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MO HealthNet Internet Provider Training Program Presented by the Provider Education Unit

MO HealthNet Internet Provider Training Program Presented by the Provider Education Unit MO HealthNet Division. Proper Completion of the Medical Referral Form of Restricted Participants Also Known as PI-118 Form. Presented by the Provider Education Unit MO HealthNet Division.

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MO HealthNet Internet Provider Training Program Presented by the Provider Education Unit

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  1. MO HealthNet Internet Provider Training Program Presented by the Provider Education Unit MO HealthNet Division MO HealthNet Division

  2. Proper Completion of the Medical Referral Form of Restricted ParticipantsAlso Known as PI-118 Form Presented by the Provider Education Unit MO HealthNet Division MO HealthNet Division

  3. If a provider feels that a participant is improperly using benefits, the provider is requested to notify the MO HealthNet Division, Program Integrity Unit, P.O. Box 6500, Jefferson City, MO 65102 or you may contact the Program Integrity Unit at 573- 751-3399. MO HealthNet Division

  4. MO HealthNet Division

  5. Name of Participant MO HealthNet ID Number MO HealthNet Division

  6. Authorized (Lock-in) Provider Name MO HealthNet Provider Identifier Provider Taxonomy Code MO HealthNet Division

  7. Signature of Authorized (Lock-in) Provider Date (Month/Day/Year) MO HealthNet Division

  8. Date of Service (Month/Day/Year) Reason For Referral MO HealthNet Division

  9. Referring To Provider Provider Address Provider Phone Number MO HealthNet Division

  10. Provider Vendor (NPI) Number Provider Taxonomy Code MO HealthNet Division

  11. MO HealthNet Division

  12. Obtaining a Copy of the Paper Form To Obtain a paper copy of the form, go to the MHD public Web site, www.dss.mo.gov/mhd/providers/index.htm. In the left hand column, click on “MO HealthNet Forms”. Then scroll down the list and click on “Medical Referral Form of Restricted Participants (PI-118)”. You can print the form once it opens up on your computer screen. MO HealthNet Division

  13. Thank you again for participating in this training program. If you have questions regarding the information in this presentation, please contact the Provider Education Unit at 573-751-6683. MO HealthNet Division

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