Missouri MO

Missouri MO HealthNet (DSS / MO HealthNet Division, MHD) expresses prior authorization in TWO main loci, NOT one. (1) MEDICAL/FFS: criteria live inside per-program Provider Manuals on mydss.mo.gov (migrated OFF the dead manuals.momed.com host). Each provider type (Physician, DME, Hospital, Therapy, Home Health, Pharmacy, ~40 programs) has its own Manual; the General Sections Manual carries the cross-cutting 'Section 8: Prior Authorization' (basis, guidelines, procedure, exceptions, emergency carve). Manuals publish as .docx (PDL as .xlsx) inside an HTML viewer wrapper at /media/pdf/<slug> or /media/<id> that redirects to /media/file/<slug> and embeds the real file under /sites/mydss/files/media/. (2) PHARMACY: STATE-ADMINISTERED (SMART PA program, Gainwell/Conduent fiscal agent) - NOT carved to per-MCO PBMs. The 'Pharmacy Clinical Edits and Preferred Drug Lists' page publishes a large alphabetical library of per-drug-class criteria docs (PDL Edit / Clinical Edit / Step Therapy Edit / Fiscal Edit shapes) plus ~17 drug-class PA forms and a master PDL (Preferred/Non-Preferred Products, .xlsx). Searchable PDL/DSP DB at mopdl.gainwelltechnologies.com. Managed care (3 MCOs: Healthy Blue/Anthem, Home State Health/Centene, UnitedHealthcare Community Plan) run their own medical PA via plan portals; pharmacy stays state-administered across FFS and MCO. AUTHORITY: MHD publishes both manual criteria and SMART PA pharmacy criteria centrally; emomed.com is the provider transaction portal (claims/PA submission), not where criteria are authored. DEAD PINS: state_meta pa_index (dss.mo.gov/mhd/cs/medical-services/prior-authorization/) 404s; provider_manual (manuals.momed.com) DNS no longer resolves. Live replacements in data.repin_candidates.

Last award: 2022-05-06. Next due: 2026-2027 (RFP for successor contract expected ahead of 7/1/2027 go-live).

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

# MO — learned PA profile (local Qwen synthesis, 2026-05-28) Synth note: map=qwen2.5:7b / reduce=qwen2.5-coder:32b, 12 docs. See [[state_shape_MO]]. Correction pass: WISeR is not applicable to MO — WISeR ("Wasteful and Inappropriate Service Reduction") is a CMS Medicare PA model limited to AZ/NJ/OH/OK/TX/WA; MO does not participate. The model's "WISeR pilot status unknown" line was a template artifact, corrected below. ## 1. How MO requires PA Missouri's Medicaid program, known as MO HealthNet, requires prior authorization (PA) through a dual system involving both per-program Provider Manuals and a state-administered SMART PA pharmacy clinical-edit/PDL criteria library. The specific requirements for PA vary by service category and provider type. For prescription drugs, the **Pharmacy Provider Manual** outlines step therapy and documentation of failure at previous steps as key criteria. Additionally, the **Preferred/Non-Preferred Products PDL** document specifies that prior authorization is required for non-step therapy drugs with medical necessity and clinical indication documentation. The **Acetaminophen Cumulative Dose Clinical Edit** provides a specific example where cumulative acetaminophen dosages must not exceed 4 grams per day over the last 90 days. For services like anticoagulants, the **Anticoagulants (oral and subcutaneous) PDL Edit** mandates compliance with preferred agents or documented reasons for non-compliance. ## 2. How MO publishes and reports PA Missouri's Medicaid program publishes PA criteria through various channels. The primary sources include: - **Provider Manuals**: Available on the Missouri Department of Social Services (DSS) website, specifically under mydss.mo.gov. They contain detailed PA requirements for different provider types such as physicians, DME providers, hospitals, and therapists. - **SMART PA Pharmacy Clinical-Edit/PDL Criteria Library**: Managed by the state; includes clinical edits and preferred drug lists (PDLs) for pharmacy services. Specific documents like the **Acne and Rosacea – Select Topical Agents PDL Edit** and **Anti-Amyloid Monoclonal Antibody Clinical Edit** are published with effective dates (e.g., August 21, 2025, and May 14, 2026, respectively). ## 3. MO's CMS-0057-F and PA-reform compliance posture Per the source documents, specific details about Missouri's CMS-0057-F submission are not provided. The state has a history of transitioning fiscal agents from ACS-Inc to Conduent/Gainwell, which may impact how PA processes are managed. An **1115 waiver** is mentioned but unnamed in the sources, indicating Missouri participates in federal Medicaid waivers for specific program enhancements; the sources do not establish whether it relates to CMS-0057-F or other PA reforms. (WISeR not applicable — MO is not one of the six WISeR-model states.) ## 4. How MO runs its own program Missouri's Medicaid program, MO HealthNet, is administered by the Missouri Department of Social Services (DSS) through the MO HealthNet Division (MHD). Per source documents, the structured procurement cycle for Managed Care Organizations (MCOs) had its last award on May 6, 2022, with the next due in 2026-2027. The program includes carve-outs for certain services: - **Pharmacy**: Carved into the state. - **Long-Term Services and Supports (LTSS)**: Carved out to state FFS. - **Behavioral Health (BH)**: Partially carved out. Specific programs like the foster-care MCO, Show Me Healthy Kids, operate under separate contracts. The program also includes specific clinical edits and PDLs for drugs such as anticoagulants and anti-amyloid monoclonal antibodies. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Dual System**: MO HealthNet uses both per-program Provider Manuals and a state-administered SMART PA pharmacy clinical-edit/PDL criteria library for PA requirements. - **Structured Procurement**: The MCO procurement cycle is well-defined with a 5-year renewal process (per source documents). - **Specific Clinical Edits**: Detailed clinical edits are provided for specific drugs, such as anticoagulants and anti-amyloid monoclonal antibodies. ### Missing/Uncertain: - **Gold Card Law**: The status of any gold card law in Missouri is unspecified in the sources. - **WISeR**: Not applicable — MO is not a WISeR-model state. - **CMS-0057-F Submission Details**: No details provided about Missouri's CMS-0057-F submission or compliance posture. - **Effective Dates and Codes**: Some documents lack specific effective dates (e.g., DME criteria) and CPT/HCPCS codes.