Missouri Department of Social Services (DSS) MO HealthNet Division (MHD) – MO HealthNet MANAGED CARE CONTRACT POLICY REVIEW SUBMISSION FORM HEALTH PLAN: Date Submitted to DSS-MHD: Type of Submission: New Revision Date of Last MHD Approval, if Revision: Policy Number: Policy Title: Contract Requirement for Policy: Policy Number: Additional Policies Submitted for Requirement(s) Title: Policy Number: Additional Policies Submitted for Requirement(s) Title: Policy Number: Additional Policies Submitted for Requirement(s) Title: Policy Number: Additional Policies Submitted for Requirement(s) Previously Other Policy(ies) Referenced in submitted during No (include with submission form) Submission current State Fiscal Year? Yes If yes, Date Submitted Date Approved Attachments Referenced in Title: Submission Name: Address: Contact Information: Phone Number: Fax Number: MO HealthNet MANAGED CARE CONTRACT HEALTH PLAN POLICY SUBMISSION FORM DSS-MHD TRACKING (State Agency Use Only) HEALTH PLAN:
Missouri Department of Social Services (DSS) – MO HealthNet Division (MHD) MO HealthNet MANAGED CARE CONTRACT POLICY REVIEW SUBMISSION FORM HEALTH PLAN: Date Submitted to DSS-MHD: Type of Submission: New Revision Date of Last MHD Approval, if Revision: Policy Number: Policy Title: Contract Requirement for Policy: Additional Policies Submitted for Requirement(s) Policy Number: Title: Additional Policies Submitted for Requirement(s) Policy Number: Title: Additional Policies Submitted for Requirement(s) Policy Number: Title: Additional Policies Submitted for Requirement(s) Policy Number: Other Policy(ies) Referenced in Submission Previously submitted during current State Fiscal Year? No (include with submission form) Yes If yes, Date Submitted Date Approved Attachments Referenced in Submission Title: Contact Information: Name: Address: Phone Number: Fax Number: MO HealthNet MANAGED CARE CONTRACT HEALTH PLAN POLICY SUBMISSION FORM DSS-MHD TRACKING (State Agency Use Only) HEALTH PLAN:
2017-policy-submission-form.docx