MoHealth Primary Care Health Home Enrollment Form
The MoHealth Primary Care Health Home Enrollment Form must be completed fully to enroll for health home services. Please ensure all fields are filled out correctly and submit via email. This form is essential for Medicaid-eligible participants to access health home benefits.
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How do I fill this out?
To fill out the MoHealth Primary Care Health Home Enrollment Form, ensure all necessary fields are completed with accurate information. The form requires details such as participant information, health conditions, and Medicaid eligibility. Submit the form via email once all sections are correctly filled out.
How to fill out the MoHealth Primary Care Health Home Enrollment Form?
1
Download the form.
2
Fill in health home provider details.
3
Complete participant information and check relevant health conditions.
4
Ensure that all required fields are accurate and complete.
5
Submit the completed form via email.
Who needs the MoHealth Primary Care Health Home Enrollment Form?
1
Medicaid-eligible participants needing health home services.
2
Primary care providers enrolling patients into the health home program.
3
Care coordinators managing patient enrollment.
4
Patients with chronic conditions requiring health home support.
5
Healthcare administrators processing Medicaid enrollments.
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1
Open the MoHealth Enrollment Form in PrintFriendly's PDF editor.
2
Fill in the required fields with accurate information.
3
Add any relevant comments or notes in the provided sections.
4
Review and double-check all entries for accuracy.
5
Save your edited form for submission.
What are the instructions for submitting this form?
To submit the completed Primary Care Health Home Enrollment Form, save a copy and email it to PCHH@dss.mo.gov using the state Proofpoint encryption system. Indicate 'PCHH ENROLLMENT' and the number of forms attached (maximum of 15) in the subject line of the email. Ensure all required fields are filled and verify Medicaid eligibility before submission. For any questions, contact your healthcare administrator for assistance. Advised to submit within the enrollment period to ensure timely processing.
What are the important dates for this form in 2024 and 2025?
Important dates for using the MoHealth Enrollment Form include the annual enrollment period starting in April 2024 and April 2025. Ensure timely submission within these periods to avoid delays.
What is the purpose of this form?
The Primary Care Health Home Enrollment Form is a critical document for Medicaid-eligible participants to access health home services. This form collects necessary information about the participant, including personal details, health conditions, and eligibility criteria. By completing and submitting this form, participants can access the coordinated care and support provided by the health home program.
Tell me about this form and its components and fields line-by-line.
- 1. Health Home Information: Includes health home provider number, which must contain 9 digits.
- 2. Date and Participant Information: Includes the date, participant name, MO HealthNet ID/DCN number, and date of birth.
- 3. Enrollment Conditions: Entails checking all applicable health conditions and ensuring that there is a minimum of 2 chronic conditions or 1 stand-alone condition.
- 4. MOHEALTHNET Use Only: Section for internal use by MoHealthNet to indicate approval or denial.
What happens if I fail to submit this form?
Failing to submit the completed form can result in delays or denial of health home services.
- Loss of Services: Participants may lose out on important health home services.
- Delays: Delays in accessing necessary care and support.
How do I know when to use this form?
- 1. Initial Enrollment: First-time enrollment of participants into the program.
- 2. Updating Information: Updating existing participant details and health conditions.
- 3. Eligibility Verification: Verifying Medicaid eligibility prior to enrollment.
Frequently Asked Question
Can I edit the MoHealth Enrollment Form on PrintFriendly?
Yes, you can edit the MoHealth Enrollment Form using PrintFriendly's PDF editor.
How do I submit the completed enrollment form?
Submit the completed form via email to PCHH@dss.mo.gov using Proofpoint encryption.
What information do I need to fill out the form?
You need participant details, health home provider information, and health conditions.
Can I sign the MoHealth Enrollment Form on PrintFriendly?
Yes, you can digitally sign the form using PrintFriendly's signing feature.
How do I verify Medicaid eligibility?
Check Medicaid eligibility through the eMOMED system before completing the form.
How do I check multiple chronic conditions?
Select all applicable chronic conditions in Part 3 of the form.
What should I do after filling out the form?
Save and submit the completed form via email to PCHH@dss.mo.gov.
Is the form usable for pediatric patients?
Yes, the form includes options for pediatric patients under relevant conditions.
Who processes the submitted forms?
Submitted forms are processed by the MoHealthNet team.
What if my form is denied?
You will receive a notification if the form is denied, specifying the reasons for denial.
