Mo healthnet exception request form 2025

1. Click ‘Get Form’ to open the mo healthnet exception request form in the editor.
2. Begin by entering the participant's name and date of birth in the designated fields. Ensure accuracy as this information is crucial for processing.
3. Input the participant's MO HealthNet number (DCN) and Social Security number. Double-check these entries to avoid delays.
4. In the 'Participant Diagnoses' section, clearly state the diagnoses related to the requested items or services. This helps justify your request.
5. List all alternative covered services that have been attempted but found ineffective for this diagnosis. This information is essential for approval.
6. Indicate whether a home health agency is making skilled nurse visits by selecting 'Yes' or 'No'.
7. Detail the requested items or services, including daily quantity and HCPCS code for each item. Be specific to ensure clarity.
8. Provide information about the MO HealthNet provider who will dispense and bill for services, including their name, telephone number, address, fax number, NPI, and provider identifier.
9. Print or type the doctor’s name or advanced practice nurse’s name and title along with their NPI and address.
10. Finally, ensure that you obtain an original signature from the doctor or APN on the form before submission. No stamps or photocopies are accepted.

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