PROCEDURES FOR COMPLETING MHSI VOUCHERS
OLD STYLE VOUCHER
MEDICAL/DENTAL/LAB/X-RAY - BLUE VOUCHERS
1. The blue portion entitled: "THIS IS A VOUCHER FOR THIS DATE OF
SERVICE ONLY" requires attaching an itemized bill/statement which must
include the CPT procedure code(s) and ICD-9 diagnosis code(s). 1500 form is
preferred.
2. The pink copy must be completed by the provider and the medical/dental/lab
report must be attached or the voucher cannot be honored for payment. MHSI
requires an itemized statement and medical/dental notes completed and attached
to the voucher, otherwise the voucher cannot be honored for payment.
DENTAL: must attach a statement that has the CDT code(s).
3. After the form has been completed and signed, return the copies as follows:
a.) Blue and Pink copies to the Central Office at the Moorhead address on the
voucher.
b.) Yellow copy is for your records.
PHARMACY - GREEN VOUCHERS
1. The green portion entitled: "THIS IS A VOUCHER FOR THIS DATE OF
SERVICE ONLY" requires attaching an RX label that contains the medication,
dosage, quantity and price.
2. After the form has been completed and signed, return the copies as follows:
a.) Green and Pink copies to the Central Office at the Moorhead address on the
voucher.
b.) Yellow copy is for your records.
NEW STYLE VOUCHERS
The new style vouchers are a single page. As with the old style vouchers, you will need to submit charges be it as a HCFA1500, UB92, ADA or some form of receipt. Medical vouchers will require chart notes.
VOUCHERS MUST BE SUBMITTED WITHIN 30 DAYS OF ISSUANCE OR THE VOUCHER WILL BE VOIDED
SERVICES NOT PAID BY MIGRANT HEALTH (This list is not an all inclusive list - please check with Central Office if questions)
MHSI does NOT pay for the following, including but not limited to:
A. Hospital:
In-patient or Out-patient surgery
In-patient or Out-patient care
Emergency Room
B. Office Visits for the following:
Annual Physical Exams Employment Physical Exams
Athletic Physical Exams Work-related Injuries
Military Physical Exams Altercation-related Injuries
MVA related Injuries Fertility/Impotence Related Concerns
Alcohol/Drug Related Injuries Acne
Pre or Post Operative Exams Weight Loss Programs
Telephone Consults Hair Loss
Dietician - Nutritional Consultation
Physician Charges for In/Out Patient Hospitalization
C. Pharmacy/Medicines
Over-The-Counter Medicines
Alcohol Wipes
Cotton Balls
No medications for under $10.00 when on voucher alone
Following Medications:
Advil (no Rx strength) Ibuprofen (no Rx strength)
Motrin (no Rx strength) Folic Acid (no Rx strength)
Naproxen Narcotics
Medications related to the following:
Acne Fertility/Impotence
Vitamins Nicotine Patches
Rogaine Medicated Shampoo
Diet/Weight Loss Experimental Drugs
Work Related Injuries/Accidents MVA Related Injuries/Accidents
Altercation Related Injuries/Accidents
No Medications not covered by Medical Assistance
D. Equipment/Supplies
Support Hose (Ted Hose) Dressing Supplies
Wheel Chairs Ace Bandages
Braces Hot Water Bottles
Crutches Heating Pads
Splints Sun screen
Miscellaneous Appliances Insect Repellant
Eye Glasses/Contacts Splints/Braces
Batteries/Pens for Blood Sugar Machines
REIMBURSEMENT LEVELS
MEDICAL
Office Visit 75% of office visit cost (max $100)
Lab/X-Ray/MRI/CT/Ultrasound $62.50
Readings $30.00
Prenatal Patient Reimbursement Levels
Office Visit $ 75.00
Lab/X-Ray/Ultrasound $125.00
Readings $ 75.00
Delivery/False Labor/Miscarriage
Mother: Hospital $360.00
Doctor $360.00
Baby: Hospital $360.00
Doctor $135.00
DENTAL
$125.00 per patient per year
RADIOLOGY/LAB/PATHOLOGY READINGS
$30.00
$75.00 (Prenatal Only)
PHARMACY
Pre-approval needed before filling prescriptions.
Please attach the RX lable to the voucher.
Only the medications written on the voucher are authorized. Should a patient presenting scripts for medications not authorized on the voucher, patient will be responsibile for the medications.
Pharmacy vouchers have a maximum of $100 per patient per 30 day supply of prescription medications only.
MHSI will reimburse for genenric medications only. In the event generic medication is not available, pricing for brand name drugs will be priced using the MHSI M.A.C. schedule plus a dispensing fee of $4.00.
If a prescription is marked DAW, a copy of the prescrition must be submitted with the original voucher or generic will be paid. No retroactive DAW will be paid.
If a Pharmacy's usual and customary price is lower than the Migrant Health Guideline, the lower price will prevail.
For Minnesota Providers: a 2% add-on fee for the Minnesota Care Tax is permitted.
Prescriptions not covered by MHSI:
Ibuprofen (no RX strength) Motrin (no RX strength) Advil (no RX strength)
Naproxen Folic Acide (no RX strenth) Narcodicts
Viagra
Medications related to the following are not covered by MHSI:
Acne Vitamins Rogain
Diet/Weight Loss Fertility/Impotence Nicotine Patches
Medicated Shampoo Experimental Drugs Yohimbine
Nutritional Supplements Motor Vehicle Accidents Altercations
Work Related Injuries Medical Equipiment/Supplies
MHSI will not pay for medications that are/aren't covered under:
Medicaid Medicare Private Insurance
MODIFICATION TO MHSI M.A.C. PRICING
(for commonly prescribed medications)
DRUG STRENGTH NEW MAC PRICE
Amox-Clav 875 MG $2.50
Cefuroxime 250 MG .80
Cefuroxime 500 MG 1.40
Clindamycin 150 MG .40
Clindamycin 300 MG 1.10
Ciprofloxacin 250 MG .30
Ciprofloxacin 500 MG .40
Clotrim/Betam Cream .60
Enalapril 2.5 MG .22
Enalapril 5 MG .27
Enalapril 10 MG .29
Enalapril 20 MG .33
Gabapentin 100 MG .30
Gabapentin 300 MG .55
Gabapentin 400 MG .60
Gabapentin 600 MG .95
Gabapentin 800 MG 1.42
Ketoconazole 200 MG 1.25
Lisinopril 2.5 MG .27
Lisinopril 5 MG .29
Lisinopril 10 MG .32
Lisinopril 20 MG .34
Lisinopril/HCTZ ALL .37
Lovastatin 10 MG .40
Lovastatin 20 MG .61
Lovastatin 40 MG 1.00
Metformin 500 MG .23
Metformin 850 MG .25
Metformin 1000 MG .31
Metformin ER 500 MG .27
Metformin/GLY 1.25/250 MG .30
Metformin/GLY 2.5/500 MG .30
Metformin/GLY 5/500MG .30
Paroxetine 10 MG 1.10
Paroxetine 20 MG 1.17
Paroxetine 30 MG 1.19
Paroxetine 40 MG 1.22