Inpatient Validation Review Record Request
Inpatient hospital admissions must be certified as medically necessary and appropriate before MO HealthNet Division (MHD) will reimburse for inpatient services. All MO HealthNet-enrolled hospitals in Missouri and bordering states are subject to the admission certification requirement. The state has given authority for Conduent, MHD’s review authority, to receive all appropriate information necessary to review admissions subject to admission certification.
Each quarter, Conduent chooses a sampling of certifications from each hospital. If the admission is chosen for review, Conduent requests medical records from the hospital and conducts a review to confirm that the information provided to Conduent from the hospital at the time of the inpatient certification request is consistent with the documentation and clinical findings in the patient’s medical record.
Providers have 30 calendar days from the date of the request to submit the documentation to Conduent. A validation review determination that an inpatient stay was not medically necessary results in the recoupment of MHD payments in accordance with state regulation 13 CSR 70-3.030.
If the medical records requested by Conduent are not received, MO HealthNet will follow up with a request for medical records to be submitted to Conduent. Providers have 15 calendar days from the date of request to submit the documentation to Conduent. Non-compliance with either request will result in the recoupment of MHD payments in accordance with state regulation 13 CSR 70-3.030.
The medical records, validating medical necessity, should be submitted to:
Conduent
P.O. Box 105110
Jefferson City, MO 65110
Refer to the Hospital Manual for more information regarding Validation Review.
For additional resources refer to the Education and Training Resources page and/or sign up for a live webinar by accessing our Provider Training Calendar. Email MHD.Education@dss.mo.gov for more information.