
63957
Wayne Medical Center
Route 4 Box 4515
Piedmont
MO
63957
Pittsfield Rural Hlth Affil
606 W Adams
Pittsfield
IL
62363
Pleasant Hill Rural Health
405 E State Street
Pleasant Hill
IL
62366
Rolla Urgent Care LLC
416 S Bishop Ave
Rolla
MO
65401
SJC-Rolla Medical Group
1601 N Bishop
Rolla
MO
65401
SJC-Rolla Internal Medicine
1100 W 10th St Ste 270
Rolla
MO
65401
SJC-Rolla Pediatrics
1100 W 10th St Ste 175
Rolla
MO
65401
Charles W Cunningham DO LLC
1010 Hwy 32 East
Salem
MO
65560
Salem Family Health Care Inc
Highway 72 North
Salem
MO
65560
SJC-Salem
404 W Rolla Rd
Salem
MO
65560
Forest City Family Practice
1000 N Jefferson
St James
MO
65559
SJC-St James
107 W Eldon Street
St James
MO
65559
Vandalia Medical Clinic
204 W Washington
Vandalia
MO
63382
Wellsville Medical Clinic
111 W Bates
Wellsville
MO
63384
 
 
 
 
Attachment 5
      
 
Jul-2008
      
EAST REGION
        
         
SAFETY NET HOSPITALS
        
         
St. Francois County:
        
Hospital
Address
City
State
ZIP
Southeast Missouri Mental Health Center
1010 W Columbia
Farmington
MO
63640
         
St. Louis City:
        
Hospital
Address
City
State
ZIP
Metropolitan St Louis Psychiatric Center
5351 Delmar
St Louis
MO
63112
St Louis Psychiatric Rehabilitation Center
5300 Arsenal
St Louis
MO
63139
         
St. Louis County:
        
Hospital
Address
City
State
ZIP
Hawthorn Childrens Psychiatric Hospital
1901 Pennsylvania
St Louis
MO
63133
         
 
 
 
EAST REGION
  
Attachment 5
    
   
Jul-2008
    
Community Mental Health Centers (CMHC)
        
         
         
Jefferson County:   (CMHC and Community Psychiatric Rehab)
      
Name
Address
City
State
ZIP
COMTREA Community Mental Health Center
227 Main Street
Festus
MO
63028
         
St. Charles County:   (CMHC and Community Psychiatric Rehab)
      
Name
Address
City
State
ZIP
Crider Center for Mental Health
1032 Crosswinds Court
Wentzville
MO
63385
         
St. Francois County:   (Community Psychiatric Rehab)
      
Name
Address
City
State
ZIP
Community Health Plus
1085 Maple Street
Farmington
MO
63640
Mineral Area CPRC Inc.
203 S Washington
Farmington
MO
63640
Southeast MO Community Treatment Ctr
512 E Main
Park Hills
MO
63601
         
St. Louis (City):   (CMHC and Community Psychiatric Rehab)
      
Name
Address
City
State
ZIP
Hopewell Center
1504 S Grand
St Louis
MO
63104
         
St. Louis (City):   (Community Psychiatric Rehab)
      
Name
Address
City
State
ZIP
Adapt
2301 Hampton Ave
St Louis
MO
63139
Community Health Plus
1430 Olive Street
St Louis
MO
63103
Family Resource Center Inc.
3309 S Kingshighway
St Louis
MO
63139
Independence Center
4380 West Pine
St Louis
MO
63108
Our Little Academy Therapeutic School
4330 Lindell Blvd
St Louis
MO
63108
Places For People Inc.
4130 Lindell Blvd
St Louis
MO
63108
         
         
Other:    (CMHC)
        
Name
Address
City
State
ZIP
Mark Twain Area Counseling Center
917 Broadway
Hannibal
MO
63401
         
Other:   (Community Psychiatric Rehab)
        
Name
Address
City
State
ZIP
Comprehensive Health Systems Inc.
Highway 61 & HH
Hannibal
MO
63401
         
Other:   (CMHC and Community Psychiatric Rehab)
      
Name
Address
City
State
ZIP
Community Counseling Center
402 S Silver Springs Road
Cape Girardeau
MO
63703
East Central Missouri Behavioral Health Svcs
321 W Promenade
Mexico
MO
65265
 
 
 
East Region - EPSDT Withhold Amounts
         
         
       
July 1, 2008
       
EPSDT
CATEGORY
      
WITHHOLD
OF AID
      
AMOUNT
NUMBER
AGE
SEX
PER % POINT
1
<1 (NEWBORNS)
MALE AND FEMALE COMBINED
$0.12
 
1-6 YEAR OLDS
MALE AND FEMALE COMBINED
$0.02
 
7-13 YEAR OLDS
MALE AND FEMALE COMBINED
$0.01
 
14-20 YEAR OLDS
FEMALE
  
$0.03
 
14-20 YEAR OLDS
MALE
  
$0.02
         
4
0-20 YEAR OLDS
MALE AND FEMALE COMBINED
$0.02
         
5
0-6 YEAR OLDS
MALE AND FEMALE COMBINED
$0.03
 
7-13 YEAR OLDS
MALE AND FEMALE COMBINED
$0.02
 
14-18 YEAR OLDS
MALE AND FEMALE COMBINED
$0.02

 
 
 
Central Region - EPSDT Withhold Amounts
         
         
       
July 1, 2008
       
EPSDT
CATEGORY
      
WITHHOLD
OF AID
      
AMOUNT
NUMBER
AGE
SEX
PER % POINT
1
<1 (NEWBORNS)
MALE AND FEMALE COMBINED
$0.12
 
1-6 YEAR OLDS
MALE AND FEMALE COMBINED
$0.02
 
7-13 YEAR OLDS
MALE AND FEMALE COMBINED
$0.02
 
14-20 YEAR OLDS
FEMALE
  
$0.04
 
14-20 YEAR OLDS
MALE
  
$0.02
         
4
0-20 YEAR OLDS
MALE AND FEMALE COMBINED
$0.03
         
5
0-6 YEAR OLDS
MALE AND FEMALE COMBINED
$0.03
 
7-13 YEAR OLDS
MALE AND FEMALE COMBINED
$0.02
 
14-18 YEAR OLDS
MALE AND FEMALE COMBINED
$0.02

 
 
 

Western Region - EPSDT Withhold Amounts
With I-70 Expansion
         
         
       
July 1, 2008
       
EPSDT
CATEGORY
      
WITHHOLD
OF AID
      
AMOUNT
NUMBER
AGE
SEX
PER % POINT
1
<1 (NEWBORNS)
MALE AND FEMALE COMBINED
$0.09
 
1-6 YEAR OLDS
MALE AND FEMALE COMBINED
$0.02
 
7-13 YEAR OLDS
MALE AND FEMALE COMBINED
$0.02
 
14-20 YEAR OLDS
FEMALE
  
$0.03
 
14-20 YEAR OLDS
MALE
  
$0.02
         
4 OSJC
0-20 YEAR OLDS
MALE AND FEMALE COMBINED
$0.03
4 JC
0-20 YEAR OLDS
MALE AND FEMALE COMBINED
$0.03
         
5
0-6 YEAR OLDS
MALE AND FEMALE COMBINED
$0.03
 
7-13 YEAR OLDS
MALE AND FEMALE COMBINED
$0.02
 
14-18 YEAR OLDS
MALE AND FEMALE COMBINED
$0.02

 
 
 

Western Region - EPSDT Withhold Amounts
With I-70 Expansion Without Pharmacy
         
         
       
July 1, 2008
       
EPSDT
CATEGORY
      
WITHHOLD
OF AID
      
AMOUNT
NUMBER
AGE
SEX
PER % POINT
1
<1 (NEWBORNS)
MALE AND FEMALE COMBINED
$0.09
 
1-6 YEAR OLDS
MALE AND FEMALE COMBINED
$0.02
 
7-13 YEAR OLDS
MALE AND FEMALE COMBINED
$0.02
 
14-20 YEAR OLDS
FEMALE
  
$0.03
 
14-20 YEAR OLDS
MALE
  
$0.02
         
4 OSJC
0-20 YEAR OLDS
MALE AND FEMALE COMBINED
$0.03
4 JC
0-20 YEAR OLDS
MALE AND FEMALE COMBINED
$0.03
         
5
0-6 YEAR OLDS
MALE AND FEMALE COMBINED
$0.03
 
7-13 YEAR OLDS
MALE AND FEMALE COMBINED
$0.02
 
14-18 YEAR OLDS
MALE AND FEMALE COMBINED
$0.02

 
 
 
 
Western Region - EPSDT Withhold Amounts
Without I-70 Expansion
         
         
       
July 1, 2008
       
EPSDT
CATEGORY
      
WITHHOLD
OF AID
      
AMOUNT
NUMBER
AGE
SEX
PER % POINT
1
<1 (NEWBORNS)
MALE AND FEMALE COMBINED
$0.08
 
1-6 YEAR OLDS
MALE AND FEMALE COMBINED
$0.02
 
7-13 YEAR OLDS
MALE AND FEMALE COMBINED
$0.02
 
14-20 YEAR OLDS
FEMALE
  
$0.03
 
14-20 YEAR OLDS
MALE
  
$0.02
         
4 OSJC
0-20 YEAR OLDS
MALE AND FEMALE COMBINED
$0.02
4 JC
0-20 YEAR OLDS
MALE AND FEMALE COMBINED
$0.03
         
5
0-6 YEAR OLDS
MALE AND FEMALE COMBINED
$0.03
 
7-13 YEAR OLDS
MALE AND FEMALE COMBINED
$0.02
 
14-18 YEAR OLDS
MALE AND FEMALE COMBINED
$0.02

 
 
 
 
Attachment 14
Page 1 of 5
OFFICE VISIT SERVICES
Procedure Code
Program Type
Allowable Fee for Dates of Service   July 1, 2006 through June 30, 2007
99201
Medical Services
$21.52
99201 GE
Medical Services
$21.52
99201 GT
Medical Services
$21.52
99201
Nurse Midwife
$21.52
99201
Podiatry
$21.52
99201GE
Podiatry
$21.52
99201 W2
Podiatry
$21.52
99201
Other Medical
$21.52
99201 GE
Other Medical
$21.52
99202
Medical Services
$38.23
99202 EP
Medical Services
$38.23
99202 GT
Medical Services
$38.23
99202 GT EP
Medical Services
$38.23
99202 GE
Medical Services
$38.23
99202 GE EP
Medical Services
$38.23
99202
Nurse Midwife
$38.23
99202 EP
Nurse Midwife
$38.23
99202
Podiatry
$38.23
99202 W2
Podiatry
$38.23
99202 GE
Podiatry
$38.23
99202
Other Medical
$38.23
99202 EP
Other Medical
$38.23
99202 GE
Other Medical
$38.23
99202 GE EP
Other Medical
$38.23
99203
Medical Services
$56.93
99203 EP
Medical Services
$56.93
99203 GE
Medical Services
$56.93
99203 GE EP
Medical Services
$56.93
99203 GT
Medical Services
$56.93
99203 GT EP
Medical Services
$56.93
99203
Nurse Midwife
$56.93
99203 EP
Medical Services
$56.93
99203
Podiatry
$56.93
99203 W2
Podiatry
$56.93
99203
Other Medical
$56.93
99203 EP
Other Medical
$56.93
99203 GE
Other Medical
$56.93
99203 GE EP
Other Medical
$56.93
99204
Medical Services
$80.62
 
 
Attachment 14
Page 2 of 5
OFFICE VISIT SERVICES
Procedure Code
Program Type
Allowable Fee for Dates of Service   July 1, 2006 through June 30, 2007
99204 EP
Medical Services
$80.62
99204 GT
Medical Services
$80.62
99204 GT EP
Medical Services
$80.62
99204
Nurse Midwife
$80.62
99204 EP
Nurse Midwife
$80.62
99204
Podiatry
$80.62
99204 W2
Podiatry
$80.62
99204
Other Medical
$80.62
99204 EP
Other Medical
$80.62
99205
Medical Services
$102.58
99205 EP
Medical Services
$102.58
99205 GT
Medical Services
$102.58
99205 GT EP
Medical Services
$102.58
99205
Nurse Midwife
$102.58
99205 EP
Nurse Midwife
$102.58
99205
Podiatry
$102.58
99205 W2
Podiatry
$102.58
99205
Other Medical
$102.58
99205 EP
Other Medical
$102.58
99211
Medical Services
$12.55
99211 GE
Medical Services
$12.55
99211 GT
Medical Services
$12.55
99211
Nurse Midwife
$12.55
99211
Podiatry
$12.55
99211 W2
Podiatry
$12.55
99211 GE
Podiatry
$12.55
99211
Other Medical
$12.55
99211 GE
Other Medical
$12.55
99212
Medical Services
$22.60
99212 GT
Medical Services
$22.60
99212 GE
Medical Services
$22.60
99212
Nurse Midwife
$22.60
99212
Podiatry
$22.60
99212 W2
Podiatry
$22.60
99212 GE
Podiatry
$22.60
99212
Other Medical
$22.60
99212 GE
Other Medical
$22.60
99213
Medical Services
$30.86
99213 GE
Medical Services
$30.86
 
 
 
 
 
Attachment 14
Page 3 of 5
OFFICE VISIT SERVICES
Procedure Code
Program Type
Allowable Fee for Dates of Service   July 1, 2006 through June 30, 2007
99213 GT
Medical Services
$30.86
99213
Nurse Midwife
$30.86
99213
Podiatry
$30.86
99213 W2
Podiatry
$30.86
99213 GE
Podiatry
$30.86
99213
Other Medical
$30.86
99213 GE
Other Medical
$30.86
99214
Medical Services
$48.45
99214 EP
Medical Services
$48.45
99214 GT
Medical Services
$48.45
99214 GT EP
Medical Services
$48.45
99214
Nurse Midwife
$48.45
99214 EP
Nurse Midwife
$48.45
99214
Podiatry
$48.45
99214 W2
Podiatry
$48.45
99214
Other Medical
$48.45
99214 EP
Other Medical
$48.45
99215
Medical Services
$70.63
99215 EP
Medical Services
$70.63
99215 GT
Medical Services
$70.63
99215 GT EP
Medical Services
$70.63
99215
Nurse Midwife
$70.63
99215 EP
Nurse Midwife
$70.63
99215
Podiatry
$70.63
99215 W2
Podiatry
$70.63
99215
Other Medical
$70.63
99215 EP
Other Medical
$70.63


 
 
 

Attachment 14
Page 4 of 5
DENTAL SERVICES July 1, 2006 through June 30, 2008
Procedure
Code
Age
D0210
0-125
D0270
0-125
D0272
0-125
D0330
0-125
D0340
0-20
D0350
0-20
D1110
13-125
D1203
0-20
D1204
21-125
D1351
0-20
D2140
0-125
D2150
0-125
D2160
0-125
D2161
0-125
D2330
0-125
D2331
0-125
D2332
0-125
D2335
0-125
D2910
0-125
D2920
0-125
D2930
0-125
D2931
0-125
D2932
0-125
D2940
0-125
D3220
0-125
D3310
0-125
D3320
0-125
D3330
0-125
D3346
0-125
D3347
0-125
D3348
0-125
D3410
0-125
D3421
0-125
D3425
0-125
D4210
0-125
D5510
0-125
D5520
0-125
D5610
0-125
D5630
0-125
D5640
0-125
 
 
Attachment 14
Page 5 of 5
DENTAL SERVICES July 1, 2006 through June 30, 2008
Procedure
Code
Age
D5650
0-125
D5660
0-125
D5710
0-125
D5711
0-125
D5721
0-125
D5730
0-125
D5731
0-125
D5740
0-125
D5741
0-125
D5750
0-125
D5751
0-125
D5760
0-125
D5761
0-125
D5820
0-125
D5821
0-125
D6930
0-125
D7220
0-125
D7230
0-125
D7240
0-125
D7241
0-125
D7960
0-125
D7970
0-125
D9110
0-125
D9241
0-125
D9910
0-125
D9951
0-125


NOTE:  The health plan shall review provider bulletins posted on the DMS website for future code changes due to HCPCS and HIPAA.