The Provider Manual is a reference tool that contains eligibility, benefits, contact information and policies/procedures for services that the Molina Healthy Connections Plan specifically provides and administers on behalf of Molina Healthcare. The Provider Manual is reviewed, evaluated and updated as needed and at a minimum annually.
The Provider Manual is a reference tool that contains eligibility, benefits, contact information and policies/procedures for services that the Molina ...
MolinaHealthcare.com
Medicaid
Provider Manual
Molina Healthcare of South Carolina
(Molina Healthcare or Molina)
Medicaid 2021
The Provider Manual is customarily updated annually but may be updated more frequently as policies or regulatory requirements change. Providers can access the most current Provider Manual at MolinaHealthcare.com.
Last Updated: February 2021
This Provider Manual shall serve as a supplement as referenced there to and incorporated therein, to the Molina Healthcare of South Carolina Provider Services Agreement. This manual shall take precedence over the Molina Dual Options Medicare-Medicaid Plan Manual concerning the care of Molina Healthy Connections members. The information contained within this manual is proprietary. The information is not to be copied in whole or in part; nor is the information to be distributed without the written consent of Molina Healthcare. The Provider Manual is a reference tool that contains eligibility, benefits, contact information and policies/procedures for services that the Molina Healthy Connections Plan specifically provides and administers on behalf of Molina Healthcare. The Provider Manual is reviewed, evaluated and updated as needed and at a minimum annually.
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Contents
Section 1. Addresses and Phone Numbers.........................................................................................................................................................................6 Section 2. Enrollment, Eligibility and Disenrollment................................................................................................................................................9 Section 3. Member Rights and Responsibilities (Member Bill of Rights)...............................................................................14 Section 4. Benefits and Covered Services........................................................................................................................................................................17 Section 5. Provider Responsibilities.............................................................................................................................................................................................31 Section 6. Healthcare Services (HCS)....................................................................................................................................................................................41 Section 7. Medical Management.....................................................................................................................................................................................................63 Section 8. Pharmacy........................................................................................................................................................................................................................................66 Section 9. Quality Improvement ...................................................................................................................................................................................................... 70 Section 10. Risk Adjustment Management Program........................................................................................................................................88 Section 11. Claims and Compensation ................................................................................................................................................................................89 Section 12. Compliance ............................................................................................................................................................................................................................103 Section 13. Cybersecurity Requirements .......................................................................................................................................................................115 Section 14. Credentialing and Recredentialing...................................................................................................................................................... 124 Section 15. Delegation................................................................................................................................................................................................................................133 Section 16. Appeals and Grievance Process.............................................................................................................................................................136
Section 1. Addresses and Phone Numbers
The main address for Molina Healthcare of South Carolina (Molina) is:
Molina Healthcare of South Carolina PO Box 40309 North Charleston, SC 29423-0309
Provider Services Department
The Provider Services department handles telephone and written inquiries from providers regarding address and Tax-ID changes, contracting and training. The department has Provider Services representatives who serve all of Molina's provider network. Eligibility verifications can be conducted at your convenience via the Provider Portal.
Phone: (855) 237-6178 Hours of Operation: Monday-Friday, 8 a.m. to 5 p.m., local time
Member Services Department
The Member Services department handles all telephone and written inquiries regarding member claims, benefits, eligibility/identification, Pharmacy inquiries, selecting or changing Primary Care Providers (PCPs), and member complaints. Member Services representatives are available from 8 a.m. to 6 p.m. Monday through Friday, excluding State holidays. Eligibility verifications can be conducted at your convenience via the Provider Portal.
Phone: (855) 882-3901 TTY/TDD: 711 Fax: (844) 834-2155 Email: MHSCMemberServices@MolinaHealthcare.com
Claims Department
Molina strongly encourages participating providers to submit claims electronically (via a clearinghouse or Provider Portal) whenever possible.
· Access the Provider Portal (https://provider.MolinaHealthcare.com) · EDI Payer ID 46299.
To verify the status of your Claims, please use the Provider Portal. For other claims questions contact Provider Services.
Claims Recovery Department
The Claims Recovery department manages recovery for Overpayment and incorrect payment of claims.
Molina Healthcare of South Carolina PO Box 602960 Charlotte, NC 28260-2960
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Compliance and Fraud AlertLine
If you suspect cases of fraud, waste, or abuse, you must report it to Molina. You may do so by contacting the Molina AlertLine or submit an electronic complaint using the website listed below. For more information about fraud, waste and abuse, please see the Compliance section of this Provider Manual.
Confidential Compliance Official Molina Healthcare, Inc. 200 Oceangate, Suite 100 Long Beach, CA 90802 Phone: (866) 606-3889 Website: https://MolinaHealthcare.alertline.com
Credentialing Department
The Credentialing department verifies all information on the Provider Application prior to contracting and re-verifies this information every three years, or sooner, depending on Molina's Credentialing criteria. The information is then presented to the Professional Review Committee to evaluate a provider's qualifications to participate in the Molina network. Email: MSC-CREDENTIALING@MolinaHealthcare.com
24-Hour Nurse Advice Line
This telephone-based nurse advice line is available to all Molina members. Members may call anytime they are experiencing symptoms or need health care information. Registered nurses are available 24 hours a day, 7 days a week to assess symptoms and help make good health care decisions.
· English Phone : (888) 275-8750 · Spanish Phone : (866) 648-3537 · TTY English : (866) 735-2929 · TTY Spanish : (866) 833-4703
Healthcare Services Department
The Healthcare Services (formerly Utilization Management) department conducts concurrent review on inpatient cases and processes Prior Authorizations/Service Requests. The Healthcare Services (HCS) department also performs Care Management for members who will benefit from Care Management services. Participating providers are required to interact with Molina's HCS Department electronically whenever possible. Prior Authorizations/Service Requests and status checks can be easily managed electronically.
Managing Prior Authorizations/Service Requests electronically provides many benefits to providers, such as:
· Easy to access 24/7 online submission and status checks. · Ensures HIPAA compliance.
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· Ability to receive real-time authorization status. · Ability to upload medical records. · Increased efficiencies through reduced telephonic interactions. · Reduces cost associated with fax and telephonic interactions.
Molina offers the following electronic Prior Authorizations/Service Requests submission options:
· Submit requests directly to Molina via the Provider Portal. See the Provider Portal Quick Reference Guide or contact your Provider Services representative for registration and submission guidance
· Submit requests via 278 transactions. See the EDI transaction section of our Molina's website for guidance.
Behavioral Health
Molina manages all components of covered services for behavioral health. For member behavioral health needs, please contact us directly at (855) 882-3901, 24 hours per day, 365 days per year.
Molina Healthcare of South Carolina Service Area Includes all 46 counties
SparGtarenebnuvrilgle
Cherokee
York
ChesterfielMdarlboro
Lancaster
Pickens
Chester Union
Kershaw
Darlington
Dillon Marion
Oconee Anderson
Laurens
Fairfield
Lee
Florence
Horry
AbbevilleGreenwood
Newberry Saluda
Richland Sumter
McCormick Edgefield
Lexington Calhoun Clarendon
WilliamsbuGrgeorgetown
Aiken
Orangeburg
Berkeley
Bamberg Barnwell
Dorchester
Allendale
Colleton
HampJtaosnperBeaufort Charleston
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Section 2. Enrollment, Eligibility and Disenrollment
Enrollment in Medicaid Programs
The Medicaid Program is the program which implements Title XIX of the Social Security Act. It is administered by the South Carolina Department of Health and Human Services (SCDHHS) with a brand name of South Carolina Healthy Connections (SCHC). SCDHHS takes applications and determines eligibility of individuals and families for Medicaid coverage in the state. Further, for the majority of individuals and families who are eligible for Medicaid coverage and are eligible to participate in managed care, SCDHHS contracts with an enrollment brokerage service called South Carolina Healthy Connections Choices (SCHCC) to assist Medicaid-eligible members with enrollment into a South Carolina-based managed care plan.
Only Medicaid recipients who are included in the eligible populations and living in counties with authorized Health Plans are eligible to enroll and receive services from Molina. Molina participates in the SCHC Medicaid program.
To enroll with Molina, the member, his/her representative, or his/her responsible parent or guardian must complete and submit an application to SCHCC. More information about SCHCC and the application/enrollment process can be found at scchoices.com.
SCHCC will enroll all eligible members with the health plan of their choice. If the member does not choose a plan, SCHCC will assign the member and his/her family to a plan that services the area where the member resides.
No eligible member shall be refused enrollment or re-enrollment, have his/her enrollment terminated, or be discriminated against in any way because of his/her health status, pre-existing physical or mental condition, including pregnancy, hospitalization or the need for frequent or highcost care.
Effective Date of Enrollment
Coverage shall begin as designated by SCDHHS on the first day of a calendar month. Before being assigned to a plan by SCDHHS, beneficiaries who are eligible for MCO plan assignment are given at least 30 days to choose a plan. Some beneficiaries not eligible for plan assignment may pro-actively enroll in a Managed Care Plan. Provided continued eligibility is maintained, all members will be enrolled in a Managed Care Organization (MCO) for a period of 12 months. SCDHHS or its Agent will automatically enroll a member into the MCO plan in which he/she was most recently enrolled if the member had a temporary loss of eligibility of less than 60 days. In this circumstance, the consecutive enrollment period will continue as though there has been no break in eligibility, keeping the original 12 month period.
Newborn Enrollment
All newborns of Molina members, where the newborn resided in the same household as the mother, are the responsibility of Molina. To assure continuity of care in the first months of the newborn's life, every effort will be made by SCDHHS to expedite the enrollment of the newborn into Molina. In cases where the newborn is not living with the mother, the newborn will be
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covered through fee-for-service Medicaid or be enrolled into a health plan by the person legally responsible for the newborn.
In cases where the mother was enrolled in Molina in the month of the birth, the newborn will be retroactively assigned to Molina, and will remain a Molina member for the remainder of the year unless the mother changes plans during the second or third months of the newborn's life.
All providers are required to notify Molina via the Pregnancy Notification Report (included in the Appendix of this manual) immediately after a positive pregnancy test and/or at the first prenatal visit of any member presenting themselves for health care services.
Eligibility Verification
Medicaid Programs
The state of South Carolina, through SCDHHS determines eligibility for Medicaid coverage. A person must meet income and resource levels as well as non-income levels, including having U.S citizenship and being a South Carolina resident to be eligible for Medicaid coverage.
Payment for services rendered is based on eligibility and benefit entitlement. The contractual agreement between providers and Molina places the responsibility for eligibility verification on the provider of services.
The program is limited to certain Medicaid eligibles who:
· Do not also have Medicare · Are under 65 years of age · Are not in a nursing home at the time of enrollment · Do not have limited benefits such as Healthy Connections Check Up, Specified Low Income
Beneficiaries, Emergency Services only, etc. · Are not participating in a Home or Community-Based Waiver program · Are not participating in Hospice · Are not participating in the PACE program · Are not enrolled in a commercial MCO through third party coverage · Are not enrolled in another Medicaid MCO
Eligibility Listing for Medicaid Programs
Providers who contract with Molina may verify a member's eligibility and/or confirm Primacy Care Provider (PCP) assignment by checking the following:
· Molina Provider Services at (855) 237-6178 · Molina Provider Portal: https://provider.MolinaHealthcare.com
Possession of a Medicaid ID card does not mean a recipient is eligible for Medicaid services. A provider should verify a recipient's eligibility each time the recipient receives services. The verification sources can be used to verify a recipient's enrollment in a managed care plan. The name and telephone number of the managed care plan are given along with other eligibility information.
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Identification Cards
Molina Healthcare of South Carolina Sample Member ID card
Member: <Member_Name_1> ID #: <Member_ID_1> DOB: <Date_of_Birth_1> PCP Name: <PCP_Name_1> PCP Phone: <PCP_Phone_Number_1> PCP Location: <PCP_Address_1> PCP Practice Name: <PCP_Group_Name_1>
24 Hour Nurse Advice Line English: 1-844-800-5155 Spanish: 1-866-648-3537
TTY: 1-866-735-2922
Program: SC Medicaid RxBIN: 004336 RxPCN: ADV RxGRP: Rx0860
MyMolina.com
MEMBERS: If you have any questions, please visit our website at www.molinahealthcare. com or call Member Services at (855) 882-3901
24 HOUR NURSE ADVICE LINE: If you have questions about your health, call our 24 hour Nurse Advice Line at (844) 800-5155 or (866) 648-3537 (Español). For hearing impaired, call TTY 711 or (866) 735-2929.
EMERGENCY SERVICES: Call 911 (if available) or go to the nearest emergency room or other appropriate setting. If you are not sure whether you need to go the emergency room, call your Primary Care Physician (PCP) at the number on the front of this card for instructions. Follow up with your PCP after all emergency room visits.
PRACTIONERS/PROVIDERS/HOSPITALS: For prior authorizations, eligibility, claims or benefits visit the Molina Web Portal at www.molinahealthcare.com or call (855) 237-6178.
PHARMACISTS: For pharmacy authorization questions, please call (855) 237-6178.
Claims Submission: PO BOX 22664, Long Beach, CA 90801 EDI Claims: Emdeon Payer ID: 46299
Molina Healthcare 4105 Faber Place Drive, STE 120,
Charleston, SC 29405
MolinaHealthcare.com
Members are reminded in their Member Handbooks to carry ID cards with them when requesting medical or pharmacy services. It is the provider's responsibility to ensure Molina members are eligible for benefits and to verify PCP assignment prior to rendering services. Unless an emergency condition exists, providers may refuse service if the member cannot produce the proper identification and eligibility cards.
Disenrollment
Voluntary Disenrollment
Members have the right to request to change plans once within the first ninety (90) days of enrollment with a MCO and at the end of each twelve (12) month enrollment period thereafter. Members may request to change plans for cause at any time. Circumstances that constitute cause for disenrollment include: the member moving out of the service area, Molina does not provide covered services, member seeks or refuses services based on moral or religious objections, member needs services that are not available within the Molina network, member's eligibility changes, or other reasons per 42 CFR 438.56(d)(2). Requests for disenrollment must be made to SCHCC. SCDHHS has final determination in all disenrollment requests.
Voluntary disenrollment does not preclude members from filing a grievance with Molina for incidents occurring during the time they were covered.
Involuntary Disenrollment
Under very limited conditions and in accordance with SCDHHS guidelines, members may be involuntarily disenrolled from a managed care program. With proper written documentation and approval by SCDHHS or its Agent, the following are acceptable reasons for which Molina may submit Involuntary Disenrollment requests to SCHCC:
· Molina ceases participation in the Medicaid Program in the member's service area · Member has moved out of the service area · Member death · Member becomes an inmate of a public institution · Member elects Hospice
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· Member's behavior is disruptive, abusive, or uncooperative and continued enrollment impairs the ability to furnish services to this member or other members
· Member's utilization of services is fraudulent or abusive · Member is placed in a long-term care nursing facility/nursing home for more than ninety
(90) continuous days · Member elects home-and community-based Waiver programs · Member's Medicaid eligibility category changes, or member otherwise becomes ineligible to
participate in Medicaid · Member becomes age 65 or older · Member becomes Medicare eligible · Member enrolls in a commercial MCO · Member is placed out of home into an Intermediate Care Facility for the Intellectually
Disabled
PCP Initiated Member Dismissal
A PCP may request the dismissal of a member from his/her practice based on member behavior. Reasons for dismissal must be documented by the PCP and may include:
· A member who continues not to comply with a recommended plan of healthcare. Such requests must be submitted at least 45 calendar days prior to the requested effective date.
· A member whose behavior is disruptive, unruly, abusive or uncooperative to the extent that his or her assignment to the provider seriously impairs the provider's ability to furnish services to either the member or other patients/members within their practice.
This section does not apply if the member's behavior is attributable to a physical or behavioral condition.
Missed Appointments
The provider will document and follow up on appointments missed and/or canceled by the member. Providers should notify Molina's Health Education and Health Management Department at (866) 891-2320 when a member misses two consecutive appointments. This will enable Molina's Care managers a chance to outreach to members to determine what barriers are preventing them from keeping scheduled appointments. Members who miss three consecutive appointments within a six-month period may be considered for disenrollment from a provider's panel. Such a request must be submitted at least 45 calendar days prior to the requested effective date. The provider agrees not to charge a member for missed appointments.
A member may only be considered for an involuntary disenrollment from a provider's panel after the member has had at least one verbal warning and at least one written warning of the full implications of his or her failure of actions. The member must receive written notification in sixth grade reading level from the PCP explaining in detail the reasons for dismissal from the practice. Action related to request for involuntary disenrollment conditions must be clearly documented by providers in the member's records and submitted to Molina. The documentation must include attempts to bring the member into compliance. A member's failure to comply with a written
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corrective action plan must be documented. For any action to be taken, it is mandatory that copies of all supporting documentation from the member's file are submitted with the request. Molina will contact the member to educate the member in the consequences of behavior that is disruptive, unruly, abusive or uncooperative and/or assist the member in selecting a new PCP. The current PCP must provide emergency care to the member until the member is transitioned to a new PCP. PCP Assignment Molina will assign a PCP to each member at the time of enrollment. Molina will take into consideration the member's last PCP (if the PCP is known and available in Molina's contracted network), closest PCP to the member's home address by ZIP code location, family linkages, age (adults versus children/adolescents) and gender. Members may request a change of PCP's at any time. Molina will assign all members that are reinstated after a temporary loss of eligibility of 180 days or less to the PCP who was treating them prior to loss of eligibility unless the member specifically requests another PCP, the PCP no longer participates in Molina or is at capacity, or the member has changed geographic areas. Molina will allow pregnant members to choose the Health Plan's obstetricians as their PCPs to the extent that the obstetrician is willing to participate as a PCP. Molina shall make available a pediatrician or other appropriate PCP to all pregnant members for the immediate care of their newborn babies prior to delivery. Once the newborn's enrollment is received by Molina, if a PCP was not selected by the mother, an appropriate pediatrician will be assigned using the same logic as mentioned above. PCP Changes A member may change their PCP at any time. The change will be effective on the date of initial enrollment, if the change is made prior to their effective date. Otherwise, the selected PCP will be effective the first date of the following month of eligibility.
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Section 3. Member Rights and Responsibilities (Member Bill of Rights)
This section explains the rights and responsibilities of Molina members as provided by SCHC and written in the Molina Member Handbook. South Carolina law requires that health care providers or health care facilities recognize member rights while they are receiving medical care and that members respect the health care provider's or health care facility's right to expect certain behavior on the part of patients. In South Carolina, these rights are known as the Member Bill of Rights.
Below are the Member Rights and Responsibilities:
Molina Member Bill of Rights
Members are guaranteed the following rights:
· To receive information about your member rights and responsibilities · To make recommendations to Molina Healthcare about these member rights and
responsibilities · To be treated with respect and with due consideration for his or her dignity and privacy · To participate in decisions regarding his or her healthcare, including the right to refuse
treatment · To be free from any form of restraint or seclusion used as a means of coercion, discipline,
convenience or retaliation, as specified in the federal regulations on the use of restrains and seclusion · To be able to request and receive a copy of his or her Medical Records, and request that they be amended or corrected · To receive health care services that are accessible, are comparable in amount, duration and scope to those provided under Medicaid FFS and are sufficient in amount, duration and scope to reasonably be expected to achieve the purpose for which the services are furnished · To have a candid discussion of appropriate or medically necessary treatment option for your condition regardless of cost or benefit coverage · To receive services that are appropriate and are not denied or reduced solely because of diagnosis, type of illness, or medical condition · To receive all information including but not limited to enrollment notices, informational materials, instructional materials, available treatment options, and alternatives in a manner and format that they may be easily understood · To receive assistance from both SCDHHS and Molina in understanding the requirements and benefits of Molina's plan · To receive oral interpretation services free of charge for all non-English languages, not just those identified as prevalent
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· To be notified that oral interpretation is available and how to access those services · As a potential member, to receive information about the basic features of managed care,
which populations may or may not enroll in the program and Molina's responsibilities for Coordination of Care in a timely manner in order to make an informed choice · To receive information on Molina's services, to include, but not limited to:
o Benefits covered o Procedures for obtaining benefits, including any authorization requirements o Any cost sharing requirements o Service area o Names, locations, telephone numbers of and non-English language spoken by
current contracted providers, including at a minimum, primary care physicians, specialists, and hospitals o Any restrictions on member's freedom of choice among network providers o Providers not accepting new patients o Benefits not offered by Molina but available to members and how to obtain those benefits, including how transportation is provided · To receive a complete description of Disenrollment rights at least annually · To receive notice of any significant changes in the Benefits Package at least thirty (30) days before the intended effective date of the change · To receive information of the grievance, appeal and Fair Hearing procedures, including the right to file · To be able to file an appeal, a grievance (complaint) or request a state hearing · To receive detailed information on emergency and after-hours coverage, to include but not limited to:
o What constitutes an emergency medical condition, emergency services and Post-Stabilization Services
o That emergency services do not require prior authorization o The process and procedures for obtaining emergency services o The locations of any emergency settings and other locations at which providers and
hospitals furnish Emergency Services and Post-Stabilization Services covered under plan o Member's right to use any hospital or other setting for emergency care o Post-Stabilization §422.113(c) · To receive Molina's policy on referrals for specialty care and other benefits not provided by the member's PCP · To have his or her privacy protected in accordance with the privacy requirements in 45 CFR parts 160 and 164 subparts A and E, to the extent that they are applicable · To exercise these rights without adversely affecting the way Molina, its providers or SCDHHS treat the members
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Member Responsibilities
· To provide information to their doctor or their healthcare plan that is needed to provide decisions about their healthcare
· To be active in decisions about their health care · To follow the care plans and instructions for care that they have agreed upon with their
doctor(s) · To build and keep a strong patient-doctor relationship; they have the responsibility to
cooperate with their doctor and staff. This includes being on time for their visits or calling the doctor if they need to cancel or reschedule an appointment · To present their Molina and SCHC card when receiving medical care and report any fraud or wrongdoing to their health care plan or the proper authorities · To understand their health problems and participate in developing mutually agreed-upon treatment goals to the degree possible · To inform Molina Member Services of any change of address or any changes to entitlement that could affect continuing eligibility · To inform Molina of the loss or theft of member ID card(s) · To be familiar with Molina's procedures to the best of their ability · To call or otherwise contact Molina to obtain information and have questions clarified · To access and use preventive care services
Second Opinions
If a member or member's authorized representative does not agree with their provider's plan of care, they have the right to request a second opinion from another provider. Members should call Member Services to find out how to get a second opinion, and under what circumstances a second option can be obtained/approved. Providers may also request a second opinion for a member if certain clinical requirements are met. Providers should call Provider Services for additional information regarding Molina's Second Opinion Policy.
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Section 4. Benefits and Covered Services
Molina benefits are comprehensive in nature and include all medically necessary services as included in the general fee-for-service SCHC Medical program as well as some expanded benefits.
There are no co-pays for Molina members under the age of 19. Additionally, Molina has eliminated the co-pays for physician visits for members over the age of 19. To find out additional information on which members are exempt from co-pays, see the "Co-payment Exclusions" section of this Manual.
This section provides an overview of the medical benefits and covered services for Molina members. Some benefits may have limitations. If there are questions as to whether a service is covered or requires Prior Authorization, please contact Molina at (855) 237-6178, Monday - Friday, 8 a.m. to 5 p.m., local time.
SERVICES
COVERAGE
LIMITS & Co-Pays for member over the age of 19
Ambulance Services
Emergency transportation given by: · Ambulance · Air ambulance
No co-pay for Molina members
Ambulatory Surgical Center Covered
Co-pay of $3.30
Autism Spectrum Disorder
Covered · Behavior Identification Assessment
(ABA) · Adaptive Behavior Treatment Protocol
Modification · Observational Behavioral Follow-up
Assessment · Exposure Behavioral Follow-up
Assessment · Adaptive Behavioral Treatment by
Protocol · Family Adaptive Behavior Treatment
Guidance · Family Training and Related Program
Development
No co-pay for Molina members
Audiological Some benefits may have limitations. Please call the Provider Services Department for additional information or for a complete list of benefits at (855) 237-6178
Covered only for children less than 21
No co-pay for Molina members
years of age.
Only for children under 21 years
Services include:
of age
· Examinations
· Fittings and related audiology services
· Diagnosis, screening, preventive and
corrective services for members with
hearing disorder or to determine
hearing disorder
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SERVICES BabyNet Chiropractic Services
COVERAGE
LIMITS & Co-Pays for member over the age of 19
Covered in accordance with requirements from SCDHHS.
Covered. Limited to manual manipulation of the spine using the hands to put the bones of the spine back in line.
Limited to 6 visits per year. 2 x-ray procedures per fiscal year
Communicable Disease Services
Exams and reviews including but not
No co-pay for Molina members
limited to:
· Contact tracing
· Counseling and health education
· Certain outreach for directly observed
therapy (DOT) for tuberculosis (TB)
cases
· Help controlling and preventing
diseases such as TB, syphilis, and other
sexually transmitted diseases (STDs)
and HIV/AIDS
Disease Management
Durable Medical Equipment and Supplies
This includes keeping track of any medical No co-pay for Molina members conditions/ diseases
Covered when medically necessary. Equipment/supplies may require prior approval Medically necessary equipment and supplies, including: · Medical products · Surgical supplies · Wheelchairs · Traction equipment · Walkers · Canes · Crutches · Ventilators · Prosthetic devices · Orthotic devices · Oxygen · Hearing aids and accessories · Diabetes supplies · Any other items when ordered by a
doctor as medically necessary
Co-pay of $3.40
Hearing aids and hearing aid accessories only covered for members under age 21
Emergency Medical Services Covered
No co-pay for Molina members
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SERVICES Family Planning
Hearing Exam, Hearing Aids and Hearing Aid Accessories
COVERAGE This includes medical visits for birth control: Counseling · Birth control drugs and supplies · Pregnancy tests · Lab tests · Tests for sexually transmitted
infections (STIs) · Sterilization, abortions and
hysterectomies · Teen pregnancy prevention program
Covered for members under age 21: · Hearing exams · Hearing aids and supplies
LIMITS & Co-Pays for member over the age of 19
No co-pay for Molina members Molina does not cover surgery to reverse sterilization
There are limited conditions for covering hysterectomies, sterilizations and abortions: · Hysterectomies: Only
covered when not elective and medically required. Not covered when only being used to prevent pregnancy. · Sterilizations: Members must be at least 21 years old, mentally competent and must have willingly given approval. · Abortions: Only covered if pregnancy is due to rape or incest; if the member has a physical disorder, injury or illness due to the pregnancy; or if the member could potentially die from the physical disorder, injury or illness due to the abortion not being performed.
No co-pay for Molina members Only for children under 21 years of age
Newborn Hearing Screening
Covered for members up to six months of age in either inpatient or outpatient setting without Prior Authorization. Must be performed within the first six (6) months of life.
No co-pay for Molina members
Home Health Services
Medical visits that take place in the home from time to time which can include: Skilled nursing · Home health aides · Medical supplies and equipment fit for
use in the home · Physical, occupational and speech
therapy
Co-pay of $3.30 50 visits are covered annually; additional visits may be allowed with prior authorization
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SERVICES
COVERAGE
LIMITS & Co-Pays for member over the age of 19
Inpatient Hospitalization including Services Normally Provided by the Hospital
These hospital services may include:
Co-pay $25.00 per admission
A semi-private room
· Maternity services
Private rooms are not covered
· Special treatment rooms
unless medically necessary
· Operating rooms
· Supplies
*Maternity services co-pay does
· Medical tests and x-rays
not apply
· Drugs the hospital gives you during
your stay
· Giving you someone else's blood
· Radiation therapy
· Chemotherapy
· Dialysis treatment
· Meals and special diets
· General nursing services
· Anesthesia
· Anesthesia for dental procedures when
it is an emergency
· Rehab in the hospital
Laboratory, X-Rays
No co-pay for Molina members
Long-Term Facilities/ Nursing Home Facilities Maternity Services
Newborn Circumcision
Covered for first 90 days (or until disenrollment from plan) when approved for and admitted to a long-term care facility
No co-pay for Molina members
This may include the following services: No co-pay for Molina members · Doctor visits and all expert care for
pregnancy, problems that have to do with pregnancy and after-delivery care when medically necessary · Services from a certified nurse-midwife · Tests such as sonograms · HIV testing, treatment and · counseling (A pregnant member may refuse to take an HIV test) · Birthing center services · Vaginal childbirth and Cesarean section (C-section) · Newborn hearing screenings
· Covered for up to 12 months from date of birth with out prior authorization
· In both inpatient and outpatient setting
No co-pay for Molina members
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SERVICES Outpatient Pediatric AIDS Clinic Services (OPAC) Outpatient Hospital Services
Prescription Drugs/ Pharmacy
COVERAGE
Services for HIV-related and exposed children and their families including: · Specialty care · Consults · Counseling · Clinical and lab tests
LIMITS & Co-Pays for member over the age of 19
No co-pay for Molina members
Services must be ordered by a doctor and Co-pay of $3.40 per claim
may include:
· Care to prevent illness
*Co-pay does not apply to
· Rehab
emergency room services
· Surgical care
· Emergency care
Neuro developmental or mental
· Psychiatric assessment
developmental assessments
· Substance abuse assessment
and testing are only for eligible
· Treatment of renal disease
members under 21 years of age
· Neuro developmental or mental
a
developmental assessment and
Co-pay only applies to members
testing
ages 19 and older who are not
· Family planning
pregnant
· Dialysis
· Emergency room use for emergency
conditions
· Drugs ordered by a doctor
· Surgery that does not end in a hospital
stay
· Sterilization
Prescription drugs that are medically necessary are covered by Molina.
Co-pay of $3.40 per prescription Special Note no copay for children under age of 19, pregnant women, institutionalized individuals (such as persons in a nursing facility or ICF-MR) and members of a federally recognized Indian tribe are exempt from most co-payments. Tribal members are exempt when services are received by the Catawba Service Unit in Rock Hill, South Carolina and when referred to a specialist or other medical provider by the Catawba Service Unit.
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SERVICES
COVERAGE
Preventive and Rehabilitative Services for Primary Care Enhancement (P/RSPCE)
Members who may have medical risk factors get: · Health status assessed · Risk factors identified · Goal-oriented plan of care done or
changed
LIMITS & Co-Pays for member over the age of 19
No co-pay for Molina members
Physician Services
· Routine physicals for children until the No co-pays for Molina members end of the month of their 21st birthday
· Adult well visits for members over age 21 covered one (1) time each year
Psychiatric Assessment/ Treatment Services
Psychiatric assessment services. The following visits may be given by the following types of providers: · Psychiatric interview exam provided by
a doctor and private psychiatrist · Psychiatric interview by a private
psychiatrist only · Behavioral health services given in the
ER
No co-pay for Molina members
Psychiatric Residential Treatment Facility (PRTF)
The following services are covered: · General Room and Board · Semi Private · Ward Psychiatric and psychological sessions, screenings, medication training and support, crisis intervention, alcohol and drug services, monitoring of medical conditions such as diabetes and waiver services not otherwise specified.
Therapeutic Home Time (THT) limited to 15 days per year
Podiatry Services
Rehabilitative Behavioral Health Services (RBHS)
Covered for certain medical conditions for No co-pay for Molina members members of all ages.
Covered. · Psychological Evaluations · Outpatient Psychotherapy · Medication Management (provided by
Medical Doctor or Nurse Practitioner) · Specialty Pharmacy Drugs (injectable) · Community Support · Consultations/Conferences · Psychological Testing · Neuro psychological testing · Crisis Intervention Services
No co-pay for Molina members
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SERVICES Rehabilitation Therapy Transplant Services
Vision Services/ Optometrists
COVERAGE
Services include non-hospital related services such as: Physical Therapy, Occupational Therapy, Speech Therapy, Audiology and Nursing Services.
LIMITS & Co-Pays for member over the age of 19
No co-pay for Molina members
Transplants are covered through Fee for Service. Molina covers all Pre and Post transplant services for: · Bone Marrow (Autologous Inpatient
and Outpatient, Allogenic Related and Unrelated, Cord, and Mismatched) · Pancreas · Heart · Liver · Liver with Small Bowel · Liver/Pancreas · Liver/Kidney · Kidney/Pancreas · Lung and Heart/Lung · Multivisceral · Small Bowel Please fax transplant requests to Molina at (866) 423-3889. Once approved by Molina, Molina will submit request to KEPRO. Molina covers pre-transplant, transplant, and post- transplant services for corneal transplants
No co-pay for Molina members
Yearly routine eye exam; one lenses and No co-pay for Molina members frames every two years for members 21 years of age and older. Glasses every year, if needed, for members under 21 years old.
Member Co-Pays for Services Covered by Molina Healthcare of South Carolina
Molina requires a co-payment from its members toward the cost of some of their care. Molina members may not be denied services if they are unable to pay the co-payment at the time the service is rendered, however, this does not relieve the member of the responsibility for the co-payment. It is the provider's responsibility to collect the co-payment from the member to receive full reimbursement for a service. The amount of the co-payment will be deducted from the Molina payment for all claims involving co-payments. When a member has Medicare or private insurance, the Molina co-payment still applies. However, if the sum of the co-payment and the Medicare/third party payment would exceed the Molina allowed amount, the co-payment should be adjusted or eliminated. In other words, though a provider may receive a primary insurance payment higher than what Molina would pay, the beneficiary's co-payment should not contribute to the excess revenue.
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Co-payment Exclusions
Pursuant to federal regulations, the following members are excluded from co-payment requirements: children under the age of 19, pregnant women, institutionalized individuals (such as persons in a nursing facility or ICF-MR), members of a Federally Recognized Indian Tribe (for services rendered by the Catawbas Service Unit in Rock Hill, SC and when referred to a specialist or other medical provider by the Catawbas Service Unit) and members of the Health Opportunity Account (HOA) program. Additionally, the following services are not subject to a co-payment: Medical equipment and supplies provided by DHEC, Orthodontic services provided by DHEC, Family Planning services, End Stage Renal Disease (ESRD) services, Infusion Center services, emergency services in the hospital emergency room, Hospice benefits and Waiver services.
Services Covered by SCDHHS through Fee-for-Service Medicaid
· Certain additional Mental Health Services (provided by state agencies) · Dental Services (Under age 21) · Dental Services (Over age 21) SCDHHS offers up to $750 coverage annually for preventive
and restorative dental services; Co-payment of $3.40 per date of service is required · Other Dental Services (age 21 and over) are covered for the following medical reasons:
o Organ Transplant o Oncology Treatment o Total Joint Replacement o Heart Valve Replacement · Non-Emergency Transportation · Medicaid Adolescent Pregnancy Prevention Services (MAPPS) · Developmental Evaluation Services (DECs) · Targeted Care Management (TCM) Services · Home and Community-Based Waiver Services
Services Not Covered
· Elective Cosmetic Surgery · Custodial Care Services · Elective Abortions · Infertility Services
Prescription Drugs
Prescription drugs are covered through Molina. There is a member co-pay of $3.40 for prescriptions for members age 19 and older. Pregnant women are exempt from any co-pays. For additional information about the pharmacy benefit and its limitations, please contact the Pharmacy department at (855) 237-6178. A list of in-network pharmacies is available on the MolinaHealthcare.com website or by contacting Molina's Provider Services Department at (855) 237-6178. An approval from Molina is required for some drugs. Some drugs are not covered.
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To see a list of covered drugs, check the Preferred Drug List (PDL). The PDL can change. It is important for Molina members and providers to check the PDL when medication needs to be filled or refilled You can find a list of the preferred drugs at MyMolina.com or MolinaHealthcare.com.
Molina members have access to an emergency supply of any medication written by their provider, even if it has not been prior authorized. This includes specialty drugs. If a provider prescribes an over-the-counter medication, members will need a prescription in order to receive the drug.
Family planning services related to the injection or insertion of a contraceptive drug or device are covered.
Access to Behavioral Health Services
Members in need of Behavioral Health Services can be referred by their PCP for services or members can self-refer by calling Molina at (855) 882-3901. Molina is available 24 hours a day, seven days a week for behavioral health needs. The services members receive will be confidential. Additionally, members may access certain Behavioral Health Services directly through programs and services offered through the state of South Carolina including the Department of Mental Health (DMH) and the Department of Alcohol and Other Drug Abuse Services (DAODAS). (Molina is responsible for services provided through DAODAS).
Behavioral health services include:
· Inpatient Services (at an acute care hospital) · Outpatient hospital services · Psychiatric doctor services
These services may require prior authorization; see Section 7 for additional information.
Emergency Behavioral Health Services
Members are directed to call "911" or go to the nearest emergency room if they need emergency behavioral health services. Examples of emergency behavioral health problems are:
· Danger to self or others · Not being able to carry out daily activities · Things that will likely cause death or serious bodily harm
Out of Area Emergencies
Members having a behavioral health emergency who cannot get to a Molina approved provider are directed to do the following:
· Go to the nearest emergency room · Call the number on ID card · Call member's PCP and follow-up within 24 to 48 hours
For out-of-area emergency care, plans will be made to transfer members to an in-network facility when member is stable.
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Obtaining Behavioral Health Services
Providers may contact Provider Services at (855) 237-6178 to request assistance in locating a behavioral health provider for a Molina member. In addition to Behavioral Health services available through Molina, some services are also available through state agencies. Molina is available to assist members in accessing services through these agencies.
Emergency and Ambulance Transportation
When a member's condition is life-threatening and requires use of special equipment, life support systems, and close monitoring by trained attendants while en route to the nearest appropriate facility, emergency transportation is thus required. Emergency transportation includes, but is not limited to, ambulance, air or boat transports.
Examples of conditions considered for emergency transports include, but are not limited to, acute and severe illnesses, untreated fractures, loss of consciousness, semi-consciousness, having a seizure or receiving CPR during transport, acute or severe injuries from auto accidents, and extensive burns.
Molina covers all transportation services provided via ambulance. These trips may be routine or non-routine, to a Medicaid covered service. Molina will provide stretcher trips as well as air ambulance or Medivac transportation.
Non-Emergency Medical Transportation
Molina does not provide non-emergency medical transportation. Non-emergency medical transportation is available to qualified individuals through the SCDHHS transportation broker system.
Medical non-ambulance transportation is defined as transportation of the beneficiary to or from a Medicaid covered service to receive medically necessary care. This transportation is only available to eligible beneficiaries who cannot obtain transportation on their own through other available means, such as family, friends or community resources. Molina will assist members in obtaining medical transportation services through the SCDHHS transportation broker system as part of its care coordination responsibilities.
If one of your members is in need of this service, please have them refer to the DHHS website for a listing of the transportation broker(s) and phone number(s). A listing is also available in the Appendix of this manual.
If your member needs further assistance, they can also call Molina Member Services at (855) 882-3901 and one of our representatives will assist them.
Preventive Care
Molina understands the importance of preventive care and encourages all members to schedule and keep primary care appointments so that overall health can be monitored. Molina expects providers to deliver preventive care and encourage Molina members to obtain services in accordance with preventive health guidelines for children, adolescents and adults.
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Immunizations
Adult members may receive immunizations as recommended by the Centers for Disease Control and Prevention (CDC) and prescribed by the member's PCP. Child members may receive immunizations in accordance with the recommendations of the American Academy of Pediatrics and prescribed by the child's PCP.
Molina covers immunizations not covered through Vaccines for Children (VFC). The following is a list of immunizations required for children and adolescents.
Immunization Hepatitis B (Hep B) Rotavirus (RV) Diphtheria, Tetanus, Pertussis (DTaP) Haemophilus influenza type b (HIB) Pneumococcal (PCV) Inactivated Poliovirus (IPV) Influenza Measles, Mumps, Rubella (MMR)
Varicella Hepatitis A (Hep A) Tetanus, Diphtheria, Pertussis (Tdap) Human Papilloma Virus (HPV) Meningococcal (MCV)
Ages
Birth, 1 2 months, and 6 18 months
2 months, 4 months and 6 months
2, 4, 6, 15 18 months and one between the ages of 4 6 years
2, 4, 6 and 12 15 months
2, 4, 6 and 12 15 months
2, 4, 6 18 months and one between the ages 4 6 years
6 months 18 years, yearly (consult your PCP)
12 15 months and one between the ages of 4 6 years
12 15 months and one between the ages of 4 6 years Two (2) doses between 12 24 months
11 12 years
Three (3) doses between 11 12 years
One (1) dose between 11 12 years and one (1) dose at 16 years
Prenatal Care
Stage of Pregnancy 1 month 6 months 7 months 8 months 9 months
How often to see the doctor 1 visit a month 2 visits a month 1 visit a week
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Well-Child Visits
The federal guidelines outlined below specify the minimum requirements included in each WellChild Care (WCC) exam for each of the following age groups; (0-18) months, (2-6) years, and (7-21) years. During Well-Child visits, providers are required to deliver the following (for a more detailed schedule, see the health resources/preventative care guidelines section on our website at MolinaHealthcare.com).
Early and Periodic Screening, Diagnostic
and Treatment (EPSDT)
Physical Exam and
·
Health History
·
·
·
·
·
·
Development and
·
Behavior Assessment ·
·
·
·
Infants (0-18) months
History Height Weight Physical exam Oral Health Body Mass Index (BMI) Blood Pressure Gross motor Fine motor Social/emotional Nutritional (any one of these)
Mental Health Assessment
Mental health (must be addressed)
Health Education/
·
Anticipatory Guidance ·
Health Reward Offered
Injury prevention Passive smoking (either one of these)
Children (2-6) years
Adolescents (7-21) years
· History · Height · Weight · Physical exam · Oral Health · Body Mass Index
(BMI) · Blood Pressure · Gross motor · Fine motor · Communication · Self-help skills · Cognitive skills · Social/emotional · Regular physical
activity · Nutritional
(any one of these)
Mental health (must be addressed)
· Injury prevention · Passive smoking
(either one of these)
· History · Height · Weight · Physical exam · Oral Health · Body Mass Index
(BMI) · Blood Pressure · Social/emotional · Regular physical
activity · Nutritional · (any one of these)
· Mental health · Substance abuse
(either one of these) · Injury prevention · STD prevention · Smoking/tobacco (any one of these)
We need your help conducting these regular exams in order to meet the SCDHHS targeted state standard. If you have questions or suggestions related to Well-Child care, please call our Health Education line at (855) 237-6178.
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Emergency Care Services
Emergency care services are covered by Molina without an authorization. This also includes noncontracted providers outside of Molina's service area.
Disease Management Programs
Molina's disease management programs incorporate a collaborative team approach comprised of health education, clinical care management and provider education. The overall goal is to provide better over all quality of life, quality of care and better clinical outcomes for Molina members. Disease management supports the practitioner-patient relationship and plan of care, emphasizes the prevention of exacerbation and complications using cost-effective, evidence-based practice guidelines and employs patient empowerment strategies such as self-management. The programs include proactive member identification and risk stratification, appropriate referral and coordination of care, member education, and provider collaboration. Currently Molina provides access to disease management programs. Examples include:
· Breathe with Ease® Asthma Management Program (for children and adults) · Building Brighter Days-Depression Management Program (for adults) · Sickle Cell Disease Program
To find out more about our disease management programs or to refer a member, please call Molina's Health Management Team at (866) 472-9483 (TTY/TDD: 711).
Practitioner/Provider Resources
Contracted practitioner/provider resources and services may include:
· For members actively managed, PCPs are also sent copies of the member completed assessments and care plan for physician consideration in the member's overall treatment plan
· Patient education resources · Health plan communications such as the Partners in Care physician newsletter promoting
the health management programs, including how to enroll patients and outcomes of the programs · Clinical Practice Guidelines · Preventive Health Guidelines
Program Evaluation
To evaluate effectiveness of the programs, the following measures are used:
· Emergency room visit rate for asthma among children and adults (ages 2 and over) · Hospitalization Rate for asthma among children and adults (ages 2 and over) · HEDIS® asthma medication measures by product line · Member/family satisfaction with their experience participating in the program · Analysis of member feedback and complaints with the disease management program
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· Active participation based on total eligible members who have had a least one interactive contact
Adult Depression Management Program
· Increase prescription adherence · Pre-post self-efficacy changes as measured by increased community tenure · Pre-post behavioral changes in actively enrolled participants · Analysis of member feedback and complaints with the depression management program · Active participation based on total eligible members who have had at least one interactive
contact · Reduction in ER visits for any mental health disorder by 10% in the cohort at one year · Reduction in inpatient stays for any mental health disorder by 10% in the cohort at one
year An annual program evaluation for each program is completed and reviewed by the Molina Quality Improvement Committee for improvement and/or enhancements.
To find out more about our disease management programs or to refer a member, please call Molina Member Services Department at (855) 882-3901.
Health Education and Management
Pregnancy Health Management Program
Although pregnancy itself is not considered a disease state, a significant percentage of pregnant females on Medicaid are found to be at moderate to high-risk for a disease condition for them other, the baby or both. Our pregnancy management program strives to reduce hospitalizations and improve birth outcome through early identification, trimester specific assessment and interventions appropriate to the potential risks and needs identified. It is the member's choice to be in the program. They can choose to be removed from the program at anytime. The program does not replace or interfere with the member's physician assessment and care. The program supports and assists physicians in the delivery of care to members.
The program activities include early identification of pregnant members, early screening for potential risk factors, provision of telephonic and written trimester appropriate education to all pregnant members and families, referral of high-risk members to prenatal care management, and provision of assessment information to physicians.
Molina requests that you or someone in your office complete the Pregnancy Notification Report (refer to Appendix for form) and return it to us as soon as pregnancy is confirmed.
Smoking Cessation
Given the diversity of Molina's membership, a health management program created around smoking cessation should improve the quality of life among our members and clinical outcomes in the future. Helping our members reduce unhealthy behaviors (i.e., quit tobacco use) will improve their ability to manage pre-existing illnesses or chronic conditions.
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Molina's members who are motivated to quit smoking can access the South Carolina Tobacco Quitline, the only statewide evidence- based telephonic cessation program. The Tobacco Quitline's fax-referral program has ready access and tools that health care providers can use to refer Molina members to the Tobacco Quitline. Participants are eligible for multi-call intervention, support materials and the program covers all 7 FDA-approved medications. Providers can receive feedback from the Tobacco Quitline on the out come of their referrals once they file HIPAA verification. To refer a member directly to the Tobacco Quitline, call (800) 784-8669 or (800) QUIT-NOW.
To find out more information about the health management programs, please call Molina Member Services Department at (855) 882-3901.
Section 5. Provider Responsibilities
Non-discrimination of Healthcare Service Delivery
Molina complies with the guidance set forth in the final rule for Section 1557 of the Affordable Care Act (ACA), which includes notification of nondiscrimination and instructions for accessing language services in all significant member materials, physical locations that serve our members, and all Molina website home pages. All providers who join the Molina provider network must also comply with the provisions and guidance set forth by the Department of Health and Human Services (HHS) and the Office for Civil Rights (OCR).
For more information about Non-discrimination of Health Care Service Delivery, please see the Cultural Competency and Linguistic Services section of this Provider Manual.
Section 1557 Investigations
All Molina providers shall disclose all investigations conducted pursuant to Section 1557 of the Patient Protection and Affordable Care Act to Molina's Civil Rights Coordinator.
Molina Healthcare Civil Rights Coordinator 200 Oceangate, Suite 100 Long Beach, CA 90807
Toll Free: (866) 606-3889 TTY/TDD: 711
Online: https://molinahealthcare.AlertLine.com Email: civil.rights@molinahealthcare.com
Facilities, Equipment and Personnel
The provider's facilities, equipment, personnel and administrative services must be at a level and quality necessary to perform duties and responsibilities to meet all applicable legal requirements including the accessibility requirements of the Americans with Disabilities Act (ADA).
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Provider Data Accuracy and Validation
It is important for providers to ensure Molina has accurate practice and business information. Accurate information allows us to better support and serve our members and provider network.
Maintaining an accurate and current Provider Directory is a State and Federal regulatory requirement, as well as an NCQA required element. Invalid information can negatively impact member access to care, member/PCP assignments and referrals. Additionally, current information is critical for timely and accurate claims processing. A Molina member may request a printed copy of the Provider Directory at any time by contacting Member Services.
Providers must validate the Provider Online Directory (POD) information regularly for correctness and completeness. Providers must notify Molina in writing (some changes can be made online) at least 30 calendar days in advance, of changes such as, but not limited to:
· Change in office location(s), office hours, phone, fax, or email · Addition or closure of office location(s) · Addition or termination of a provider (within an existing clinic/practice) · Change in practice name, TaxID and/or National Provider Identifier (NPI) · Opening or closing your practice to new patients (PCPs only) · Any other information that may impact member access to care
Please visit our Provider Online Directory at https://providersearch.MolinaHealthcare.com to validate your information. A convenient provider web form can be found on the POD and on the Provider Portal at https://provider.MolinaHealthcare.com. Please email practice updates to MHSCPODValidation@MolinaHealthcare.com. You may also contact your Provider Services Representative or (855) 237-6178 if your information needs to be updated or corrected.
Note: Some changes may impact credentialing. Providers are required to notify Molina of changes to credentialing information in accordance with the requirements outlined in the credentialing section of this Provider Manual.
Molina is required to audit and validate our Provider Network data and Provider Directories on a routine basis. As part of our validation efforts, we may reach out to our Network of Providers through various methods, such as: letters, phone campaigns, face-to-face contact, fax and faxback verification, etc. Molina also may use a vendor to conduct routine outreach to validate data that impacts the Provider Directory or otherwise impacts its membership or ability to coordinate member care. Providers are required to supply timely responses to such communications.
National Plan and Provider Enumeration System (NPPES) Data Verification
CMS recommends that providers routinely verify and attest to the accuracy of their National Plan and Provider Enumeration System (NPPES) data.
NPPES allows providers to attest to the accuracy of their data. If the data is correct, the provider is able to attest and NPPES will reflect the attestation date. If the information is not correct, the provider is able to request a change to the record and attest to the changed data, resulting in an updated certification date.
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Molina supports the CMS recommendations around NPPES data verification and encourages our provider network to verify provider data via https://nppes.cms.hhs.gov. Additional information regarding the use of NPPES is available in the Frequently Asked Questions (FAQs) document published at the following link: https://www.cms.gov/Medicare/Health-Plans/ ManagedCareMarketing/index.
Molina Electronic Solutions Participation
Molina encourages participating providers to utilize electronic solutions and tools.
Molina encourages all contracted providers to participate in and comply with Molina's Electronic Solution Requirements, which include, but are not limited to, electronic submission of prior authorization requests, prior authorization status inquiries, electronic claims submission, electronic fund transfers (EFT), electronic remittance advice (ERA), electronic Claims Appeal and registration for and use of the Provider Portal.
Electronic claims include claims submitted via a clearinghouse using the EDI process and claims submitted through the Provider Portal.
Any provider entering the network as a Contracted Provider will be encouraged to comply with Molina's Electronic Solution Policy by registering for the Provider Portal, and submitting electronic claims upon entry into the network. Providers entering the network as a Contracted provider must enroll for EFT/ERA payments within 30 days of entering the Molina network.
Molina is committed to complying with all HIPAA Transactions, Code Sets, and Identifiers (TCI) standards. Providers must comply with all HIPAA requirements when using electronic solutions with Molina. Providers must obtain a National Provider Identifier (NPI) and use their NPI in HIPAA Transactions, including claims submitted to Molina. Providers may obtain additional information by visiting Molina's HIPAA Resource Center located on our website at MolinaHealthcare.com.
Balance Billing
Providers contracted with Molina cannot bill the member for any covered services beyond applicable copayments, deductibles, or coinsurance. The provider is responsible for verifying eligibility and obtaining approval for those services that require prior authorization.
Providers may not charge members fees for covered services beyond copayments, deductibles or coinsurance.
Providers agree that under no circumstance shall a member be liable to the provider for any sums owed by Molina to the provider. Balance billing a Molina member for services covered by Molina is prohibited. This includes asking the member to pay the difference between the discounted and negotiated fees, and the provider's usual and customary fees.
Providers agree that under no circumstance shall a member be liable to the provider for any sums owed by Molina to the provider for Medicaid covered services. Balance billing a Molina member is prohibited.
For additional information please refer to the Compliance and Claims and Compensation sections of this Provider Manual. Providers agree that under no circumstance shall a member be
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liable to the provider for any sums owed by Molina to the provider for Medicaid covered services. Balance billing a Molina member is prohibited.
Electronic Solutions/Tools Available to Providers Electronic Tools/Solutions available to Molina providers include:
· Electronic Claims Submission Options · Electronic Payment (Electronic Funds Transfer) with Electronic Remittance Advice (ERA) · Provider Web Portal
Electronic Claims Submission Requirement Molina strongly encourages participating providers to submit Claims electronically. Electronic Claims submission provides significant benefits to the provider such as:
· Promoting HIPAA compliance · Helping to reduce operational costs associated with paper claims (printing, postage, etc.) · Increasing accuracy of data and efficient information delivery · Reducing claim processing delays as errors can be corrected and resubmitted electronically · Eliminating mailing time and enables claims to reach Molina faster Molina offers the following electronic Claims submission options: · Submit Claims directly to Molina of State via the Provider Portal. See the Provider Portal
Quick Reference Guide at https://provider.MolinaHealthcare.com or contact your Provider Services Representative for registration and Claim submission guidance. · Submit Claims to Molina through your EDI clearinghouse using Payer ID 46299, or refer to our website, MolinaHealthcare.com, for additional information. While both options are embraced by Molina, submitting claims via the Provider Portal (available to all Providers at no cost) offers a number of additional claims processing benefits beyond the possible cost savings achieved from the reduction of high-cost paper claims. Electronic claims submitting benefits include: · Ability to add attachments to claims. · Submit corrected claims. · Easily and quickly void claims. · Check claims status. · Receive timely notification of a change in status for a particular claim. · Ability to save incomplete/un-submitted claims. · Create/manage claim templates. For more information on EDI Claims submission, see the Claims Section of this Provider Manual.
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Electronic Payment (EFT/ERA) Requirement
Participating providers are strongly encouraged to enroll in Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA). Providers enrolled in EFT payments will automatically receive ERAs as well. EFT/ERA services give Providers the ability to reduce paperwork, utilize searchable ERAs, and receive payment and ERA access faster than the paper check and RA processes. There is no cost to the Provider for EFT enrollment, and Providers are not required to be in-network to enroll. Molina uses a vendor to facilitate the HIPAA compliant EFT payment and ERA delivery process.
Below is the link to register with Change Healthcare Provider Net to receive electronic payments and remittance advices. Additional instructions on how to register are available under the EDI/ ERA/EFT tab on Molina's website: MolinaHealthcare.com.
Any questions during this process should be directed to Change Healthcare Provider Services at wco.provider.registration@changehealthcare.com or (877) 389-1160.
Provider Portal
Providers and third-party billers can use the no cost Provider Portal to perform many functions online without the need to call or fax Molina. Registration can be performed online and once completed the easy to use tool offers the following features:
· Verify Member eligibility, covered services and view HEDIS needed services (gaps) · Claims:
o Submit Professional (CMS1500) and Institutional (UB04) Claims with attached files o Correct/void claims o Add attachments to previously submitted claims o Check claims status o Create and manage claim templates o Create and submit a claim appeal with attached files · Prior authorizations/service requests o Create and submit prior authorization/service requests o Check status of authorization/service requests · View HEDIS® Scores and compare to national benchmarks · View a roster of assigned Molina members for Primary Care Providers (PCP(s) · Download forms and documents · Send/receive secure messages to/from Molina
Balance Billing
The Provider is responsible for verifying eligibility and obtaining approval for those services that require prior authorization.
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Providers agree that under no circumstance shall a member be liable to the provider for any sums that are the legal obligation of Molina to the provider. Balance billing a Molina Member for covered services is prohibited, other than for the member's applicable copayment, coinsurance and deductible amounts.
Member Rights and Responsibilities
Providers are required to comply with the Member Rights and Responsibilities as outlined in Molina's member materials (such as Member Handbook). For additional information please refer to the Member Rights and Responsibilities section of this Provider Manual.
Member Information and Marketing
Any written informational or marketing materials directed to Molina members must be developed and distributed in a manner compliant with all State and Federal Laws and regulations and must be approved by Molina prior to use. Please contact your Provider Services Representative for information and review of proposed materials.
Member Eligibility Verification
Any written informational or marketing materials directed to Molina members must be developed and distributed in a manner compliant with all State and Federal Laws and regulations and be approved by Molina prior to use. Please contact your Provider Services Representative for information and review of proposed materials.
Possession of a Molina ID card does not guarantee Member eligibility or coverage. Providers should verify eligibility of Molina Members prior to rendering services. Payment for services rendered is based on enrollment and benefit eligibility. The contractual agreement between Providers and Molina places the responsibility for eligibility verification on the Provider of services. For additional information please refer to the Eligibility, Enrollment, Disenrollment and Grace Period section of this Provider Manual.
Member Cost Share
Providers should verify the Molina member's cost share status prior to requiring the member to pay co-pay, co-insurance, deductible or other cost share that may be applicable to the member's specific benefit plan. Some plans have a total maximum cost share that frees the member from any further out-of-pocket charges once reached (during that calendar year).
Healthcare Services (Utilization Management and Care Management)
Providers are required to participate in and comply with Molina's Utilization Management (UM) and Care Management programs, including all policies and procedures regarding Molina's facility admission, prior authorization, and Medical Necessity review determination and Interdisciplinary Care Team (ICT) procedures. Providers will also cooperate with Molina in audits to identify, confirm, and/or assess utilization levels of covered services. For additional information, please refer to the Healthcare Services section of this Provider Manual.
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In-Office Laboratory Tests
Molina Healthcare's policies allow only certain lab tests to be performed in a physician's office regardless of the line of business. All other lab testing must be referred to an In-Network Laboratory Provider that is a certified, full service laboratory, offering a comprehensive test menu that includes routine, complex, drug, genetic testing and pathology. A list of those lab services that are allowed to be performed in the physician's office is found on the Molina website at MolinaHealthcare.com.
Additional information regarding in-network laboratory providers and in-network laboratory provider patient service centers is found on the laboratory providers' respective websites at https://appointment.questdiagnostics.com/patient/confirmation and https://www.labcorp.com/labs-and-appointments.
Specimen collection is allowed in a physician's office and shall be compensated in accordance with your agreement with Molina and applicable state and federal billing and payment rules and regulations.
Claims for tests performed in the physician office, but not on Molina's list of allowed in-office laboratory tests will be denied.
Referrals
A referral is necessary when a provider determines medically necessary services are beyond the scope of the PCP's practice or it is necessary to consult or obtain services from other in-network specialty health professionals unless the situation is one involving the delivery of emergency services. Information is to be exchanged between the PCP and Specialist to coordinate care of the patient to ensure continuity of care. Providers need to document referrals that are made in the patient's medical record. Documentation needs to include the specialty, services requested, and diagnosis for which the referral is being made.
Providers should direct members to health professionals, hospitals, laboratories, and other facilities and providers which are contracted and credentialed (if applicable) with Molina Healthcare except in the case of emergency services. There may be circumstances in which referrals may require an out of network provider; prior authorization will be required from Molina except in the case of emergency services. For additional information please refer to the Healthcare Services section of this Provider Manual.
Treatment Alternatives and Communication with Members
Molina endorses open provider-member communication regarding appropriate treatment alternatives and any follow up care. Molina promotes open discussion between provider and members regarding medically necessary or appropriate patient care, regardless of covered benefits limitations. Providers are free to communicate any and all treatment options to members regardless of benefit coverage limitations. Providers are also encouraged to promote and facilitate training in self-care and other measures members may take to promote their own health.
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Pharmacy Program
Providers are required to adhere to Molina's Preferred Drug List and prescription policies. You can find a list of the preferred drugs at MyMolina.com or MolinaHealthcare.com. For additional information please refer to the Pharmacy section of this Provider Manual.
Participation in Quality Programs
Providers are expected to participate in Molina's Quality Programs and collaborate with Molina in conducting peer review and audits of care rendered by providers. Such participation includes, but is not limited to:
· Access to Care Standards · Site and Medical Record-Keeping Practice Reviews, as applicable · Delivery of Patient Care Information
For additional information please refer to the Quality section of this Provider Manual.
Compliance
Providers must comply with all State and Federal Laws and regulations related to the care and management of Molina members.
Confidentiality of Member Health Information and HIPAA Transactions
Molina requires that its contracted providers respect the privacy of Molina members (including Molina members who are not patients of the provider) and comply with all applicable Laws and regulations regarding the privacy of patient and member PHI. For additional information please refer to the Compliance section of this Provider Manual.
Participation in Grievance and Appeals Programs
Providers are required to participate in Molina's Grievance Program and cooperate with Molina in identifying, processing, and promptly resolving all member complaints, grievances, or inquiries. If a member has a complaint regarding a provider, the provider will participate in the investigation of the grievance. If a member submits an appeal, the provider will participate by providing medical records or statements if needed. This includes the maintenance and retention of member records for a period of not less than 10 years for adult patients and at least 13 years for minors, and retained further if the records are under review or audit until such time that the review or audit is complete.
For additional information please refer to the Complaints, Grievance and Appeals Process section of this Provider Manual.
Participation in Credentialing
Providers are required to participate in Molina's credentialing and re-credentialing process and will satisfy, throughout the term of their contract, all credentialing and re-credentialing criteria established by Molina. This includes providing prompt responses to Molina's requests for information related to the credentialing or re-credentialing process.
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Providers must notify Molina no less than 30 days in advance when they relocate or open an additional office.
More information about Molina's Credentialing program, including Policies and Procedures is available in the Credentialing and Recredentialing section of this Provider Manual.
Delegation
Delegated entities must comply with the terms and conditions outlined in Molina's Delegation Policies and Delegated Services Addendum. Please see the Delegation section of this Provider Manual for more information about Molina's delegation requirements and delegation oversight.
After Hours
All providers must have back-up (on call) coverage after hours or during the practitioner's absence or unavailability. Molina requires practitioners to maintain a 24 hour phone service, seven days a week. This access may be through an answering service or a recorded message after office hours. The service or recorded message should instruct members with an emergency to hang-up and call 911 or go immediately to the nearest emergency room. Voicemail alone after-hours is not acceptable.
Appointment Scheduling
1. Each practitioner must implement an appointment scheduling system. The following are the minimum standards:
2. The practitioner must have an adequate telephone system to handle patient volume. Appointment intervals between patients should be based on the type of service provided and a policy defining required intervals for services. Flexibility in scheduling is needed to allow for urgent walk-in appointments
3. A process for documenting missed appointments must be established. When a member does not keep a scheduled appointment, it is to be noted in the member's record and the practitioner is to assess if a visit is still medically indicated. All efforts to notify the member must be documented in the medical record. If a second appointment is missed, the practitioner is to notify the Molina Member Services Department toll free at (855) 882-3901, TTY/TDD: 711
4. When the practitioner must cancel a scheduled appointment, the member is given the option of seeing an associate or having the next available appointment time
5. Special needs of members must be accommodated when scheduling appointments. This includes but is not limited to wheelchair-using members and members requiring language interpretation
6. A process for member notification of preventive care appointments must be established. This includes but is not limited to immunizations and mammograms
7. A process must be established for member recall in the case of missed appointments for a condition which requires treatment, abnormal diagnostic test results or the scheduling of procedures which must be performed prior to the next visit
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In applying the standards listed above, participating practitioners/providers have agreed that they will not discriminate against any member on the basis of age, race, creed, color, religion, sex, national origin, sexual orientation, marital status, physical, mental or sensory handicap, place of residence, socioeconomic status, or status as a recipient of Medicaid benefits. Additionally, a participating practitioner/provider or contracted medical group/IPA may not limit his/her practice because of a member's medical (physical or mental) condition or the expectation for the need of frequent or high cost care.
Molina will annually perform provider availability and after hours telephonic surveys of its contracted providers. The survey evaluates primary care, specialty care and behavioral healthcare appointment availability for routine care visits, urgent care visits, and consultation. The survey also evaluates the average wait time in the practitioner's office.
Women's Health Access
Molina allows members the option to seek obstetric and gynecological care from an obstetrician or gynecologist or directly from a participating PCP designated by Molina as providing obstetrical and gynecological services. Member access to obstetrical and gynecological services is monitored to ensure members have direct access to participating providers for obstetrical and gynecological services.
Additional information on access to care is available from the Molina QI department.
Monitoring Access for Compliance with Standards
Access to care standards are reviewed, revised as necessary, and approved by the Quality Improvement Committee on an annual basis.
Provider network adherence to access standards is monitored via one or more of the following mechanisms:
1. Provider access studies provider office assessment of appointment availability, after hours access, provider ratios and geographic access.
2. Member complaint data assessment of member complaints related to access and availability of care.
3. Member satisfaction survey evaluation of members' self-reported satisfaction with appointment and after-hours access.
Analysis of access data includes assessment of performance against established standards, review of trends over time, and identification of barriers. Results of analysis are reported to the Quality Improvement Committee at least annually for review and determination of opportunities for improvement. Corrective actions are initiated when performance goals are not met and for identified provider-specific and/or organizational trends. Performance goals are reviewed and approved annually by the Quality Improvement Committee.
Screening, Brief Intervention and Referral to Treatment (SBIRT)
Molina has partnered with SCDHHS, DAODAS, DHEC and DMH to expand and enhance state substance use identification and treatment for pregnant members. Providers are encouraged to
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screen ALL pregnant women, to include up to 12 months postpartum, utilizing the SBIRT Integrated Screening Tool (form located in Appendix). Keep all completed screening tools in the patient's record and send copies to the referral resource and to Molina. Completed tools for Molina members can be faxed to (866) 423-3889. Two codes can be billed in support of SBIRT services: H0002 (SBIRT behavioral health screening) and H0004 (SBIRT behavioral health brief intervention).
Relocations and Additional Sites
Providers should notify Molina 30 days in advance when they relocate or open an additional office, or a time frame as may be required by applicable state regulations, whichever is greater. When this notification is received, a site review of the new office may be conducted before the provider's recredentialing date.
Section 6. Healthcare Services (HCS)
Introduction
Healthcare Services is comprised of Utilization Management (UM) and Care Management (CM) departments that work together to achieve an integrated model based upon empirically validated best practices that have demonstrated positive results. Research and experience show that a higher-touch, Member-centric care environment for at-risk Members supports better health outcomes. Molina provides care management services to Members to address a broad spectrum of needs, including chronic conditions that require the coordination and provision of health care services. Elements of the Molina utilization management program include pre-service authorization review and inpatient authorization management that includes pre-admission, admission and concurrent review, medical necessity review, and restrictions on the use of out-ofnetwork Providers.
Utilization Management (UM)
Molina ensures the service delivered is medically necessary and demonstrates an appropriate use of resources based on the level of care needed for a member. This program promotes the provision of quality, cost-effective, and medically appropriate services that are offered across a continuum of care as well as integrating a range of services appropriate to meet individual needs. It maintains flexibility to adapt to changes in the member's condition and is designed to influence member's care by:
· Managing available benefits effectively and efficiently while ensuring quality care is provided;.
· Evaluating the medical necessity and efficiency of health care services across the continuum of care;.
· Defining the review criteria, information sources, and processes that are used to review and approve the provision of items and services, including prescription drugs;.
· Coordinating, directing, and monitoring the quality and cost effectiveness of health care resource utilization;.
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· Implementing comprehensive processes to monitor and control the utilization of health care resources;.
· Ensuring that services are available in a timely manner, in appropriate settings, and are planned, individualized, and measured for effectiveness;.
· Reviewing processes to ensure care is safe and accessible;.
· Ensuring that qualified health care professionals perform all components of the UM and CM processes; and
· Ensuring that UM decision making tools are appropriately applied in determining medical necessity decision.
The table below outlines the key functions of the UM program.
Activity Inpatient Admission Review Prior Authorization Review
Post-Service Claim Audits Discharge Planning Transitions of Care
Resource Management
Evaluation
Eligibility verification
Utilization data analysis
Prior authorization of planned elective admissions
Urgent/Emergent inpatient admission
Eligibility verification
Benefit administration and interpretation.
Verification of current provider contract status
Redirection of services to participating providers
Medical necessity review of requested services to meet member need & benefit plan provisions
Utilization data analysis
Geo-access analysis by Provider Contracting
Ensure authorized care meets Utilization data analysis.
member need and benefit plan Monitoring for over and under-
provisions
utilization of clinical resources
Ensure safe and effective transition from inpatient or facility-based care to a lower level of care
Utilization data analysis, including hospital readmission rates
Coordinate and facilitate Immediate post-hospital discharge and service needs including follow-up appointments
Analyze re-admission data
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Activity
Resource Management
Evaluation
Care Management
UM staff auditing and oversight
Manage members with complex care needs and services.
Ensures appropriate level of care and services is achieved for optional health outcomes
Staff education on consistent application of UM functions
Monitor utilization data.
Satisfaction of the care management process with quality surveys, member and provider input.
Monitor for adherence to CMS, NCQA©, State and health plan UM standards
This Molina Provider Manual contains excerpts from Molina's Healthcare Services Program Description. For a complete copy of your state's Healthcare Services Program Description you can access the Molina website or contact the UM department to receive a written copy. You can always find more information about Molina's UM program, including information about obtaining a copy of clinical criteria used for authorizations and how to contact a UM reviewer on Molina's website or by calling the UM department.
UM Decisions
A decision is any determination (e.g., an approval or denial) made by Molina with respect to the following:
· Determination to authorize, provide or pay for services (favorable determination); · Determination to deny payment of request (adverse determination); · Discontinuation of a payment for a service; · Payment for temporarily out-of-the-area renal dialysis services; and, · Payment for Emergency Services, post stabilization care or urgently needed services.
Board certified licensed providers from appropriate specialty areas are utilized to assist in making determinations of medical necessity, as appropriate. All utilization decisions must be made in a timely manner to accommodate the clinical urgency of the situation, in accordance with Federal regulatory requirements and NCQA© standards.
Requests for authorization not meeting criteria are reviewed by a designated Molina Medical Director or other appropriate clinical professional. Only a licensed physician or pharmacist, doctoral level clinical psychologist or certified addiction medicine specialist as appropriate may determine to delay, modify or deny services to a Member for reasons of medical necessity.
Providers can contact Molina's Healthcare Services department at (855) 237-6178 to obtain Molina's UM Criteria.
Upon receipt of an adverse determination, the provider (peer) may request a peer to peer discussion within 3 days of the decision for prior authorization requests. For inpatient admissions, a request for a peer to peer discussion may be granted as long as the member is still in the facility.
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A "peer" is considered a physician, physician assistant, nurse practitioner, or PhD psychologist who is directly providing care to the member or a Medical Director on site at the facility. Calls from EHR and other similar contracted external parties, administrators, or facility UM staff are not peers and calls will not be returned.
When requesting a peer to peer discussion, please be prepared with the following information:
· Member name and ID# · Auth ID# · Requesting Provider Name and contact number, best times to call
If a Medical Director is not immediately available, the call will be returned within 2 business days. Every effort will be made to return calls as expeditiously as possible.
Medical Necessity
"Medically Necessary" or "Medical Necessity" means that a service is directed toward the maintenance, improvement, or protection of health or toward the diagnosis and treatment of illness or disability (the provision of which may be limited by specific manual provisions, bulletins and/or other directives). These services furnished or ordered are
1. Necessary to protect life, to prevent significant illness or significant disability or alleviate severe pain
2. Individualized, specific and consistent with symptoms or confirm diagnosis or the illness or injury under treatment and not in excess of patient's needs
3. Consistent with the generally accepted professional medical standards as determined by the Medicaid program, and not be experiment or investigational
4. Reflective of the level of service that can be furnished safely and for which no equally effective and more conservative or less costly treatment is available statewide
5. Furnished in a manner not primarily intended for the convenience of the member, the members' caretaker or the provider.
The fact that the provider has prescribed, recommended or approved medical or allied goods and services does not, in itself, make such care, goods or services medically necessary, a medical necessity or a covered service/benefit.
Medical Necessity Review
Molina only reimburses for services that are medically necessary. Medical necessity review may take place prospectively, as part of the inpatient admission notification/concurrent review, as part of the prior authorization review for outpatient and elective inpatient review or retrospectively (under limited circumstances as deemed by Molina). To determine medical necessity, in conjunction with independent professional medical judgment, Molina uses nationally recognized evidence-based guidelines, third party guidelines, CMS guidelines, state guidelines, guidelines from recognized professional societies, and advice from authoritative review articles and textbooks.
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Utilization Management and Levels of Review
Administrative Review: The Molina review process begins with administrative review followed by clinical review if appropriate. The administrative review includes verifying eligibility, appropriate vendor or participating provider, and benefit coverage.
· Verifying Member eligibility. · Requested service is a covered benefit. · Requested service is within the provider's scope of practice. · The requested covered service is directed to the most appropriate contracted specialist,
facility or vendor.
Clinical Review: The Clinical review includes medical necessity and level of care.
· Requested service is not experimental or investigation in nature. · Servicing provider can provide the service in a timely manner. · The receiving specialist(s) and/or hospital is/are provided the required medical information
to evaluate a Member's condition. · Medical necessity criteria (according to accepted, nationally-recognized resources) is met. · The service is provided at the appropriate level of care in the appropriate facility; e.g.,
outpatient versus inpatient or at appropriate level of inpatient care. · Continuity and coordination of care is maintained. · The PCP is kept appraised of service requests and of the service provided to the Member
by other Providers.
Medical Review of Denied Services: All UM requests that may lead to a denial, in whole or in part, are reviewed by a healthcare professional at Molina (medical director, pharmacy director, or appropriately licensed health professional).
Molina's Provider training includes information on the UM processes and Authorization requirements.
Clinical Information
Molina requires copies of clinical information be submitted for documentation in all medical necessity determination processes. Clinical information includes but is not limited to the following:
1. physician emergency department notes, 2. inpatient history/physical exams, 3. discharge summaries, 4. physician progress or office notes, nursing notes 5. physician orders, 6. results of laboratory or imaging studies, 7. therapy evaluations and therapist notes.
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Molina does not accept clinical summaries, telephone summaries or inpatient care manager reviews as meeting the clinical information requirements.
Information generally required to support the decision-making process includes:
· Adequate patient history related to the requested service(s) · Physical examination that addresses the area of the request · Issue(s)/concern(s) identified during an EPSDT/Well-Child visit · Supporting lab and/or x-rays results to support the request · Relevant PCP and/or Specialist progress notes and/or consultations · Any other relevant information or data specific to the request.
Referral vs. Prior Authorization
Referral: An authorization from Molina is NOT required to refer a patient to a participating Specialist. In referring a patient, the PCP should forward pertinent medical information and/or findings to the Specialist.
Authorization: Generally, prior authorization requirements are designed to assure the medical necessity of service, prevent anticipated denials of coverage and ensure participating providers are utilized and all services are provided at the appropriate level of care for the member's needs.
Availability of the Criteria used in a UM Decision
Providers who request prior authorization approval for patient services and/or procedures may request to review the criteria used to make the final decision. Molina has a full-time Medical Director available to discuss medical necessity decisions with the requesting Provider at (885) 237-6178.
Prior Authorization
Services that Require Prior Authorization
Molina requires prior authorization for specified services as long as the requirement complies with Federal or State regulations and the Molina Hospital or Provider Services Agreement. The list of services that require prior authorization is available in narrative form, along with a more detailed list by CPT and HCPCS codes and found on Molina's Provider Portal and website MolinaHealthcare.com. This includes a self-service authorization Look-Up Tool that allows a search by individual CPT and/o HCPCS codes to determine if prior authorization is necessary. This Look-Up Tool also provides useful information and rules around authorization of specific codes. Molina prior authorization documents are customarily updated quarterly but may be updated more frequently as appropriate or required by the SCDHHS.
Prior Authorization Forms: Forms are located on the website and provider encouraged to submit prior authorization requests electronically. Additionally, Molina accepts the universal authorization forms located on the SCDHHS website under Reference Tools in the Managed Care Section.
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Providers are encouraged to use the Molina prior authorization form provided on the Molina web site. If using a different form, the prior authorization request must include the following information:
· Member demographic information (name, date of birth, Molina ID number). · Provider demographic information (referring Provider and referred to Provider/facility). · Member diagnosis and ICD-10 codes. · Requested service/procedure, including all appropriate CPT and HCPCS codes. · Location where service will be performed. · Clinical information sufficient to document the medical necessity of the requested service
is required including: o Pertinent medical history (include treatment, diagnostic tests, examination data). o Requested length of stay (for inpatient requests). o Rationale for expedited processing.
IMPORTANT NOTE: Services performed without authorization may not be eligible for payment. Services provided emergently (as defined by Federal and State Law) are excluded from prior authorization requirements. Prior Authorization is not a guarantee of payment. Payment is contingent upon medical necessity and member eligibility at the time of service. Timeliness of Utilization Management Decisions Molina makes UM decisions in a timely manner to accommodate the urgency of the situation as determined by the member's clinical situation. Expedited/Urgent Prior Authorization Requests are defined when the situation where the standard time frame or decision-making process could seriously jeopardize the life or health of the member, the health or safety of the member or others, due to the member's psychological state, or in the opinion of the provider with knowledge of the enrollee's medical or behavioral health condition, would subject the member to adverse health consequences without the care or treatment that is subject of the request or could jeopardize the member's ability to regain maximum function. Supporting documentation is required to justify the expedited request.
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Timelines for UM Decisions
Type of Request
Defined
Standard Prior
Elective services and
Authorization Request procedures
Determination Timeline
Decision made and notification provided within fourteen (14) calendar days
Notification
Approvals, the provider will receive an authorization number, by phone or fax.
Denied services, the provider will receive a faxed letter. Member will receive letter by mail.
The letter will explain the reason for the denial and additional information regarding the grievance and appeals process.
Expedited Prior
Decisions where the
Decision made and
Approvals, the
Authorization Request member's life or health notification provided provider will receive an
may be jeopardized; or within seventy-two
authorization number,
could jeopardize the
(72) hours or 3 calendar by phone or fax.
member's ability to regain days from receipt of the
maximum function.
request.
Denied services, the
provider will receive a
Providers must
faxed letter. Member will
provide supporting
receive letter by mail.
documentation to justify an expedited authorization request. Without sufficient justification the authorization request may be downgraded and
The letter will explain the reason for the denial and additional information regarding the grievance and appeals process.
processed as a standard
request
Requesting Prior Authorization
Notwithstanding any provision in the Provider Agreement that requires provider to obtain a prior authorization directly from Molina, Molina may choose to contract with external vendors to help manage prior authorization requests.
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For additional information regarding the prior authorization of specialized clinical services, please refer to the Prior Authorization tools located on the MolinaHealthcare.com website:
· Prior Authorization Code Look-up Tool · Prior Authorization Code Matrix · Prior Authorization Guide
Provider Portal: Participating Providers are encouraged to use the Provider Portal for prior authorization submissions whenever possible. Instructions for how to submit a prior authorization request are also available on the Provider Portal. The benefits of submitting your prior authorization request through the Provider Portal are:
· Create and submit a Prior Authorization Request electronically. · Check status of an Authorization Requests. · Receive notification of change in status of an Authorization Requests. · Attach medical documentation required for timely medical review and decision making.
Fax: The Prior Authorization Request Form can be faxed to Molina at: (866) 423-3889.
Mail: Prior authorization requests and supporting documentation can be submitted via U.S. Mail at the following address:
Molina Healthcare of South Carolina Attn: Healthcare Services Dept. PO Box 40309 North Charleston, SC 29423-0309
Services and/or Procedures That Require Prior Authorization
Molina has a list of services that require prior authorization located on the Provider Portal which can be reached at MolinaHealthcare.com. This list is searchable by unique CPT and HCPCS code and also provides information.
Emergency Services
Emergency Services means: Covered Inpatient and Outpatient Services that are as follows:
· Furnished by a Provider that is qualified to furnish these services under this title; and · Needed to evaluate or stabilize an Emergency Medical Condition
Emergency Medical Condition or Emergency means:
Medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: placing the health of the individual (or, with respect to a pregnant woman, the health of the woman and/or her unborn child) in serious jeopardy; serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.
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A medical screening exam performed by licensed medical personnel in the emergency department and subsequent Emergency Services rendered to the Member do NOT require prior authorization from Molina.
Emergency Services are covered on a 24 hour basis without the need for prior authorization for all Members experiencing an Emergency Medical Condition.
Molina accomplishes this service by providing a 24 hour Nurse Advise line for post business hours. In addition, the 911 information is given to all Members at the onset of any call to the plan.
For Members within our service area: Molina contracts with vendors that provide 24 hour Emergency Services for ambulance and hospitals. An out of network emergency hospital stay will be covered until the Member has stabilized sufficiently to transfer to a participating facility. Services provided after stabilization in a non-participating facility are not covered and the Member will be responsible for payment. Members over-utilizing the emergency department will be contacted by Molina's Healthcare Services team to provide assistance whenever possible and determine the reason for using Emergency Services.
The Healthcare Services Team will also contact the PCP to ensure that Members are not accessing the emergency department because of an inability to be seen by the PCP.
Post Stabilization Services After Emergency Care
Post stabilization care services are covered services, whether inside or outside Molina's service area, that are related to an Emergency Medical Condition and provided after a member is stabilized in order to maintain the stabilized condition, or to improve or resolve the member's condition until one of the following occurs:
A. The member is discharged; or B. A Molina participating physician with privileges at the treating hospital assumes
responsibility for the member's care; or C. A Molina participating physician assumes responsibility for the member's care through
transfer; or D. A Molina medical director and the treating physician reach an agreement concerning the
member's care.
Members who are admitted to the acute care facility then follow Molina's emergent inpatient admission process.
Nurse Advice Line
Members may call the Nurse Advice Line anytime they are experiencing symptoms or need health care information. Registered nurses are available 24 hours a day, seven days a week to assess symptoms and help make good health care decisions.
English Phone : (888) 275-8750 Spanish Phone : (866) 648-3537 TTY English : (866) 735-2929 TTY Spanish : (866) 833-4703
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Molina is committed to helping our members:
· Prudently use the services of your office · Understand how to handle routine problems at home · Avoid making non-emergent visits to the emergency room (ER)
These registered nurses do not diagnose. They assess symptoms and guide the patient to the most appropriate level of care following specifically designed algorithms unique to the Nurse Advice Line. The Nurse Advice Line may refer back to the PCP, a specialist, 911 or the ER. By educating patients, it reduces costs and over utilization on the health care system.
Pregnancy Notification Process
The PCP shall submit to Molina the Pregnancy Notification Report Form (available at MolinaHealthcare.com) within one (1) working day of the first prenatal visit and/or positive pregnancy test. The form should be faxed to Molina at (866) 423-3889.
Inpatient Management
Elective Inpatient Admissions
Molina requires prior authorization for all elective/scheduled inpatient admissions and procedures to any facility. Facilities are required to also notify Molina within one business day once the admission has occurred for concurrent review. Elective inpatient admission services performed without prior authorization may not be eligible for payment.
Emergent Inpatient Admissions
Molina requires notification of all emergent inpatient admissions by the next business day or within one business day from the date of the admission. one business day. Notification of admission is required to verify eligibility, authorize care, including level of care (LOC), and initiate concurrent review and discharge planning.
Molina requires that notification includes Member demographic information, facility information, date of admission and clinical information sufficient to document the medical necessity of the admission. Emergent inpatient admission services performed without meeting notification, medical necessity requirements or failure to include all of the needed clinical documentation to support the need for an inpatient admission will result in a denial of authorization for the inpatient stay.
NOTE OB Deliveries: Normal deliveries not resulting in a Neonatal Intensive Care Unit (NICU) stay require notification only and must include the following:
· Baby's full name · Baby's gender · Baby's date of birth · Type of birth (e.g. normal vaginal delivery or c-section) · Newborn status (e.g. normal newborn or NICU admission
Facilities are encouraged to submit their delivery admission discharge summary form or use Molina's Labor and Delivery Notification form found on our website at molinahealthcare.com/forms.
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Observation Stay Converted to Inpatient Admission
Molina does NOT require authorization for Observation stays. However, if an Observation stay then converts to an Inpatient admission, Molina requires notification of that admission within ONE business day from the date the patient was made inpatient.
Example: Member was an Observation stay on Monday 1/13/2020 and converted to an inpatient admission on Wed 1/15/2020. Molina would require faxed notification of that inpatient admission no later than Thursday 1/16/2020.
IMPORTANT: Please submit clinical information that supports the reason(s) the member transitioning from an Observation stay to an inpatient admit.
Calling Molina or submitting notification of the Observation stay does NOT serve as notification of the inpatient admission.
Untimely notification of such an inpatient admission will result in a denial of payment.
Inpatient at time of Termination of Coverage
If a Member's coverage with Molina terminates during a hospital stay, all services received after their termination of eligibility are not covered services.
Inpatient/Concurrent Review
Molina performs concurrent inpatient review in order to ensure patient safety, medical necessity of ongoing inpatient services and adequate progress of treatment and development of appropriate discharge plans. We have streamlined the process by increasing the time frame between admission and the next concurrent review date. Additionally, we only request current clinical information instead of daily notes. This will allow greater focus on monitoring patient progress and assisting with discharge planning.
Molina requires that any requested clinical information and updates be received by the inpatient facility within 24 hours of the review. Failure to provide timely clinical information updates will result in a denial of authorization for the remainder of the inpatient admission.
Molina will authorize hospital care as an inpatient, when the clinical record supports the medical necessity for the need for continued hospital stay. Additionally, upon discharge the Provider must provide Molina with a copy of Member's discharge summary to include demographic information, date of discharge, discharge plan and instructions, medications, follow-up appointment and disposition.
Discharge Planning
The goal of discharge planning is to initiate cost-effective, quality-driven treatment interventions for post-hospital care at the earliest point in the admission.
UM staff work closely with the hospital discharge planners to determine the most appropriate discharge setting for our Members. The clinical staff review medical necessity and appropriateness for home health, infusion therapy, durable medical equipment (DME), skilled nursing facility and rehabilitative services.
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Readmissions
Readmission review is an important part of Molina's Quality Improvement Program to ensure that Molina Members are receiving hospital care that is compliant with nationally recognized guidelines as well as Federal regulations, State Medicaid regulations and CMS.
When a subsequent admission to the same participating hospital or facility is identified within 30 calendar days from the date of discharge, Molina's Medical Director will conduct a review of both stays to determine if the subsequent admission is in fact a readmission. There are two situations for Readmissions: Readmissions occurring within 24 hours from discharge (same or similar diagnosis); and Readmissions occurring within 2-30 days of discharge (same or similar diagnosis PLUS preventable).
When a subsequent admission to the same facility with the same or similar diagnosis occurs within 24 hours of discharge, the hospital will be informed that the readmission will be combined with the initial admission and will be processed as a continued stay.
When a subsequent admission to the same facility occurs within 2-30 days of discharge, and it is determined that the readmission is related to the first admission and determined to be preventable, then a single payment may be considered as payment in full for both the first and second hospital admissions.
· A Readmission is considered potentially preventable if it is clinically related to the prior admission and includes, but not limited to, the following circumstances: o Premature or inadequate discharge from the same hospital; o Issues with transition or coordination of care from the initial admission; including but not limited to care considered incomplete or substandard care o For an acute medical complication plausibly related to care that occurred during the initial admission. o The subsequent admission was due to a hospital acquired condition.
Readmissions that are excluded from consideration as preventable readmissions include:
· Planned readmissions associated with major or metastatic malignancies, multiple trauma, and burns.
· Neonatal and obstetrical Readmissions. · Initial admissions with a discharge status of "left against medical advice" because the
intended care was not completed. · Behavioral Health readmissions. · Transplant related readmissions.
Post Service Review
Failure to obtain authorization when required will result in denial of payment for those services. The only possible exception for payment as a result of post-service review is if information is received indicating the Provider did not know nor reasonably could have known that patient was a Molina Member or there was a Molina error, a Medical Necessity review will be performed.
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Decisions, in this circumstance, will be based on medical need, appropriateness of care guidelines defined by UM policies and criteria, regulation, guidance and evidence-based criteria sets.
Specific Federal or State requirements or Provider contracts that prohibit administrative denials supersede this policy.
Affirmative Statement about Incentives
All medical decisions are coordinated and rendered by qualified physicians and licensed staff unhindered by fiscal or administrative concerns. Molina do not use incentive arrangements to reward the restriction of medical care to Members.
Molina requires that all utilization-related decisions regarding member coverage and/or services are based solely on appropriateness of care and service and existence of coverage. Molina does not specifically reward practitioners or other individuals for issuing denials of coverage or care. And, Molina does not receive financial incentives or other types of compensation to encourage decisions that result in underutilization.
Open Communication about Treatment
Molina prohibits contracted Providers from limiting Provider or Member communication regarding a Member's health care. Providers may freely communicate with, and act as an advocate for their patients. Molina requires provisions within Provider contracts that prohibit solicitation of Members for alternative coverage arrangements for the primary purpose of securing financial gain. No communication regarding treatment options may be represented or construed to expand or revise the scope of benefits under a health plan or insurance contract.
Molina and its contracted Providers may not enter into contracts that interfere with any ethical responsibility or legal right of Providers to discuss information with a Member about the Member's health care. This includes, but is not limited to, treatment options, alternative plans or other coverage arrangements.
Delegated Utilization Management Functions
Molina may delegate UM functions to qualifying delegated entities. They must have the ability to meet, perform the delegated activities and maintain specific delegation criteria in compliance with all current Molina policies and regulatory and certification requirements. For more information about delegated UM functions and the oversight of such delegation, please refer to the Delegation section of this Provider Manual.
Communication and Availability to Members and Providers
During business hours HCS staff is available for inbound and outbound calls through an automatic rotating call system triaged by designated staff by calling (855) 237-6178 during normal business hours, Monday through Friday (except for Holidays) from 8 a.m. to 5 p.m. All staff Members identify themselves by providing their first name, job title, and organization.
Molina offers TTY/TDD services for Members who are deaf, hard of hearing, or speech impaired. Language assistance is also always available for Members.
After business hours, Providers can also utilize fax and the Provider Portal for UM access.
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Molina's Nurse Advice Line is available to Members and Providers 24 hours a day, 7 days a week at (888) 275-8750. Molina's Nurse Advice Line handles urgent and emergent after-hours UM calls. PCPs are notified via fax of all Nurse Advice Line encounters.
Out of Network Providers and Services
Molina maintains a contracted network of qualified health care professionals who have undergone a comprehensive credentialing process in order to provide medical care to Molina Members. Molina requires Members to receive medical care within the participating, contracted network of Providers unless it is for Emergency Services as defined by Federal Law. If there is a need to go to a non-contracted Provider, all care provided by non-contracted, non-network Providers must be prior authorized by Molina. Non-network Providers may provide Emergency Services for a Member who is temporarily outside the service area, without prior authorization or as otherwise required by Federal or State Laws or regulations.
Coordination of Care and Services
Molina HCS staff work with Providers to assist with coordinating referrals, services and benefits for Members with complex needs and issues who have been identified for Molina's Integrated Care Management (ICM) program via assessment or referral such as self-referral, provider referral, etc. In addition, the coordination of care process assists Molina Members, as necessary, in transitioning to other care when benefits end.
Molina staff provide an integrated approach to care needs by assisting members with identification of resources available to the member, such as community programs, national support groups, appropriate specialists and facilities, identifying best practice or new and innovative approaches to care. Care coordination by Molina HCS staff is done in partnership with Providers, Members and/or their authorized representative(s) to ensure efforts are efficient and non-duplicative.
Continuity of Care and Transition of Members
It is Molina's policy to provide Members with advance notice when a Provider they are seeing will no longer be in-network. Members and Providers are encouraged to use this time to transition care to an in-network Provider. The Provider leaving the network shall provide all appropriate information related to course of treatment, medical treatment, etc. to the Provider(s) assuming care. Under certain circumstances, Members may be able to continue treatment with the out of network Provider for a given period of time and provide continued services to Members undergoing a course of treatment by a Provider that has terminated their contractual agreement if the following conditions exist at the time of termination.
· Acute condition or serious chronic condition Following termination, the terminated Provider will continue to provide covered services to the Member up to 90 days or longer if necessary for a safe transfer to another Provider as determined by Molina.
· The second or third trimester of pregnancy The terminated Provider will continue to provide services following termination until postpartum services related to delivery are completed or longer if necessary for a safe transfer.
For each member identified in the categories above, Molina will work with the treating provider
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on a transition plan over a reasonable period of time. Each case will be individualized to meet the member's needs.
Requests for continued care should be submitted to Molina's Healthcare Services Department via the address or fax listed at the beginning of this section. All requests for continuity of care will be reviewed by a Medical Director. Molina typically will not approve continued care by a nonparticipating provider if:
· The member only requires monitoring of a chronic condition · The provider does not qualify for Molina credentialing based on a previous professional
review action · The provider is unwilling to continue care for the member · The provider has never seen the member prior to enrolling with Molina
For additional information regarding continuity of care and transition of Members, please contact Molina at (855) 237-6178.
Continuity and Coordination of Provider Communication
Molina stresses the importance of timely communication between providers involved in a member's care. This is especially critical between specialists, including behavioral health providers, and the member's PCP. Information should be shared in such a manner as to facilitate communication of urgent needs or significant findings.
Reporting of Suspected Abuse and/or Neglect
A vulnerable adult is a person who is receiving or may be in need of receiving community care services by reason of mental or other disability, age or illness; and who is or may be unable to take care of him or herself, or unable to protect him or herself against significant harm or exploitation. When working with children one may encounter situations suggesting abuse, neglect and/or unsafe living environments.
Every person who knows or has reasonable suspicion that a child or adult is being abused or neglected must report the matter immediately. Specific professionals mentioned under the law as mandated reporters are:
· Physicians, dentists, interns, residents, or nurses · Public or private school employees or child care givers · Psychologists, social workers, family protection workers, or family protection specialists · Attorneys, ministers, or law enforcement officers.
Suspected abuse and/or neglect should be reported as follows:
The South Carolina Department of Social Services. Phone numbers to report vary by county and can be accessed via the Department's website or address noted below. www.dss.sc.gov/abuseneglect
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South Carolina Department of Social Services 1535 Confederate Avenue Columbia, SC 29201-1915
Client Services phone number (800) 616-1309.
Additionally, you may contact the National Child Abuse Hotline at (800) 422-4453 to report suspected child abuse as well.
Adult Abuse:
Molina's HCS teams will work with PCPs and Medical Groups/IPA and other delegated entities who are obligated to communicate with each other when there is a concern that a Member is being abused. Final actions are taken by the PCP/Medical Group/IPA, other delegated entities or other clinical personnel. Under State and Federal Law, a person participating in good faith in making a report or testifying about alleged abuse, neglect, abandonment, financial exploitation or self-neglect of a vulnerable adult in a judicial or administrative proceeding may be immune from liability resulting from the report or testimony.
Molina will follow up with Members that are reported to have been abused, exploited or neglected to ensure appropriate measures were taken, and follow up on safety issues. Molina will track, analyze, and report aggregate information regarding abuse reporting to the Healthcare Services Committee and the proper State agency.
PCP Responsibilities in Care Management Referrals
The member's PCP is the primary leader of the health team involved in the coordination and direction of services for the member. The care manager provides the PCP with the member's ICP, interdisciplinary care team (ICT) updates, and information regarding the member's progress through the ICP when requested by the PCP. The PCP is responsible for the provision of preventive services and for the primary medical care of members.
Care Manager Responsibilities
The care manager collaborates with the member and any additional participants as directed by the member to develop a plan of care which includes a multidisciplinary action plan (care plan), a link to the appropriate institutional and community resources, and a statement of expected outcomes. Jointly, the care manager, and the member are responsible for implementing the plan of care. Additionally the care manager:
The CM program is individualized to accommodate the member's needs. The Molina care manager will collaborate with the member's providers to arrange individual services for members that may include coordination and continuity of medical care, home health care, rehabilitation services, and preventive services. The Molina care manager is responsible for the assessment of the member and will communicate directly with the PCP regarding the Care Management Care Plan. The member, PCP, and/or other providers will also be invited to participate in Interdisciplinary Care Team meetings to ensure care coordination as well as continuity of care. If unable to participate, the care manager will communicate any recommendations from the meeting to the member and provider via telephone and written correspondence.
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Referrals to Care Management: Members with high-risk medical conditions may be referred by their PCP or specialty care provider to the CM program. The care manager works collaboratively with all members of the health care team, including the PCP, hospital CM staff, discharge planners, specialist providers, ancillary providers, the local Health Department and other community resources. The referral source provides the care manager with demographic, health care and social data about the member.
Members with the following conditions may qualify for CM and should be referred to the Molina CM Program for evaluation:
· Monitors and communicates the progress of the implemented plan of care to all involved resources
· Serves as a coordinator and resource to team members throughout the implementation of the plan, and makes revisions to the plan as suggested and needed
· Coordinates appropriate education and encourages the member's role in self-help · Monitors progress toward the member's achievement of treatment plan goals in order to
determine an appropriate time for the member's discharge from the CM program
Members are able to access our easy-to-read materials are about nutrition, preventive services guidelines, stress management, exercise, cholesterol management, asthma diabetes and other topics. To get these materials, Members are directed to ask their doctor or visit our website.
Program Eligibility Criteria and Referral Source
Health Management(HM) Programs are designed for Molina Members with a confirmed diagnosis. Identified Members will receive targeted outreach such as educational newsletters, telephonic outreach or other materials to access information on their condition. Members can contact Molina Member Services at any time and request to be removed from the program.
Members may be identified for or referred to HM programs from multiple pathways which may include the following:
· Pharmacy Claims data for all classifications of medications. · Encounter Data or paid claims with a relevant CMS accepted diagnosis or procedure code. · Member Services welcome calls made by staff to new Member households and incoming
Member calls have the potential to identify eligible program participants. Eligible Members are referred to the program registry. · Member Assessment calls made by staff for the initial Health Risk Assessments (HRA) for newly enrolled Members. · External referrals from provider(s), caregivers or community-based organizations. · Internal referrals from Nurse Advice Line, Medication Management Care Management or Utilization Management. · Member self-referral due to general plan promotion of program through Member newsletter or other Member communication.
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Provider Participation
Contracted Providers are notified as appropriate, when their patients are enrolled in a Health Management Program. Provider resources and services may include:
· Annual Provider feedback letters containing a list of patients identified with the relevant disease;
· Clinical resources such as patient assessment forms and diagnostic tools; · Patient education resources; · Provider newsletters promoting the Health Management Programs, including how to enroll
patients and outcomes of the programs; · Clinical Practice Guidelines; and, · Preventive Health Guidelines.
Additional information on Health Management Programs is available from your local Molina Healthcare Services department toll free at (855) 237-6178.
Telehealth and Telemedicine Services
Molina members may obtain covered services by participating providers, through the use of Telehealth and Telemedicine services. Not all participating providers offer these services. The following additional provisions apply to the use of Telehealth and Telemedicine services:
· Services must be obtained from a participating provider. · Services are meant to be used when care is needed now for non-emergency medical issues. · Services are a method of accessing covered services, and not a separate benefit. · Services are not permitted when the member and participating provider are in the same
physical location. · Services do not include texting, facsimile or email only. · Services include preventive and/or other routine or consultative visits during a pandemic. · Covered services provided through store-and-forward technology, must include an in-
person office visit to determine diagnosis or treatment.
Upon at least 10 days prior notice to provider, Molina shall further have the right to a demonstration and testing of provider telehealth service platform and operations. This demonstration may be conducted either virtually or face-to-face, as appropriate for telehealth capabilities and according to the preference of Molina. Provider shall make its personnel reasonably available to answer questions from Molina regarding telehealth operations.
For additional information on Telehealth and Telemedicine Claims and billing, please refer to the Claims and Compensation section of this Provider Manual.
Care Management (CM)
Molina provides a comprehensive CM program to all members who meet the criteria for services. The CM program focuses on coordinating the care, services, and resources needed by members
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throughout the continuum of care. Molina adheres to Care Management Society of America Standards of Practice Guidelines in its execution of the program.
The Molina care managers may be licensed professionals and are educated, trained and experienced in the Care Management process. The CM program is based on a member advocacy philosophy, designed and administered to assure the member value-added coordination of health care and services, to increase continuity and efficiency, and to produce optimal outcomes. The CM program is individualized to accommodate a Member's needs with collaboration and approval from the member's PCP. The Molina care manager will assess the member upon engagement after identification for ICM enrollment, assist with arrangement of individual services for members whose needs include ongoing medical care, home health care, rehabilitation services, and preventive services. The Molina care manager is responsible for assessing the Member's appropriateness for the CM program and for notifying the PCP of Integrated Care Management (ICM) program enrollment, as well as making a recommendation for a treatment plan facilitating and assisting with the development of the member's' ICP.
Referral to Care Management: Members with high-risk medical conditions and/or other care needs may be referred by their PCP or specialty care Provider to the CM program. The care manager works collaboratively with the member and all participants of the integrated care team (ICT), including the PCP and specialty providers, such as, discharge planners, ancillary providers, the local Health Department or other community-based resources when identified. The referral source should be prepared to provide the care manager with demographic, health care and social data about the member being referred.
Members with the following conditions may qualify for Care Management and should be referred to the Molina CM Program for evaluation:
· High-risk pregnancy, including Members with a history of a previous preterm delivery · Catastrophic or end-stage medical conditions (e.g. neoplasm, organ/tissue transplants) · Comorbid chronic illnesses (e.g. asthma, diabetes, COPD, CHF, etc) · Preterm births · High-technology home care requiring more than two weeks of treatment · Member accessing emergency department services inappropriately · Children with Special Health Care Needs · Sickle Cell
Referrals to the CM program may be made by contacting Molina at (855) 237-6178
Any drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply used in or directly related to the diagnosis, evaluation, or treatment of a disease, injury, illness, or other health condition which we determine in our sole discretion to be Experimental/ Investigational is not covered.
We will deem any drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply to be Experimental/Investigational if we determine that one or more of the following criteria apply when the service is rendered with respect to the use for which benefits are
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sought. The drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply:
· Cannot be legally marketed in the United States without the final approval of the Food and Drug Administration (FDA), or other licensing or regulatory agency, and such final approval has not been granted;
· Has been determined by the FDA to be contraindicated for the specific use; or,
· Is provided as part of a clinical research protocol or clinical trial or is provided in any other manner that is intended to evaluate the safety, toxicity, or efficacy of the drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply; or,
· Is subject to review and approval of an Institutional Review Board (IRB) or other body serving a similar function; or,
· Is provided pursuant to informed consent documents that describe the drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply as Experimental/Investigational, or otherwise indicate that the safety, toxicity, or, efficacy of the drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply is under evaluation.
Any service not deemed Experimental/Investigational based on the criteria above may still be deemed Experimental/Investigational by Us. In determining whether a Service is Experimental/ Investigational, We will consider the information described below and assess whether:
· The scientific evidence is conclusory concerning the effect of the service or drug on health outcomes;
· The evidence demonstrates the service or drug improves net health outcomes of the total population for whom the service or drug might be proposed by producing beneficial effects that outweigh any harmful effects;
· The evidence demonstrates the service or drug has been shown to be as beneficial for the total population for whom the service or drug might be proposed as any established alternatives; and,
· The evidence demonstrates the service or drug has been shown to improve the net health outcomes of the total population for whom the service or drug might be proposed under the usual conditions of medical practice outside clinical investigatory settings.
The information considered or evaluated by us to determine whether a drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply is Experimental/ Investigational under the above criteria may include one or more items from the following list which is not all inclusive:
· Published authoritative, peer-reviewed medical or scientific literature, or the absence thereof; or,
· Evaluations of national medical associations, consensus panels, and other technology evaluation bodies; or,
· Documents issued by and/or filed with the FDA or other Federal, State or local agency with the authority to approve, regulate, or investigate the use of the drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply; or,
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· Documents of an IRB or other similar body performing substantially the same function; or, · Whether there is FDA approval for the use for which benefits are sought; or · Consent document(s) and/or the written protocol(s) used by the treating physicians,
other medical professionals, or facilities or by other treating physicians, other medical professionals or facilities studying substantially the same drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply; or · Medical records; or, · The opinions of consulting Providers and other experts in the field. We have the sole authority and discretion to identify and weigh all information and determine all questions pertaining to whether a drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply is Experimental/Investigational. This exclusion does not apply to services covered under "Approved Clinical Trials" in the "What is Covered Under My Plan?" section.
Notice Act
Under the NOTICE Act, hospitals and CAHs must deliver the Medicare Outpatient Observation Notice (MOON) to any beneficiary (including an MA Member) who receives observation services as an outpatient for more than twenty-four (24) hours. See the final rule that went on display August 2, 2016 (published August 22, 2016) at: https://www.federalregister.gov/ documents/2016/08/22/2016-18476/medicare-program-hospital-inpatient-prospectivepayment-systems-for-acute-care-hospitals-and-the https://www.Federalregister.gov/documents/2016/08/22/2016-18476
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Section 7. Medical Management
Molina maintains a medical management program to ensure patient safety, ensure quality services are being provided as well as detect and prevent fraud, waste and abuse in its programs. The program ensures Molina only reimburses for services identified as a covered benefit that are medically necessary. Elements of the Molina medical management program include medical necessity review, prior authorization, inpatient management and review of the use of nonparticipating providers.
This section on Referrals, Authorizations, and HealthCare Services (Utilization Management) describes procedures that apply to directly contracted Molina providers. All contracted providers must obtain Molina's authorization for specific services that require prior approval. Molina providers must ensure members receive medically necessary health care services in a timely manner without undue interruption. The member's PCP is responsible for:
· Providing routine medical care to Molina members · Following up on missed appointments · Prescribing diagnostic and/or laboratory tests and procedures · Coordinating Referrals and obtaining prior authorization when required
Referral Versus Prior Authorization
Referral: An authorization from Molina is not required to refer a patient to a participating specialist. In referring a patient, the PCP should forward pertinent patient information/findings to the Specialist.
Authorization: Generally, prior authorization requirements are designed to assure the medical necessity of service, prevent unanticipated denials of coverage, and ensure participating providers are utilized and all services are provided at the appropriate level of care for the member's needs.
Surgical Procedures
Molina does not provide additional reimbursement for the use of robotic equipment during surgical procedures.
How to Submit an Authorization Request
Providers should send requests for prior authorizations to the Molina Healthcare Services Department Authorization requests may be submitted via Molina's e-portal at MolinaHealthcare.com 24 hours/day, seven days/week. For the current version of the Prior Authorization Guide and Prior Authorization Request Form, please visit the Molina Provider Portal at molinahealthcare.com/ providers/sc/medicaid/forms/Pages/fuf.aspx. Prior authorizations may also be submitted by fax, mail or in urgent situations by phone. Contact information is listed below:
Phone: (855) 237-6178 Fax: (866) 423-3889
Mail: Prior authorization requests and supporting documentation can be submitted via U.S. mail at the following address: Molina Healthcare of South Carolina
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Attn: Healthcare Services Dept. PO Box 40309 North Charleston, SC 29423-0309
Emergency Care
A medical screening exam performed by licensed medical personnel in the emergency department and subsequent emergency care services rendered to the member do not require prior authorization from Molina.
Members accessing the emergency department inappropriately will be contacted by Molina care managers whenever possible to determine the reason for using emergency services. Care managers will also contact the PCP to ensure that members are not accessing the emergency department because of an inability to be seen by the PCP.
Prior Authorization Decision Time Frames
Pursuant to South Carolina state-established time frames, Molina will process any non-urgent prior authorization requests no later than 14 calendar days following receipt of the request for service. Urgent requests will be processed as expeditiously as possible and within 72 hours of receipt of the request for service. A Molina member can request up to 14 extra calendar days if he/she or the provider needs to submit more information before Molina makes a decision. Molina can also request additional days if more information is needed to make a decision. For standard decisions Molina can request up to 14 extra calendar days, and if an expedited decision is needed Molina can request up to 48 extra hours. Molina will notify the member in writing if an extension is needed.
Non-Network Providers and Services - Molina maintains a contracted network of qualified health care professionals who have under gone a comprehensive credentialing process in order to provide medical care for Molina members. Molina requires members to receive medical care within the participating, contracted network of providers. All care provided by non-contracted, non-network providers must be prior authorized by Molina. Non-network providers may provide emergent/urgent care and dialysis services for a member who is temporarily outside the service area, without prior authorization or as otherwise required by federal or state laws or regulations.
Decision Making Process
The HCS Department affirms its decision-making is based on appropriateness of care and service and the existence of benefit coverage.
Molina does not reward providers or other individuals for issuing denials of coverage or care. Furthermore, Molina never provides financial incentives to encourage authorization decision makers to make determinations that result in under-utilization. Also, we require our delegated medical groups/IPAs to agree to the same process.
Specialty Pharmaceuticals
Molina contracts with a specialty pharmacy services vendors to provide an innovative specialty drug delivery program. This service eliminates the costs and special storage requirements associated with stocking and billing for office administered specialty injectable drugs for Molina members.
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Molina's specialty pharmacy vendors will coordinate with Molina and ship the prescription directly to your office or the member's home. All packages are individually marked for each member, and refrigerated drugs are shipped in insulated packages with frozen gel packs. The service also offers the additional convenience of enclosing needed ancillary supplies (needles, syringes and alcohol swabs) with each prescription at no charge. Injectable medications that must be administered by a healthcare professional in settings such as a physician's office, infusion center, or other clinical settings are not routinely covered under Pharmacy Services. When billing for a provider-administered drug administered in the office, the physician must bill an injection code with the accurate units for dosing. A prescription for a medication that must be administered by a healthcare professional cannot be filled by a pharmacist and then returned to a physician's office for administration. Prior authorization requests for medications that must be administered by a health care professional should be submitted to the Molina Healthcare Services prior authorization team via fax at (866) 423-3889. Newly FDA approved drugs are considered non-formulary and subject to non-formulary policies and other non-formulary utilization criteria until a coverage decision is rendered by the Molina Pharmacy and Therapeutics Committee.
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Section 8. Pharmacy
Prescription drug therapy is an integral component of your patient's comprehensive treatment program. Molina's goal is to provide our Members with high quality, cost effective drug therapy. Molina works with our Providers and Pharmacists to ensure medications used to treat a variety of conditions and diseases are offered. Molina covers prescription and certain over-the-counter drugs.
Pharmacy and Therapeutics Committee
The National Pharmacy and Therapeutics Committee (P&T) meets quarterly to review and recommend medications for formulary consideration. The P&T Committee is organized to assist Molina with managing pharmacy resources and to improve the overall satisfaction of Molina Members and Providers. It seeks to ensure Molina Members receive appropriate and necessary medications. An annual pharmacy work plan governs all the activities of the committee. The committee voting membership consists of external physicians and pharmacists from various clinical specialties.
Pharmacy Network
Members must use their Molina ID card to get prescriptions filled. Additional information regarding the pharmacy benefits, limitations, and network pharmacies is available by visiting MolinaHealthcare.com or calling Molina at (855) 882-3901.
Drug Formulary
The pharmacy program does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage and/or quantities. For a complete list of covered medications please visit MolinaHealthcare.com.
Information on procedures to obtain these medications is described within this document and also available on the Molina website at MolinaHealthcare.com.
Formulary Medications
In some cases, Members may only be able to receive certain quantities of medication. Information on limits are included and can be found in the formulary document.
Formulary medications with PA may require the use of first-line medications before they are approved.
Quantity Limitations
Quantity limitations have been placed on certain medications to ensure safe and appropriate use of the medication.
Age Limits
Some medications may have age limits. Age limits align with current U.S. Food and Drug Administration (FDA) alerts for the appropriate use of pharmaceuticals.
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Step Therapy
Plan restrictions for certain drugs may require that other drugs be tried first. The Preferred Drug List (PDL) designates drugs that may process under the pharmacy benefit without prior authorization if the member's pharmacy fill history with Molina shows other drugs have been tried for certain lengths of time. If the member has trialed certain drugs prior to joining Molina, documentation in the clinical record can serve to satisfy requirements when submitted to Molina for review. Drug samples from providers or manufacturers are not considered as meeting step therapy requirements or as justification for exception requests.
Non-Formulary Medications
Non-formulary medications may be considered for exception when formulary medications are not appropriate for a particular Member or have proven ineffective. Requests for formulary exceptions should be submitted using a Universal Medication Prior Authorization Request Form. Clinical evidence must be provided and is taken into account when evaluating the request to determine medical necessity. The use of manufacturer's samples of Non-Formulary or "Prior Authorization Required" medications does not override Preferred Drug List requirements.
Generic Substitution
Generic drugs should be dispensed when available. If the use of a particular brand name becomes medically necessary as determined by the Provider, PA must be obtained through the standard PA process.
New to Market Drugs
Newly approved drug products will not normally be placed on the formulary during their first six months on the market. During this period, access to these medications will be considered through the PA process.
Medications Not Covered
Medications not covered by Medicaid are excluded from coverage. Below is a list of some of the medications that are NOT covered:
· Appetite Suppressants / Anorexiants for weight loss (except for lipase inhibitors) · Drugs for cosmetic purposes, including hair growth · Drugs used to treat infertility · Drugs used to treat erectile dysfunction · Pharmaceuticals determined by the Federal Drug Administration (FDA) to be less than
effective and identical, related, or similar drugs (frequently referred to as "DESI 5 and 6" drugs) · Experimental or Investigational Medications · Convenience Dosage Forms (Transdermal Patches) not Listed in the Preferred Drug List · OTC (Over-the-Counter non-prescription medications) unless specifically listed in the
Preferred Drug List · OTC Analgesics unless specifically listed in the Preferred Drug List
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· OTC cough and cold products unless specifically listed in the Preferred Drug List · OTC vitamin and mineral products including calcium supplements/TUMS unless specifically
listed in the Preferred Drug List
Submitting a Prior Authorization Request
In order for Molina to process completed Universal Medication Prior Authorization Request Forms, the following information MUST be included for the request form to be considered complete.
· Member first name, last name, date of birth and identification number · Prescriber first name, last name, NPI, phone number and fax number · Drug name, strength, quantity and directions of use · Diagnosis
Molina's decisions are based upon the information included with the Universal Medication Prior Authorization request. Clinical notes are recommended. If clinical information and/or medical justification is missing Molina will either fax or call your office to request clinical information be sent in to complete the review. To avoid delays in decisions, be sure to complete the Universal Medication Prior Authorization Form in its entirety, including medical justification and/or supporting clinical notes.
Fax a completed Universal Medication Prior Authorization Form to Molina at (855) 571-3011. A blank Universal Medication Prior Authorization Form may be obtained by accessing MolinaHealthcare.com or by calling (855) 237-6178.
Member and Provider "Patient Safety Notifications"
Molina has a process to notify Members and Providers regarding a variety of safety issues which include voluntary recalls, FDA required recalls and drug withdrawals for patient safety reasons. This is also a requirement as an NCQA accredited organization.
Specialty Pharmaceuticals, Injectable and Infusion Services
Many specialty medications are covered by Molina through the pharmacy benefit using National Drug Codes (NDC) for billing and specialty pharmacy for dispensing to the Member or Provider. Some of these same medications maybe covered through the medical benefit using Healthcare Common Procedure Coding System (HCPCS) via paper or electronic medical claim submission.
Molina, during the utilization management review process, will review the requested medication for the most cost-effective, yet clinically appropriate benefit (medical or pharmacy) of select specialty medications. All reviewers will first identify Member eligibility, any Federal or State regulatory requirements, and the Member specific benefit plan coverage prior to determination of benefit processing.
If it is determined to be a Pharmacy benefit, Molina's pharmacy vendor will coordinate with Molina and ship the prescription directly to your office or the Member's home. All packages are individually marked for each Member, and refrigerated drugs are shipped in insulated packages with frozen gel packs. The service also offers the additional convenience of enclosing needed ancillary supplies
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(needles, syringes and alcohol swabs) with each prescription at no charge. Please contact your Provider Relations representative with any further questions about the program. Newly FDA approved medications are considered non-formulary and subject to non-formulary policies and other non-formulary utilization criteria until a coverage decision is rendered by the Molina Pharmacy and Therapeutics Committee. "Buy-and-bill" drugs are pharmaceuticals which a Provider purchases and administers, and for which the Provider submits a claim to Molina for reimbursement. Pain Safety Initiative (PSI) Resources Safe and appropriate opioid prescribing and utilization is a priority for all of us in health care. Molina requires Providers to adhere to Molina's drug formularies and prescription policies designed to prevent abuse or misuse of high-risk chronic pain medication. Providers are expected to offer additional education and support to Members regarding Opioid and pain safety as needed. Molina is dedicated to ensuring Providers are equipped with additional resources, which can be found on the Molina Provider website. Providers may access additional Opioid-safety and Substance Use Disorder resources at MolinaHealthcare.com under the Health Resource tab. Please consult with your Provider Services representative or reference the medication formulary for more information on Molina's Pain Safety Initiatives.
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Section 9. Quality Improvement
Molina maintains a Quality Improvement (QI) department to work with members and practitioners/providers in administering the Molina Quality Improvement Program. You may contact the Molina QI department toll free at (855) 237-6178.
Provider will promptly deliver to Health Plan, upon request or as may be required by Law, Health Plan's policies and procedures, Government Program Requirements, or third party payers, any information, statistical data, Encounter Data, or Record pertaining to members served by provider. Provider is responsible for the fees associated with producing such records. Provider will further give direct access to said patient care information as requested by Health Plan or as required by any state or federal authority/agency with jurisdiction over Health Plan. Health Plan has the right to withhold compensation from provider if provider fails or refuses to give such information to Health Plan promptly. This section will survive any termination.
Provider will give members access to members' Record and other applicable information, in accordance with Laws, Government Program Requirements, and Health Plan's policies and procedures. This section will survive any termination.
The address for mail requests is:
Molina Healthcare of South Carolina Quality Improvement Department PO Box 40309 North Charleston, SC 29423-0309
This Provider Manual contains excerpts from the Molina Quality Improvement Program (QIP). For a complete copy of Molina's QIP that complies with regulatory and accreditation guidelines, you can contact your Provider Services Representative or call the telephone number above to receive a written copy.
The QIP provides structure and outlines specific activities designed to improve the care, service and health of our members.
Molina does not delegate QI activities to Medical Groups/IPAs. However, Molina requires contracted Medical Groups/IPAs to comply with the following core elements and standards of care. Molina Medical Groups/IPAs must:
· Have a quality improvement program in place. · Comply with and participate in Molina's QI Program including reporting of Access and
Availability Survey and activity results and provision of medical records as part of the HEDIS® review process and during Potential Quality of Care and/or Critical Incident investigations. · Cooperate with Molina's quality improvement activities that are designed to improve quality of care and services and member experience. · Allow Molina to collect, use and evaluate data related to Provider performance for quality improvement activities, including but not limited to focus areas, such as clinical care, care coordination and management, service, and access and availability.
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· Allow access to Molina QI personnel for site and medical record review processes.
Quality of Care
Molina has established a systematic process to identify, investigate, review and report any Quality of Care, Adverse Event/Never Event, Critical Incident (as applicable), and/or service issues affecting Member care. Molina will research, resolve, track and trend issues. Confirmed Adverse Events/Never Events are reportable when related to an error in medical care that is clearly identifiable, preventable and/or found to have caused serious injury or death to a patient. Some examples of never events include:
· Surgery on the wrong body part. · Surgery on the wrong patient. · Wrong surgery on a patient.
Molina is not required to pay for inpatient care related to "never events."
Access to Care Standards
Molina is committed to providing timely access to care for all members in a safe and healthy environment. Molina will ensure providers offer hours of operation no less than offered to commercial members. Access standards have been developed to ensure that all health care services are provided in a timely manner. The PCP or designee must be available 24 hours a day, seven days a week to members for emergency services. This access may be by telephone. Appointment and waiting time standards are shown below. Any member assigned to a PCP is considered his or her patient. Molina may also assist with scheduling preventative health care appointments for our members. All specialty referrals should be coordinated by the primary care provider.
Primary Care Practitioner (PCP)
Types of Care for Appointment Appointment Wait Time (Appointment Standards)
Routine Primary Care
Within 4 weeks
Urgent Care
Within 48 hours
Emergent visits
Immediately upon referral
Urgent Medical Condition Care Within 48 hours of referral or notification
Routine Specialist Care Emergency Care Walk-in Patients
Appointment time: within 12 weeks; Wait time: within 45 minutes
Immediately upon presentation at treatment site. Access by telephone for emergent medical conditions.
Should be seen if possible. Urgent needs must be seen within forty-eight hours of walk-in. Non-urgent needs must be seen within routine care guidelines above.
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Primary Care Practitioner (PCP) Types of Care for Appointment Appointment Wait Time (Appointment Standards)
Office Wait Times
After-Hours Emergency Instructions After-Hours Care
Within 45 minutes for a scheduled appointment of a routine nature
"If this is an emergency, please hang up and dial 911"
Available by phone 24 hours/seven days Behavioral Health
Types of Care for Appointment Appointment Wait Time (Appointment Standards)
Non-life Threatening Emergency Care
Urgent Care Routine Care Follow-up Routine Care
Within six hours of request
Within 48 hours Within 10 calendar days Within 30 calendar days
Office Wait Time
For scheduled appointments, the wait time in offices should not exceed 45 minutes. All PCPs are required to monitor waiting times and to adhere to this standard.
Medical Records
Molina requires that medical records are maintained in a manner that is current, detailed and organized to ensure that care rendered to members is consistently documented and that necessary information is readily available in the medical record. All entries will be indelibly added to the member's record. Molina annually conducts a review of member's medical records from a representative sample of Primary Care Practitioners (PCP) of the Molina provider network against the medical record keeping standards and requirements as well as other providers as determined necessary. PCPs should maintain the following medical record components, that include but are not limited to:
· Medical record confidentiality and release of medical records within medical and behavioral health care records.
· Medical record content and documentation standards, including preventive health care.
· Storage maintenance and disposal processes.
· Process for archiving medical records and implementing improvement activities.
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Medical Record Keeping Practices
Below is a list of the minimum items that are necessary in the maintenance of the member's medical records:
· Each patient has a separate record. · Medical records are stored away from patient areas and preferably locked. · Medical records are available at each visit and archived records are available within 24
hours. · If hard copy, pages are securely attached in the medical record and records are organized
by dividers or color-coded when thickness of the record dictates. · If electronic, all those with access have individual passwords. · Record keeping is monitored for Quality and HIPAA compliance. · Storage maintenance for the determined timeline and disposal per record management
processes. · Process for archiving medical records and implementing improvement activities. · Medical records are kept confidential and there is a process for release of medical records
including behavioral health care records.
Practitioners/providers must demonstrate compliance with Molina's medical record documentation guidelines. The provider is responsible to retain their records for at least ten (10) years for adult patients and at least thirteen (13) years for minors. Medical records are assessed based on the following standards:
Content
Providers must remain consistent in their practices with Molina's medical record documentation guidelines. Medical records are maintained and should include the following information:
· Each page in the record contains the patient's name or ID number. · Member name, date of birth, sex, marital status, address, employer, home and work
telephone numbers, and emergency contact. · Legible signatures and credentials of provider and other staff members within a paper
chart. · All providers who participate in the member's care. · Information about services delivered by these providers. · A problem list that describes the member's medical and behavioral health conditions. · Presenting complaints, diagnoses, and treatment plans, including follow-up visits and
referrals to other providers. · Medication reconciliation within 30 days of an inpatient discharge should include evidence
of current and discharge medication reconciliation and the date performed. · Prescribed medications, including dosages and dates of initial or refill prescriptions. · Allergies and adverse reactions (or notation that none are known).
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· Documentation that Advanced Directives, Power of Attorney and Living Will have been discussed with member, and a copy of Advance Directives when in place.
· Past medical and surgical history, including physical examinations, treatments, preventive services and risk factors.
· Treatment plans that are consistent with diagnosis. · A working diagnosis that is recorded with the clinical findings. · Pertinent history for the presenting problem. · Pertinent physical exam for the presenting problem. · Lab and other diagnostic tests that are ordered as appropriate by the provider. · Clear and thorough progress notes that state the intent for all ordered services and
treatments. · Notations regarding follow-up care, calls or visits. The specific time of return is noted in
weeks, months or as needed, included in the next preventative care visit when appropriate. · Notes from consultants if applicable. · Up-to-date immunization records and documentation of appropriate history. · All staff and provider notes are signed physically or electronically with either name or initials. · All entries are dated. · All abnormal lab/imaging results show explicit follow up plan(s). · All ancillary services reports. · Documentation of all emergency care provided in any setting. · Documentation of all hospital admissions, inpatient and outpatient, including the hospital
discharge summaries, hospital history and physicals and operative report. · Labor and Delivery Record for any child seen since birth. · A signed document stating with whom protected health information may be shared.
Organization
· The medical record is legible to someone other than the writer. · Each patient has an individual record. · Chart pages are bound, clipped, or attached to the file. · Chart sections are easily recognized for retrieval of information. · A release document for each member authorizing Molina to release medical information for
facilitation of medical care.
Retrieval
· The medical record is available to practitioner/provider at each encounter. · The medical record is available to Molina for purposes of Quality Improvement. · The medical record is available to the applicable State and/or Federal agency and the
External Quality Review Organization upon request.
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· The medical record is available to the member upon their request. · A storage system for inactive member medical records which allows retrieval within 24
hours, is consistent with State and Federal requirements, and the record is maintained for not less than 10 years from the last date of treat mentor for a minor, one year past their 20th birthday but, never less than 10 years. · An established and functional data recovery procedure in the event of data loss.
Confidentiality
Molina Providers shall develop and implement confidentiality procedures to guard Member protected health information, in accordance with HIPAA privacy standards and all other applicable Federal and State regulations. This should include, and is not limited to, the following:
· Ensure that medical information is released only in accordance with applicable Federal or State Law in pursuant to court orders or subpoenas.
· Maintain records and information in an accurate and timely manner. · Ensure timely access by Members to the records and information that pertain to them. · Abide by all Federal and State Laws regarding confidentiality and disclosure of medical
records or other health and enrollment information. · Medical Records are protected from unauthorized access. · Access to computerized confidential information is restricted. · Precautions are taken to prevent inadvertent or unnecessary disclosure of protected health
information. · Education and training for all staff on handling and maintaining protected health care
information.
Additional information on medical records is available from your local Molina Quality department toll free at (855) 237-6178. See also the Compliance Section of this Provider Manual for additional information regarding HIPAA.
If you have any questions regarding this information, please contact the Molina's QI Department. For additional information regarding HIPAA, please see the Compliance section of this Provider Manual.
Monitoring Access Standards
Access to care standards are reviewed, revised as necessary, and approved by the Quality Improvement Committee on an annual basis.
Provider network adherence to access standards is monitored via the following mechanisms:
1. Provider access studies provider office assessment of appointment availability, and after hours access.
2. Member complaint data assessment of member complaints related to access to care. 3. Member satisfaction survey evaluation of members' self-reported satisfaction with
appointment and after-hours access.
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Analysis of access data includes assessment of performance against established standards, review of trends over time, and identification of barriers. Results of analysis are reported to the Quality Improvement Committee at least annually for review and determination of opportunities for improvement. Corrective actions are initiated when performance goals are not met and for identified provider-specific or organizational trends. Performance goals are reviewed and approved annually by the Quality Improvement Committee.
Quality of Provider Office Sites
Molina Providers are to maintain office-site and medical record keeping practices standards. Molina continually monitors Member complaints and appeals/grievances for all office sites to determine the need of an office site visit and will conduct office site visits as needed. Molina assesses the quality, safety and accessibility of office sites where care is delivered against standards and thresholds. A standard survey form is completed at the time of each visit. This includes an assessment of:
· Physical Accessibility · Physical Appearance · Adequacy of Waiting and Examining Room Space
Physical Accessibility
Molina evaluates office sites as applicable, to ensure that members have safe and appropriate access to the office site. This includes, but is not limited to, ease of entry into the building, accessibility of space within the office site, and ease of access for patients with physical disabilities.
Physical Appearance
The site visits include, but are not limited to, an evaluation of office site cleanliness, appropriateness of lighting, and patient safety as needed.
Adequacy of Waiting and Examining Room Space
During the site visit as required, Molina assesses waiting and examining room spaces to ensure that the office offers appropriate accommodations to members. The evaluation includes, but is not limited to, appropriate seating in the waiting room areas and availability of exam tables in exam rooms.
Advance Directives (Patient Self-Determination Act)
Advance Directives
Practitioners/providers must inform adult Molina members (18 years old and up) of their right to make health care decisions and execute advance directives. It is important that members are informed about advance directives. During routine Medical Record review, Molina auditors will look for document edevidence of discussion between the practitioner/provider and the member. Molina will notify the provider of an individual member's advance directives identified through care management, care coordination or care management. Providers are instructed to document the
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presence of an advance directive in a prominent location of the Medical Record. Auditors will also look for copies of the advance directive form. Advance directives forms are state specific to meet state regulations.
Each Molina practitioner/provider must honor advance directives to the fullest extent permitted under law. Members may select a new PCP if the assigned provider has an objection to the beneficiary's desired decision. Molina will facilitate finding a new PCP or specialist as needed.
PCPs must discuss advance directives with a member and provide appropriate medical advice if the member desires guidance or assistance. Molina's network practitioners and facilities are expected to communicate any objections they may have to a member directive prior to service whenever possible. In no event may any practitioner/provider refuse to treat a member or otherwise discriminate against a member because the member has completed an advance directive. Members have the right to file a grievance with Molina or the state survey and certification agency if the member is dissatisfied with Molina's handling of advance directives and/or if a practitioner/provider fails to comply with advance directives instructions.
Advance directives are a written choice for health care. There are three types of Advance Directives:
· Durable Power of Attorney for Health Care: allows an agent to be appointed to carry out health care decisions
· Living Will: allows choices about withholding or withdrawing life support and accepting or refusing nutrition and/or hydration
· Guardian Appointment: allows one to nominate someone to be appointed as Guardian if a court determines that a guardian is necessary
Advance directives completed prior to the establishment of the current combined form are still valid. Advance directives that were executed in another state, using another state's form are also valid.
When There Is No Advance Directive: The member's family and practitioner will work together to decide on the best care for the member based on information they may know about the member's end-of-life plans. Providers must inform adult Molina Members, eighteen (18) years old and up, of their right to make health care decisions and execute Advance Directives. It is important that Members are informed about Advance Directives.
New adult Members or their identified personal representative will receive educational information and instructions on how to access advance directives forms in their Member Handbook, Evidence of Coverage (EOC) and other Member communications such as newsletters and the Molina website. If a Member is incapacitated at the time of enrollment, Molina will provide advance directive information to the Member's family or representative, and will follow up with information to the Member at the appropriate time. All current Members will receive annual notice explaining this information, in addition to newsletter information.
Members who would like more information are instructed to contact Member Services or are directed to the CaringInfo website at http://www.caringinfo.org/stateaddownload for forms available to download. Additionally, the Molina website offers information to both Providers and Members regarding advance directives, with a link to forms that can be downloaded and printed.
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PCPs must discuss Advance Directives with a Member and provide appropriate medical advice if the Member desires guidance or assistance.
Molina network Providers and facilities are expected to communicate any objections they may have to a Member directive prior to service when possible. Members may select a new PCP if the assigned Provider has an objection to the Member's desired decision. Molina will facilitate finding a new PCP or specialist as needed.
In no event may any Provider refuse to treat a Member or otherwise discriminate against a Member because the Member has completed an Advance Directive. CMS Law gives Members the right to file a complaint with Molina or the State survey and certification agency if the Member is dissatisfied with Molina's handling of Advance Directives and/or if a Provider fails to comply with Advance Directives instructions.
Molina will notify the Provider of an individual Member's Advance Directives identified through Care Management, Care Coordination or Case Management. Providers are instructed to document the presence of an Advance Directive in a prominent location of the Medical Record. Auditors will also look for copies of the Advance Directive form. Advance Directives forms are State specific to meet State regulations. Molina will look for documented evidence of the discussion between the Provider and the Member during routine Medical Record reviews.
EPSDT Services to Members From Birth To Age Twenty-One (21) Years
Molina maintains monitoring mechanisms to ensure all required EPSDT services to Members from birth to age 21 years of age are timely according to required guidelines. All Members from birth to age 21 years of age should receive screening examinations including appropriate childhood immunizations at intervals as specified by the EPSDT Program as set forth in §§1902(a)(43)and 1905(a)(4)(B) of the Social Security Act and 89 Ill. Adm. Code 140.485. Children under three years of age, who are screened at-risk for, or with developmental delay, must be referred to SCDHHS's Early Intervention Program for further assessment. Molina's QI or Provider Services department is also available to perform provider training to ensure that best practice guidelines are followed in relation to Well-Child services and care for acute and chronic health care needs.
Services to Members Under Twenty-One (21) Years of Age
Molina maintains systematic and robust monitoring mechanisms to ensure all required Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services to Enrollees under twentyone (21) years of age are timely according to required preventive guidelines. All Enrollees under twenty-one (21) years of age should receive preventive, diagnostic and treatment services at intervals as set forth in Section 1905(R) of the Social Security Act. Molina's Quality or the Provider Services department is also available to perform Provider training to ensure that best practice guidelines are followed in relation to well child services and care for acute and chronic health care needs.
Well-Child / Adolescent Visits
Visits consist of age-appropriate components, that include but are not limited to:
· Comprehensive health history
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· Nutritional assessment · Height and weight and growth charting · Comprehensive unclothed physical examination · Appropriate immunizations according to the Advisory Committee on Immunization Practices. · Laboratory procedures, including lead toxicity testing · Periodic developmental and behavioral screening using a recognized, standardized
developmental screening tool, as approved by SCDHHS. · Objective vision and hearing screening · Risk assessment · Health education, including anticipatory guidance such as child development, healthy
lifestyles, accident and disease prevention. · Periodic objective screening for social, emotional, development using a recognized,
standardized tool, as approved by SCDHHS. · Perinatal depression for mothers of infants in the most appropriate clinical setting, e.g., at
the pediatric, behavioral health or OB/GYN visit.
Any condition discovered during the screening examination or screening test requiring further diagnostic study or treatment must be provided if within the member's Covered Benefit Services. Members will be referred to an appropriate source of care for any required services that are not Covered Services. If, as a result of EPSDT services, it is determined that the member is in need of services that are not Covered Services but are services otherwise provided for under the SCDHHS Program, Molina will ensure that the member is referred to an appropriate source of care. Molina shall have no obligation to pay for services that are not Covered Services.
Quality Improvement Activities and Programs
Molina maintains an active Quality Improvement Program (QIP). The QIP provides structure and key processes to carry out our ongoing commitment to improvement of care and service. The goals identified are based on an evaluation of programs and services; regulatory, contractual and accreditation requirements; and strategic planning initiatives.
Clinical Practice Guidelines and Preventive Health Guidelines
1. Molina adopts and disseminates Clinical Practice Guidelines (CPGs) to Providers. All guidelines are based on scientific evidence, review of medical literature and/or appropriately established authority. CPGs are reviewed on an annual basis and are updated as new recommendations are published.
Molina's Clinical Practice Guidelines (CPG) are as follows:
· Acute Stress and Post Traumatic Stress Disorder (PTSD) · Anxiety/Panic Disorder · Asthma · Attention-Defcit/Hyperactivity Disorder (ADHD) in Children and Adolescents
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· Bipolar Disorder · Chronic Kidney Disease · Chronic Obstructive Pulmonary Disease (COPD) · Depression · Detoxifcation and Substance Abuse Treatment · Diabetes · Heart Failure · Hypertension · Obesity · Opioid Management · Perinatal/Prenatal/Postnatal Care · Pregnancy Management · Sickle Cell Disease
The guidelines are disseminated through Provider newsletters, electronic Provider Bulletins and other media and are available on the Molina website. Individual Providers or Members may request copies from the local Molina Quality department.
2. Preventive Health Guidelines (PHG) - Molina provides coverage of diagnostic preventive procedures based on recommendations published by the U.S. Preventive Services Task Force (USPSTF), Bright Futures/American Academy of Pediatrics and Centers for Disease Control and Prevention (CDC), in accordance with Centers for Medicare & Medicaid Services (CMS) guidelines. Diagnostic preventive procedures include, but are not limited to:
· Adult · Children and Adolescents · Immunization Schedules · Children and Adolescents Adult
Molina reviews and revises Preventive Health Guidelines (PHGs) on an annual basis. Individual providers may request copies of the guidelines by calling the Provider Services Department toll free at (855) 237-6178 or by visiting the Molina website: https://www.molinahealthcare.com/ Providers/SC/Medicaid/Resource/Pages/Clinical.aspx. Notification of the availability of the Preventive Health Guidelines is published in the Molina Provider Newsletter.
Cultural Competency Plan
Background
The Cultural Competency Plan exists to ensure the delivery of culturally competent services and ensure the provision of Linguistic Access and Disability-related Access to all members including those with limited English proficiency (LEP). The plan is based on guidelines outlined in National Standards for Culturally and Linguistically Appropriate Services (CLAS) in HealthCare, published
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by the US Department of Health and Human Services (HHS), Office of Minority Health (OMH). The Cultural Competency Plan describes how the individuals and systems within the Organization will effectively provide services to people of all cultures, races, ethnic backgrounds, genders, gender identities, sexual orientations, ages and religions as well as those with disabilities in a manner that recognizes values, affirms and respects the worth of the individuals and protects and preserves the dignity of each.
Training of employees and providers, and quality monitoring are the cornerstones of successful culturally competent service delivery. For that reason, the Cultural Competency Program is integrated into the overall provider training and quality monitoring programs. An integrated quality approach is aimed at enhancing the way people think about our members, service delivery and program development so that cultural competency becomes a part of everyday thinking.
Integrated Quality Improvement Ensuring Access
Molina ensures member access to language services such as oral interpreting, written translation and access to programs and services that are congruent with cultural norms and provide quality care.
Molina provides oral interpreting of written information to any plan member who speaks any nonEnglish language regardless of whether that language meets the threshold of a prevalent nonEnglish language. Molina notifies plan members of the availability of or a linterpreting services and informs them of how to access or a linterpreting services. Members are in formed that there is no charge for interpreting and translation services.
Members may also request written member materials in alternate languages and formats, which are provided within fourteen (14) business days. Such congruency with member populations leads to better communication, understanding and member satisfaction. Key member information, including appeals and grievance forms, are also available in threshold languages on the Molina Healthcare member website.
Program and Policy Review Guidelines
Molina conducts assessments at regular intervals of the following information in order to ensure its programs are most effectively meeting the needs of its members and providers:
· Annual review of membership demographics (preferred language, ethnicity, race) · Local geographic population demographics and trends derived from publicly available
sources (Group Needs Assessment) · Network Assessment · Applicable national demographics and trends derived from publicly available sources · Health status measures such as those measured by HEDIS® as available comparison with
selected measures such as those in Healthy People 2020
Cultural Competency and Linguistic Services
Molina works to ensure all members receive culturally competent care across the service continuum to reduce health disparities and improve health out comes. The Culturally and Linguistically
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Appropriate Services in HealthCare (CLAS) standards published by the US Department of Health and Human Services (HHS), Office of Minority Health (OMH) guide the activities to deliver culturally competent services. Molina complies with Title VI of the Civil Rights Act, the Americans with Disabilities Act (ADA) Section 504 of the Rehabilitation Act of 1973, Section 1557 of the Affordable Care Act (ACA) and other regulatory/contract requirements. Compliance ensures the provision of linguistic access and disability-related access to all members, including those with Limited English Proficiency and members who are deaf, hard of hearing or have speech or cognitive/intellectual impairments. Policies and procedures address how individuals and systems within the organization will effectively provide services to people of all cultures, races, ethnic backgrounds, gender, gender identity, sexual orientation, age and religions as well as those with disabilities in a manner that recognizes values, affirms and respects the worth of the individuals and protects and preserves the dignity of each.
Additional information on cultural competency and linguistic services is available at MolinaHealthcare.com, from your local Provider Services Representative and by calling Molina Provider Services at (855)-237-6178.
Nondiscrimination of Healthcare Service Delivery
Molina complies with the guidance set forth in the final rule for Section 1557 of the Affordable Care Act (ACA), which includes notification of non discrimination and instructions for accessing language services in all significant member materials, physical locations that serve our members, and all Molina website home pages. All providers who join the Molina provider Network must also comply with the provisions and guidance set forth by the Department of Health and Human Services (HHS) and the Office for Civil Rights (OCR). Molina requires providers to deliver services to Molina members without regard to race, ethnicity, national origin, religion, gender, age, mental or physical disability, sexual orientation, genetic information, or source of payment. Providers must post a non-discrimination notification in a conspicuous location in their office along with translated non-English tag lines in the top 15 languages spoken in the state to ensure Molina members understand their rights, how to access language services, and the process to file a complaint if they believe discrimination has occurred.
Additionally, participating providers or contracted medical groups/Independent Physician Associations (IPAs) may not limit their practices because of a member's medical (physical or mental) condition or the expectation for the need of frequent or high cost-care.
Providers can refer Molina members who are complaining of discrimination to the Molina Civil Rights Coordinator at: (866) 606-3889, or TTY 711.
Members can also email the complaint to civil.rights@molinahealthcare.com.
Members can mail their complaint to Molina at:
Civil Rights Coordinator 200 Oceangate Long Beach, CA 90802
Members can also file a civil rights complaint with the U.S. Department of Health and Human Services, OCR. Complaint forms are available at https://www.hhs.gov/ocr/complaints/index.html. The form can be mailed to U.S. Department of Health and Human Services at:
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200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201
Members can also send it to a website through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf.
If you or a Molina Member needs help, call (800) 368-1019; TTY (800) 537-7697.
Should you or a Molina member need more information you can refer to the Health and Human Services website for more information: https://www.federalregister.gov/ documents/2020/06/19/2020-11758/nondiscrimination-in-health-and-health-educationprograms-or-activities-delegation-of-authority.
Cultural Competency
Molina is committed to reducing healthcare disparities. Training employees, providers and their staff, and quality monitoring are the cornerstones of successful culturally competent service delivery. Molina integrates cultural competency training into the overall provider training and quality-monitoring programs. An integrated quality approach enhances the way people think about our members, service delivery and program development so that cultural competency becomes a part of everyday thinking.
Provider and Community Training
Molina offers educational opportunities in cultural competency concepts for providers, their staff, and Community Based Organizations. Molina conducts provider training during provider orientation with annual reinforcement training offered through Provider Services and/or online/ web-based training modules.
Training modules, delivered through a variety of methods, include:
1. Provider written communications and resource materials; 2. On-site cultural competency training; 3. Online cultural competency provider training modules; and 4. Integration of cultural competency concepts and nondiscrimination of service delivery into
provider communications.
Integrated Quality Improvement Ensuring Access
Molina ensures Member access to language services such as oral interpretation, American Sign Language (ASL) and, written translation. and Molina must also ensure access to programs, aids, and services that are congruent with cultural norms. Molina supports Members with disabilities, and assists Members with LEP.
Molina develops member materials according to Plain Language Guidelines. Members or providers may also request written member materials in alternate languages and formats (i.e. braille, audio, large print), leading to better communication, understanding and member satisfaction. Online materials found on MolinaHealthcare.com and information delivered in digital form meet Section 508 accessibility requirements to support members with visual impairments.
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Key member information, including Appeals and Grievance forms, are also available in threshold languages on the Molina member website.
Program and Policy Review Guidelines
Molina conducts assessments at regular intervals of the following information to ensure its programs are most effectively meeting the needs of its members and providers:
· Annual collection and analysis of race, ethnicity and language data from: o Eligible individuals to identify significant culturally and linguistically diverse populations within a plan's membership o Revalidate data at least annually o Contracted providers to assess gaps in network demographics
· Local geographic population demographics and trends derived from publicly available sources (Community Health Measures and State Rankings Report)
· Applicable national demographics and trends derived from publicly available sources · Assessment of Provider Network
o Collection of data and reporting for the Diversity of Membership HEDIS® measure · Determination of threshold languages annually and processes in place to provide members
with vital information in threshold languages o Identification of specific cultural and linguistic disparities found within the plan's diverse populations o Analysis of HEDIS® and CAHPS®/Qualified Health Plan Enrollee Experience survey results for potential cultural and linguistic disparities that prevent members from obtaining the recommended key chronic and preventive services
Access to Interpreter Services
Molina providers must support member access to telephonic interpreter services by offering a telephone with speaker capability or a telephone with a dual headset. Providers may offer Molina members interpreter services if the members do not request them on their own. Please remember it is never permissible to ask a family member, friend or minor to interpret.
Molina offers qualified face-to-face interpreter services to providers and members at medical appointments based on complex medical cases such as medical or surgical procedures or tests, end-of-life care, cancer/oncology care, organ transplants, behavioral health/psychiatric appointments, physical, occupational and speech therapies, DME/orthotic/prosthetic appointments, hearing and vision loss, complex specialty care, and others as directed by a medical director. Providers and members may call our Member and Provider Contact Center to submit a request.
Documentation
As a contracted Molina provider, your responsibilities for documenting member language services/needs in the member's medical record are as follows:
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· Record the member's language preference in a prominent location in the medical record. This information is provided to you on the electronic member lists that are sent to you each month by Molina.
· Document all member requests for interpreter services. · Document who provided the interpreter service. This includes the name of Molina's internal
staff or someone from a commercial interpreter service vendor. Information should include the interpreter's name, operator code and vendor. · Document all counseling and treatment done using interpreter services. · Document if a member insists on using a family member, friend or minor as an interpreter, or refuses the use of interpreter services after being notified of his or her right to have a qualified interpreter at no cost.
Members with Hearing Impairment
Molina provides a TTY/TDD connection, which may be reached by dialing 711.This connection provides access to Member & Provider Contact Center, Quality Improvement, Healthcare Services and all other health plan functions.
Molina strongly recommends that provider offices make assistive listening devices available for members who are deaf and hard of hearing. Assistive listening devices enhance the sound of the provider's voice to facilitate a better interaction with the member.
Molina will provide face-to-face service delivery for ASL to support our members who have a hearing impairment. Requests should be made three business days in advance of an appointment to ensure availability of the service. In most cases, members will have made this request via Molina Member Services.
Nurse Advice Line
Molina provides nurse advice services for members 24 hours per day, seven days per week. The Nurse Advice Line provides access to 24 hour interpretive services. Members may call Molina's Nurse Advice Line directly (English line (888) 275-8750) or (Spanish line at (866) 648-3537) or for assistance in other languages. The Nurse Advice TTY/TDD is 711. The Nurse Advice Line telephone numbers are also printed on membership cards.
Measurement of Clinical and Service Quality
Molina monitors and evaluates the quality of care and services provided to members through the following mechanisms:
· Healthcare Effectiveness Data and Information Set (HEDIS®) · Consumer Assessment of Healthcare Providers and Systems (CAHPS®) · Provider Satisfaction Survey · Effectiveness of Quality Improvement Initiatives · Behavioral Health Survey
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Molina's most recent results can be obtained from the Molina QI department or by visiting our website at MolinaHealthcare.com. Contracted providers and facilities must allow Molina to use its performance data collected in accordance with the provider's or facility's contract. The use of performance data may include, but is not limited to, the following: (1) development of quality improvement activities; (2) public reporting to consumers; (3) preferred status designation in the network; (4) and/or reduced member cost sharing.
HEDIS®
Molina utilizes the NCQA HEDIS® as a measurement tool to provide a fair and accurate assessment of specific aspects of managed care organization performance. HEDIS® is an annual activity conducted in the spring. The data comes from on-site medical record review and available administrative data. All reported measures must follow rigorous specifications and are externally audited to assure continuity and comparability of results. The HEDIS® measurement set currently includes a variety of health care aspects including immunizations, women's health screening, diabetes care, well check-ups, medication use, and cardio vascular disease. HEDIS® results are used in a variety of ways. The results are the measurement standard form any of Molina's clinical quality improvement activities and health improvement programs. The standards are based on established clinical guidelines and protocols, providing a firm foundation to measure the success of these programs.
Selected HEDIS® results are provided to regulatory and accreditation agencies as part of our contracts with these agencies. The data are also used to compare to established health plan performance benchmarks.
CAHPS®
CAHPS® is the tool used by Molina to summarize member satisfaction with the providers, health care and service they receive. CAHPS® examines specific measures, including: getting needed care, getting care quickly, how well doctors communicate, coordination of care, customer service, rating of healthcare and getting needed prescription drugs. The CAHPS® survey is administered annually in the spring to randomly selected members by a NCQA certified vendor.
CAHPS® results are used in much the same way as HEDIS® results, only the focus is on the service aspect of care rather than clinical activities. They form the basis for several of Molina's quality improvement activities and are used by external agencies to help ascertain the quality of services being delivered.
Provider Satisfaction Survey
Recognizing that HEDIS® and CAHPS® both focus on member experience with health care practitioners/providers and health plans, Molina conducts a Provider Satisfaction Survey annually. The results from this survey are very important to Molina, as this is one of the primary methods we use to identify improvement areas pertaining to the Molina Provider Network. The survey results have helped establish improvement activities relating to Molina's specialty network, interprovider communications, and pharmacy authorizations. This survey is fielded to a random sample of practitioners/providers each year. If your office is selected to participate, please take a few minutes to complete and return the survey.
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Effectiveness of Quality Improvement Initiatives Molina monitors the effectiveness of clinical and service activities through metrics selected to demonstrate clinical out comes and service levels. The plan's performance is compared to that of available national benchmarks indicating "best practices". The evaluation includes an assessment of clinical and service improvements on an ongoing basis. Results of these measurements guide activities for the successive periods. In addition to the methods described above, Molina also compiles complaint and appeals data as well as requests for out-of-network services to determine opportunities for service improvements. Provider Profiling Program Molina has developed a mechanism that evaluates and analyzes provider performance based on meeting specific performance measures. Such measures include, but are not limited to, Withhold and HEDIS measures, medical record documentation, generic prescription rates and formulary compliance, and inpatient/emergency room utilization. Providers who meet these quality and utilization management thresholds are referred by Molina to the Preferred Provider Program. This program provides a designation to the provider and makes them eligible for increased member assignment, reduction and simplification of the prior authorization process based on their quality recognition and ability to effectively manage care. All participating providers are eligible for the Preferred Provider Program when criteria is met. Molina will inform providers when they have been accepted into the program after reviewing and approving performance metrics and program eligibility requirements. Providers approved for the Preferred Provider Program are subject to bi-annual analysis of quality and utilization management performance metrics to establish continued eligibility and participation in the program. Molina makes the final recommendation for a provider's ongoing program participation.
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Section 10. Risk Adjustment Management Program
What is Risk Adjustment?
The Centers for Medicare & Medicaid Services (CMS) defines Risk Adjustment as a process that helps accurately measure the health status of a plan's membership based on medical conditions and demographic information.
This process helps ensure health plans receive accurate payment for services provided to Molina members and prepares for resources that may be needed in the future to treat members who have multiple clinical conditions.
Why is Risk Adjustment Important?
Molina relies on our Provider Network to take care of our members based on their health care needs. Risk Adjustment looks at a number of clinical data elements of a member's health profile to determine any documentation gaps from past visits and identifies opportunities for gap closure for future visits. In addition, Risk Adjustment allows us to:
· Focus on quality and efficiency. · Recognize and address current and potential health conditions early. · Indentify members for Care Management referral. · Ensure adequate resources for the acuity levels of Molina members. · Have the resources to deliver the highest quality of care to Molina members.
Your Role as a Provider
As a provider your complete and accurate documentation in a member's medical record and submitted claims are critical to a member's quality of care. We encourage providers to code all diagnoses to the highest specificity as this will ensure Molina receives adequate resources to provide quality programs to you and our members.
For a complete and accurate medical record, all provider documentation must:
· Address clinical data elements provided by Molina and reviewed with the member. · Be compliant with CMS correct coding initiative. · Use the correct ICD-10 code by coding the condition to the highest level of specificity. · Only use diagnosis codes confirmed during a visit with the member. · Contain a treatment plan and progress notes. · Contain the member's name and date of service. · Have the provider's signature and credentials.
RADV Audits
As part of the regulatory process, State and/or Federal agencies may conduct Risk Adjustment Data Validation (RADV) audits to ensure the diagnosis data submitted by Molina is appropriate
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and accurate. All claims/encounters submitted to Molina are subject to State and/or Federal and internal health plan auditing. If Molina is selected for a RADV audit, providers will be required to submit medical records in a timely manner to validate the previously submitted data.
Contact Information
For questions about Molina's Risk Adjustment programs, please contact our team at: RiskAdjustment.Programs@MolinaHealthcare.com
Section 11. Claims and Compensation
Hospital-Acquired Conditions and Present on Admission Program
The Deficit Reduction Act of 2005 (DRA) mandated that Medicare establish a program that would modify reimbursement for fee for service beneficiaries when certain conditions occurred as a direct result of a hospital stay that could have reasonably been prevented by the use of evidenced-based guidelines. CMS titled the program "Hospital-Acquired Conditions and Present on Admission Indicator Reporting" (HAC and POA).
The following is a list of CMS Hospital Acquired Conditions. CMS reduces payment for hospitalizations complicated by these categories of conditions that were not present on admission (POA):
1. Foreign Object Retained After Surgery 2. Air Embolism 3. Blood Incompatibility 4. Stage III and IV Pressure Ulcers 5. Falls and Trauma
a. Fractures b. Dislocations c. Intracranial Injuries d. Crushing Injuries e. Burn f. Other Injuries 6. Manifestations of Poor Glycemic Control a. Hypoglycemic Coma b. Diabetic Ketoacidosis c. Non-Ketotic Hyperosmolar Coma d. Secondary Diabetes with Ketoacidosis e. Secondary Diabetes with Hyperosmolarity 7. Catheter-Associated Urinary Tract Infection (UTI) 8. Vascular Catheter-Associated Infection
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9. Surgical Site Infection Following Coronary Artery Bypass Graft Mediastinitis 10. Surgical Site Infection Following Certain Orthopedic Procedures:
a. Spine b. Neck c. Shoulder d. Elbow 11. Surgical Site Infection Following Bariatric Surgery Procedures for Obesity a. Laparoscopic Gastric Restrictive Surgery b. Laparoscopic Gastric Bypass c. Gastroenterostomy 12. Surgical Site Infection Following Placement of Cardiac Implantable Electronic Device (CIED) 13. Iatrogenic Pneumothorax with Venous Catheterization 14. Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Following Certain Orthopedic Procedures a. Total Knee Replacement b. Hip Replacement
What this means to Providers:
· Acute IPPS Hospital claims will be returned with no payment if the POA indicator is coded incorrectly or missing.
· No additional payment will be made on IPPS hospital claims for conditions that are acquired during the patient's hospitalization.
If you would like to find out more information regarding the Medicare HAC/POA program, including billing requirements, the following CMS site provides further information: http://www.cms.hhs.gov/HospitalAcqCond/.
Claim Submission
Molina Healthcare of South Carolina PO Box 22664 Long Beach, CA 90801
Providers billing Molina electronically should use current HIPAA compliant ANSI X12N format (e.g., 837I for institutional claims, 837P for professional claims, and 837D for dental claims) and use electronic payor ID number: 46299.
Providers must use good faith effort to bill Molina for services with the most current CMSapproved diagnostic and procedural coding available as of the date the service was provided, or for inpatient facility claims, the date of discharge. The following information must be included on every claim:
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· Institutional Providers: o The completed UB 04 data set or its successor format adopted by the National Uniform Billing Committee (NUBC), submitted on the designated paper or electronic format as adopted by the NUBC. Entries stated as mandatory by NUBC and required by federal statue and regulations and any state designated data requirements included in statues or regulation.
· Physicians and Other Professional Providers: o The Centers for Medicare and Medicaid Services (CMS) Form 1500 or its success or adopted by the National Uniform Claim Committee (NUCC) submitted on the designated paper or electronic format. Current Procedural Terminology (CPT) codes and modifiers and International Classification of Diseases (ICD) codes. Entries stated as mandatory by NUCC and required by federal statute and regulation and any state designated data requirements included in statutes or regulations. Participating Providers are required to submit Claims to Molina with appropriate documentation. Providers must follow the appropriate State and CMS Provider billing guidelines. Providers are encouraged to utilize electronic billing though a clearing house or Molina's Provider Portal, and use current HIPAA compliant ANSI X 12N format (e.g., 837I for institutional Claims, 837P for professional Claims, and 837D for dental Claims) and use electronic Payer ID number: 46299
Providers must bill Molina for services with the most current CMS approved diagnostic and procedural coding available as of the date the service was provided, or for inpatient facility Claims, the date of discharge.
Required Elements
The following information must be included on every claim:
· Member name, date of birth and Molina Member ID number · Member's gender · Member's address · Date(s) of service · Valid International Classification of Diseases diagnosis and procedure codes · Valid revenue, CPT or HCPCS for services or items provided · Valid Diagnosis Pointers · Total billed charges · Place and type of service code · Days or units as applicable · Provider tax identification number (TIN) · 10-digit National Provider Identifier (NPI) · Rendering Provider name as applicable
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· Billing/Pay-to Provider name and billing address · Place of service and type (for facilities) · Disclosure of any other health benefit plans · E-signature · Service Facility Location information · Inpatient facility claims require applicable condition, occurrence and value codes and
applicable dates Inaccurate, incomplete, or untimely submissions and re-submissions may result in denial of the claim.
National Provider Identifier (NPI) A valid NPI is required on all Claim submissions. Providers must report any changes in their NPI or subparts to Molina as soon as possible, not to exceed thirty (30) calendar days from the change.
Electronic Claim Submission Molina strongly encourages participating providers to submit Claims electronically, including secondary claims. Electronic Claims submission provides significant benefits to the provider including:
· Helps to reduce operation costs associated with paper claims (printing, postage, etc.) · Increases accuracy of data and efficient information delivery · Reduces Claim delays since errors can be corrected and resubmitted electronically · Eliminates mailing time and Claims reach Molina faster
Molina offers the following electronic Claims submission options: · Submit Claims directly to Molina via the Provider Portal · Submit Claims to Molina via your regular EDI clearinghouse using Payer ID 46299
Provider Portal: The Provider Portal is a no cost online platform that offers a number of Claims processing features:
· Submit Professional (CMS1500) and Institutional (UB04) Claims with attached files. · Correct/Void Claims. · Add attachments to previously submitted Claims. · Check Claims status. · Create and manage Claim Templates. · Create and submit a Claim Appeal with attached files.
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Clearinghouse:
Molina uses Change Healthcare as its gateway clearinghouse. Change Healthcare has relationships with hundreds of other clearing houses. Typically, providers can continue to submit Claims to their usual clearinghouse.
Molina accepts EDI transactions through our gateway clearinghouse for Claims via the 837P for Professional and 837I for institutional. In order to ensure that all data being submitted to our gateway is received properly your submitter must utilize the latest version of the 837 standard. It is important to track your electronic transmissions using your acknowledgment reports. The reports assure Claims are received for processing in a timely manner.
When your Claims are filed via a Clearinghouse
· You should receive a 999 acknowledgment from your clearinghouse. · You should also receive 227CA response file with initial status of the claims from your
clearinghouse. · You should contact your local clearinghouse representative if you experience any problems
with your transmission.
EDI Claims Submission Issues
Providers who are experiencing EDI Submission issues should work with their clearinghouse to resolve this issue. If the provider's clearinghouse is unable to resolve, the provider may call the Molina EDI Customer Service line at (866) 409-2935 or email us at EDI. Claims@MolinaHealthcare.com for additional support.
Paper Claim Submissions
If electronic submission is not possible, please submit paper claims to the following address:
Molina Healthcare of South Carolina PO Box 22664 Long Beach, CA 90801
Please keep the following in mind when submitting paper claims:
· Paper claims should be submitted on original red colored CMS 1500 claims forms · Paper claims must be printed, using black ink.
Timely Claim Filing
The Provider shall promptly submit to Molina claims for Covered Services rendered to members. All claims shall be submitted in a form acceptable to and approved by Molina, and shall include any and all medical records pertaining to the claim if requested by Molina or otherwise required by Molina's policies and procedures. Claims must be submitted by provider to Molina within twelve (12) months/365 days after the following have occurred: discharge for inpatient services or the date of service for out patient services; and provider has been furnished with the correct name and address of the member's health maintenance organization. If Molina is
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not the primary payer under coordination of benefits, provider must submit claims to Molina within twelve (12) months/365 days from date of service after final determination by the primary payer. Except as other wise provided by law or provided by government sponsored program requirements, any claims that are not submitted to Molina within these timelines shall not be eligible for payment, and provider hereby waives any right to payment.
Reimbursement Guidance and Payment Guidelines
Providers are responsible for submission of accurate claims. Molina requires coding of both diagnoses and procedures for all claims. The required coding schemes are the International Classification of Diseases, 10th Revision, Clinical Modification ICD-10-CM for diagnoses. For procedures, the Healthcare Common Procedure Coding System Level 1 (CPT codes), Level 2 and 3 (HCPCS codes) are required for professional and outpatient claims. Inpatient hospital claims require ICD-10-PCS (International Classification of Diseases, 10th Revision, Procedure Coding System). Further more, Molina requires that all claims be coded in accordance with the HIPAA transaction code set guidelines and follow the guidelines within each code set.
Molina utilizes a claims adjudication system that encompasses edits and audits that follow State and Federal requirements as well as administers payment rules based on generally accepted principles of correct coding. These rules include, but are not limited to, the following:
· Manuals and Relative Value Unit (RVU) files published by the Centers for Medicare & Medicaid Services (CMS), including: o National Correct Coding Initiative (NCCI) edits, including procedure-to-procedure (PTP) bundling edits and Medically Unlikely Edits (MUE). In the event a State benefit limit is more stringent/restrictive than a Federal MUE, Molina will apply the State benefit limit. Further more, if a professional organization has a more stringent/ restrictive standard than a Federal MUE or State benefit limit, the professional organization standard may be used. o In the absence of State guidance, Medicare National Coverage Determinations (NCD). o In the absence of State guidance, Medicare Local Coverage Determinations (LCD). o CMS Physician Fee Schedule RVU indicators.
· Current Procedural Technology (CPT) guidance published by the American Medical Association (AMA).
· ICD-10 guidance published by the National Center for Health Statistics. · State-specific claims reimbursement guidance. · Other coding guidelines published by industry-recognized resources. · Payment policies based on professional associations or other industry-recognized
guidance for specific services. Such payment policies may be more stringent than State and Federal guidelines. · Molina policies based on the appropriateness of health care and medical necessity. · Payment policies published by Molina.
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Telehealth Claims and Billing
Providers must follow CMS guidelines as well as State-level requirements.
All telehealth claims for Molina members must be submitted to Molina with correct codes for the plan type. Use the telehealth Place of Service (POS) Code 02, which certifies that the service meets the telehealth requirements. By coding and billing a place of service 02 with a covered telehealth procedure code, the provider is certifying the member was present at an eligible originating site when the telehealth services were performed. Modifier GQ is required when applicable. Qualifying telehealth units of service for an originating site must be billed with Q3014 for reimbursement of facility fee.
General Coding Requirements
Correct coding is required to properly process claims. Molina requires that all claims be coded in accordance with the HIPAA transaction code set guidelines and follow the guidelines within each code set.
CPT and HCPCS Codes
Codes must be submitted in accordance with the chapter and code-specific guidelines set forth in the current/applicable version of the AMA CPT and HCPCS codebooks. In order to ensure proper and timely reimbursement, codes must be effective on the date of service (DOS) for which the procedure or service was rendered and not the date of submission.
Modifiers
Modifiers consist of two alphanumeric characters and are appended to HCPCS/CPT codes to provide additional information about the services rendered. Modifiers may be appended only if the clinical circumstances justify the use of the modifier(s). For example, modifiers may be used to indicate whether a:
· Service or procedure has a professional component · Service or procedure has a technical component · Service or procedure was performed by more than one physician · Unilateral procedure was performed · Bilateral procedure was performed · Service or procedure was provided more than once · Only part of a service was performed
For a complete listing of modifiers and their appropriate use, consult the AMA CPT and the HCPCS code books.
ICD-10-CM/PCS codes
Effective 10/01/2015, Molina utilizes International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) and International Classification of Diseases 10th Revision, Procedure Coding System (ICD-10-PCS) billing rules and will deny claims that do not meet
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Molina's ICD-10 Claim Submission Guidelines. To ensure proper and timely reimbursement, codes must be effective on the dates of service (DOS) for which the procedure or service was rendered and not the date of submission. Refer to the ICD-10 CM/PCS Official Guidelines for Coding and Reporting on the proper assignment of principal and additional diagnosis codes.
Place of Service (POS) Codes
Place of Service Codes (POS) are two-digit codes placed on health care professional claims (CMS 1500) to indicate the setting in which a service was provided. CMS maintains POS codes used throughout the health care industry. The POS should be indicative of where that specific procedure/service was rendered. If billing multiple lines, each line should indicate the POS for the procedure/service on that line.
Type of Bill
Type of bill is a four-digit alphanumeric code that gives three specific pieces of information after the first digit, a leading zero. The second digit identifies the type of facility. The third classifies the type of care. The fourth indicates the sequence of this bill in this particular episode of care, also referred to as a "frequency" code. For a complete list of codes, reference the National Uniform Billing Committee's (NUBC's) Official UB-04 Data Specifications Manual.
Revenue Codes
Revenue codes are four-digit codes used to identify specific accommodation and/or ancillary charges. There are certain revenue codes that require CPT/HCPCS codes to be billed. For a complete list of codes, reference the NUBC's Official UB-04 Data Specifications Manual.
Diagnosis Related Group (DRG)
Facilities contracted to use DRG payment methodology submit claims with DRG coding. Claims submitted for payment by DRG must contain the minimum requirements to ensure accurate claim payment.
Molina processes DRG claims through DRG software. If the submitted DRG and systemassigned DRG differ, the Molina-assigned DRG will take precedence. Providers may appeal with medical record documentation to support the ICD-10-CM principal and secondary diagnoses (if applicable) and/or the ICD-10-PCS procedure codes (if applicable). If the claim cannot be grouped due to insufficient information, it will be denied and returned for lack of sufficient information.
National Drug Code (NDC)
The 11-digit National Drug Code number (NDC) must be reported on all professional and outpatient claims when submitted on the CMS-1500 Claim form, UB-04 or its electronic equivalent.
Providers will need to submit claims with both HCPCS and NDC codes with the exact NDC that appears on the medication packaging in the 5-4-2 digit format (i.e., xxxxx-xxxx-xx) as well as the NDC units and descriptors. Claims submitted without the NDC number will be denied.
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Coding Sources
Definitions
CPT Current Procedural Terminology 4th Edition; an American Medical Association (AMA) maintained uniform coding system consisting of descriptive terms and codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals. There are three types of CPT codes:
· Category I Code Procedures/Services · Category II Code Performance Measurement · Category III Code Emerging Technology
HCPCS HealthCare Common Procedural Coding System; a CMS maintained uniform coding system consisting of descriptive terms and codes that are used primarily to identify procedure, supply and durable medical equipment codes furnished by physicians and other health care professionals.
ICD-10-CM International Classification of Diseases, 10th revision, Clinical Modification ICD10-CM diagnosis codes are maintained by the National Center for Health Statistics, Centers for Disease Control (CDC) within the Department of Health and Human Services (HHS).
ICD-10-PCS International Classification of Diseases, 10th revision, Procedure Coding System used to report procedures for inpatient hospital services.
Fraud and Abuse
Failure to report instances of suspected Fraud and Abuse is a violation of the law and subject to the penalties provided by law. Please refer to the Fraud and Abuse section of this manual for more information.
Timely Claim Processing
Claims processing will be completed for contracted Providers in accordance with the timeliness provisions set forth in the Provider's contract. Unless the Provider and Molina or contracted medical group/IPA have agreed in writing to an alternate schedule, Molina will process the claim for service within 30 calendar days after receipt of Clean Claims.
The receipt date of a claim is the date Molina receives either written or electronic notice of the claim.
Claim Review
Claims will be reviewed and paid in accordance with industry standard billing and payment rules, including, but not limited to, current Uniform Billing ("UB") manual and editor,Current Procedural Terminology ("CPT") and Healthcare Common Procedure Coding System ("HCPCS"), Federal, and State billing and payment rules, National Correct Coding Initiative ("NCCI") Edits, and Federal Drug Administration ("FDA") definitions and determinations of designated implantable devices and/or implantable orthopedic devices.
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Furthermore, Provider acknowledges Molina's right to conduct Medical Necessity reviews and apply clinical practices to determine appropriate payment. Payment may exclude certain items not billed in accordance with industry standard billing and payment rules or certain items which do not meet certain Medical Necessity criteria.
Claim Auditing
Molina shall use established industry claims adjudication and/or clinical practices, State, and Federal guidelines, and/or Molina's policies and data to determine the appropriateness of the billing, coding and payment.
Provider acknowledges Molina's right to conduct pre and post-payment billing audits. Provider shall cooperate with Molina's Special Investigations Unit and audits of Claims and payments by providing access at reasonable times to requested Claims information, all supporting medical records, Provider's charging policies, and other related data as deemed relevant to support the transactions billed. Providers are required to submit, or provide access to, medical records upon Molina's request. Failure to do so in a timely manner may result in an audit failure and/or denial, resulting in an overpayment.
In reviewing medical records for a procedure, Molina may select a statistically valid random sample, or smaller subset of the statistically valid random sample. This sample gives an estimate of the proportion of claims Molina paid in error. The estimated proportion, or error rate, may be projected across all claims to determine the amount of overpayment.
Provider audits may be telephonic, an on-site visit, internal claims review, client-directed/ regulatory investigation and/or compliance reviews and may be vendor assisted. Molina asks that you provide us, or our designee, during normal business hours, access to examine, audit, scan and copy any and all records necessary to determine compliance and accuracy of billing.
If Molina's Special Investigations Unit suspects that there is fraudulent or abusive activity, we may conduct an on-site audit without notice. Should you refuse to allow access to your facilities, Molina reserves the right to recover the full amount paid or due to you.
Coordination of Benefits (COB) and Third Party Liability (TPL)
COB
Medicaid is the payer of last resort. Private and governmental carriers must be billed prior to billing Molina or medical groups/IPAs. Provider shall make reasonable inquiry of members to learn whether member has health insurance, benefits or Covered Services other than from Molina or is entitled to payment by a third party under any other insurance or plan of any type, and Provider shall immediately notify Molina of said entitlement. In the event that coordination of benefits occurs, provider shall be compensated based on the state regulatory COB methodology. Primary carrier payment information is required with the Claim submission. Providers can submit Claims with attachments, including explanation of benefits (EOBs) and other required documents, by utilizing the Provider Portal. Providers can also submit this information through EDI and paper submissions.
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TPL
Molina is the payer of last resort and will make every effort to determine the appropriate third party payer for services rendered. Molina may deny Claims when the third party has been established and will process Claims for Covered Services when probable Third Party Liability (TPL) has not been established or third party benefits are not available to pay a Claim. Molina will attempt to recover any third party resources available to members and shall maintain records pertaining to TPL collections on behalf of members for audit and review.
Reimbursement Guidance and Payment Guidelines
Providers are responsible for submission of accurate claims. Molina requires coding of both diagnoses and procedures for all claims. The required coding schemes are the International Classification of Diseases, 10th Revision, Clinical Modification ICD-10-CM for diagnoses. For procedures, the Healthcare Common Procedure Coding System Level 1 (CPT codes), Level 2 and 3 (HCPCS codes) are required for professional and outpatient claims. Inpatient hospital claims require ICD-10-PCS (International Classification of Diseases, 10th Revision, Procedure Coding System). Further more, Molina requires that all claims be coded in accordance with the HIPAA transaction code set guidelines and follow the guidelines within each code set.
Molina utilizes a claims adjudication system that encompasses edits and audits that follow State and Federal requirements and also administers payment rules based on generally accepted principles of correct coding. Payment rules based on generally accepted principles of correct coding include, but are not limited to, the following:
· Manuals and RVU files published by the Centers for Medicare and Medicaid Services (CMS), including:
o National Correct Coding Initiative (NCCI) edits, including procedure-to-procedure (PTP) bundling edits and Medically Unlikely Edits (MUEs). In the event a State benefit limit is more stringent/restrictive than a Federal MUE, Molina will apply the State benefit limit. Further more, if a professional organization has a more stringent/ restrictive standard than a Federal MUE or State benefit limit the professional organization standard may be used.
o In the absence of State guidance, Medicare National Coverage Determinations (NCDs).
o In the absence of State guidance, Medicare Local Coverage Determinations (LCDs). o CMS Physician Fee Schedule Relative Value File (RVU) indicators. o Current Procedural Technology (CPT) guidance published by the American Medical
Association (AMA). o ICD-10 guidance published by the National Center for Health Statistics. o State-specific claims reimbursement guidance. o Other coding guidelines published by industry-recognized resources. o Payment policies based on professional associations or other industry-recognized
guidance for specific services. Such payment policies may be more stringent than State and Federal guidelines.
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o Molina policies based on the appropriateness of health care and medical necessity. o Payment policies published by Molina.
Claim Disputes/Reconsiderations
Claim Disputes/Reconsiderations Providers disputing a Claim previously adjudicated must request such action within 90 calendar days of Molina's original remittance advice date. Regardless of type of denial/dispute (service denied, incorrect payment, administrative, etc.); all Claim disputes must be submitted on the Molina Claims Request for Reconsideration (CRRF) found on Provider website and the Provider Portal. The form must be filled out completely in order to be processed. Additionally, the item(s) being resubmitted should be clearly marked as reconsideration and must include the following documentation:
· Any documentation to support the adjustment and a copy of the Authorization form (if applicable) must accompany there consideration request.
· The Claim number clearly marked on all supporting documents.
Forms may be submitted via fax or mail. Claims Disputes/Reconsideration requested via the CRRF may be sent to the following address:
Molina Healthcare of South Carolina, Inc. Attention: Claims Disputes / Adjustments
PO Box 40309 North Charleston, SC 29423-0309
Submitted via fax: (877) 901-8182
Please Note: Requests for adjustments of claims paid by a delegated medical group/IPA must be submitted to the group responsible for payment of the original claim.
The provider will be notified of Molina's decision in writing within 30 business days of receipt of the Claims Dispute/Adjustment request.
Corrected Claims
Corrected claims are considered new claims for processing purposes. Corrected claims may be submitted electronically with the appropriate field on the 837I or 837P completed. Paper corrected claims need to be marked as corrected and should be submitted to the following address:
Molina Healthcare of South Carolina PO Box 22664
Long Beach, CA 90801
The Provider Portal includes functionality to submit corrected Institutional and Professional claims. Corrected claims must include the correct coding to denote if the claim is Replacement of Prior Claim or Corrected Claim for an 837I or the correct Resubmission Code for an 837P. Claims submitted without the correct coding will be returned to the provider for resubmission.
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EDI (Clearinghouse) Submission:
837P
· In the 2300 Loop, the CLM segment (claim information) CLM05-3 (claim frequency type code) must indicate one of the following qualifier codes: o "1" - ORIGINAL (initial claim) o "7" - REPLACEMENT(replacement of prior claim) o "8" - VOID (void/cancel of prior claim)
· In the 2300 Loop, the REF *F8 segment (claim information) must include the original reference number (Internal Control Number/Document Control Number ICN/DCN).
837I
· Bill type for UB claims are billed in loop 2300/CLM05-1. In Bill Type for UB, the "1""7"or"8" goes in the third digit for "frequency".
· In the 2300 Loop, the REF *F8 segment (claim information) must include the original reference number (Internal Control Number/Document Control Number ICN/DCN).
Over payments and Incorrect Payments Refund Requests
If, as a result of retroactive review of coverage decisions or payment levels, Molina determines that it has made an overpayment to a provider for services rendered to a member, it will make a claim for such overpayment. Molina will not reduce payment to that provider for other services unless the provider agrees to the reduction or fails to respond to Molina's claim as required in this subsection.
A provider shall pay a claim for an overpayment made by Molina which the provider does not contest or deny within the specified number of days on the refund request letter mailed to the provider.
All correspondence, including disputes/appeals regarding recoveries should be sent to:
Molina Healthcare of South Carolina PO Box 2470
Spokane, WA 99210-2470
If a provider does not repay or dispute the over paid amount within the time frame allowed Molina may offset the over payment amount(s) against future payments made to the provider.
Payment of a claim for over payment is considered made on the date payment was received or electronically transferred or otherwise delivered to the organization, or the date that the provider receives a payment from the organization that reduces or deducts the overpayment.
Balance Billing
The provider is responsible for verifying eligibility and obtaining approval for those services that require prior authorization.
Providers agree that under no circumstance shall a member be liable to the provider for any sums that are the legal obligation of Molina to the provider. Balance billing a Molina member for covered
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services is prohibited, other than for the member's applicable copayment, coinsurance and deductible amounts. Members who are dually eligible for Medicare and Medicaid shall not be held liable for Medicare Part A and B cost sharing when the State or another payer such as a Medicaid Managed Care Plan is responsible for paying such amounts. Encounter Data Each capitated provider/organization delegated for claims payment is required to submit encounter data to Molina for all adjudicated claims. The data is used for many purposes, such as reporting to HFS, rate setting and risk adjustment, hospital rate setting, the QIP and HEDIS® reporting. Encounter data must be submitted once per month, and must be submitted via HIPAA compliant transactions, including the ANSI X12N837I Institutional, 837P Professional, and 837D Dental. Data must be submitted with claims level detail for all non- institutional services provided. Molina has a comprehensive automated and integrated encounter data system capable of requirements supporting all 837 file formats and proprietary formats if needed. Providers must correct and resubmit any encounters which are rejected (non-HIPAA compliant) or denied by Molina. Encounters must be corrected and resubmitted within 15 days from the rejection/denial. Molina has created 837P, 837I, and 837D Companion Guides with the specific submission requirements available to providers.
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Section 12. Compliance
Fraud, Waste, and Abuse Introduction
Molina's Compliance program monitors compliance with federal and State laws, including health care fraud, waste and abuse statutes and regulations. Molina is dedicated to the detection, prevention, investigation, and reporting of potential health care fraud, waste, and abuse. As such, Molina's Compliance department maintains a comprehensive plan, which is designed to address how will uphold and follow State and federal statutes and regulations pertaining to fraud, waste, and abuse. The plan also addresses education of appropriate employees, vendors, providers and associates doing business with Molina.
A Special Investigations Unit (SIU) is a key element of the program. Molina's Special Investigation Unit (SIU) supports Compliance in its efforts to deter and prevent fraud, waste, and abuse by conducting investigations aimed at identifying suspect activity and report findings to the appropriate regulatory and/or law enforcement agencies.
Mission Statement
Molina regards health care fraud, waste, and abuse as unacceptable, unlawful, and harmful to the provision of quality health care in an efficient and affordable manner. Molina has therefore implemented a plan to detect, prevent, investigate, and report suspected health care fraud, waste, and abuse in order to reduce health care cost and to promote quality health care.
Definitions
"Fraud": An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable federal or state law. (42 CFR § 455.2)
"Waste": Health care spending that can be eliminated without reducing the quality of care. Quality Waste includes overuse, under use, and ineffective use. Inefficiency Waste includes redundancy, delays, and unnecessary process complexity. For example: the attempt to obtain reimbursement for items or services where there was no intent to deceive or misrepresent, however the outcome of poor or inefficient billing methods (e.g. coding) causes unnecessary costs to the Medicaid program.
"Abuse": Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary costs to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Medicaid programs. (42 CFR § 455.2)
"Clean Claim": A clean claim is one that is accurate, complete (that is, includes all information necessary to determine Molina Healthcare Inc liability), not a claim on appeal, and not contested (that is, not reasonably believed to be fraudulent and not subject to a necessary release, consent or assignment).
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Regulatory Requirements
Federal False Claims Act
The False Claims Act is a federal statute that covers fraud involving any federally funded contract or program, including the Medicare and Medicaid programs. The act establishes liability for any person who knowingly presents or causes to be presented a false or fraudulent claim to the U.S. government for payment.
The term "knowing" is defined to mean that a person with respect to information:
· Has actual knowledge of falsity of information in the claim · Acts in deliberate ignorance of the truth or falsity of the information in a claim; or acts in
reckless disregard of the truth or falsity of the information in a claim
The act does not require proof of a specific intent to defraud the U.S. government. Instead, health care providers can be prosecuted for a wide variety of conduct that leads to the submission of fraudulent claims to the government, such as knowingly making false statements, falsifying records, double-billing for items or services, submitting bills for services never performed or items never furnished or otherwise causing a false claim to be submitted.
Deficit Reduction Act
The Deficit Reduction Act (DRA) aims to cut fraud, waste and abuse from the Medicare and Medicaid programs.
As a contractor doing business with Molina, providers and their staff have the same obligation to report any actual or suspected violation of Medicare/Medicaid funds either by fraud, waste or abuse. Entities must have written policies that inform employees, contractors, and agents of the following:
· The Federal False Claims Act and state laws pertaining to submitting false claims · How providers will detect and prevent fraud, waste, and abuse · Employee protection rights as a whistle blowers
These provisions encourage employees (current or former) and others to report instances of fraud, waste or abuse to the government. The government may then proceed to file a law suit against the organization/individual accused of violating the False Claims acts. The whistle blower may also file a lawsuit independently. Cases found in favor of the government will result in the whistle blower receiving a portion of the amount awarded to the government.
Whistle blower protections state that employees who have been discharged, demoted, suspended, threatened, harassed or otherwise discriminated against due to their role in disclosing or reporting a false claim are entitled to all relief necessary to make the employee whole including:
· Employment reinstatement at the same level of seniority · Two times the amount of back pay plus interest · Compensation for special damages incurred by the employee as a result of the employer's
inappropriate actions
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Affected entities who fail to comply with the law will beat risk of forfeiting all Medicaid payments until compliance is met. Molina will take steps to monitor Molina contracted providers to ensure compliance with the law.
Anti-Kick back Statute Provides criminal penalties for individuals or entities that knowingly and willfully offer, pay, solicit, or receive remuneration in order to induce or reward business payable or reimbursable under the Medicare or other Federal health care programs.
Stark Statute Similar to the Anti-Kickback Statute, but more narrowly defined and applied. It applies specifically to Medicare and Medicaid services provided only by physicians, rather than by all health care providers.
Sarbanes - Oxley Act of 2002 Requires certification of financial statements by both the Chief Executive Officer and the Chief Financial Officer. The Act states that a corporation must assess the effectiveness of its internal controls and report this assessment annually to the Securities and Exchange Commission.
Examples of Fraud, Waste and Abuse by a Provider
The types of questionable Provider schemes investigated by Molina include, but are not limited to the following:
· A Provider knowingly and willfully referring a Medicaid members to health care facilities in which or with which the Provider has a financial relationship. (Stark Law)
· Altering Claims and/or medical record documentation in order to get a higher level of reimbursement.
· Balance billing a Medicaid Member for Medicaid covered services. For example, asking the Member to pay the difference between the discounted fees, negotiated fees, and the Provider's usual and customary fees.
· Billing and providing for services to Members that are not medically necessary. · Billing for services, procedures and/or supplies that have not been rendered. · Billing under an invalid place of service in order to receive or maximize reimbursement. · Completing certificates of Medical Necessity for Members not personally and professionally
known by the Provider. · Concealing a Member's misuse of a Molina identification card. · Failing to report a Member's forgery or alteration of a prescription or other medical
document. · False coding in order to receive or maximize reimbursement. · Inappropriate billing of modifiers in order to receive or maximize reimbursement. · Inappropriately billing of a procedure that does not match the diagnosis in order to receive
or maximize reimbursement. · Knowingly and willfully soliciting or receiving payment of kickbacks or bribes in exchange
for referring patients. · Not following incident to billing guidelines in order to receive or maximize reimbursement.
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· Overutilization. · Participating in schemes that involve collusion between a Provider and a Member that
result in higher costs or charges. · Questionable prescribing practices. · Unbundling services in order to get more reimbursement, which involves separating a
procedure into parts and charging for each part rather than using a single global code. · Underutilization, which means failing to provide services that are Medically Necessary. · Upcoding, which is when a Provider does not bill the correct code for the service rendered,
and instead uses a code for a like services that costs more. · Using the adjustment payment process to generate fraudulent payments.
Examples of Fraud, Waste, and Abuse by a Member
The types of questionable Member schemes investigated by Molina include, but are not limited to, the following:
· Benefit sharing with persons not entitled to the Member's benefits. · Conspiracy to defraud Medicaid. · Doctor shopping, which occurs when a Member consults a number of Providers for the
purpose of inappropriately obtaining services. · Falsifying documentation in order to get services approved. · Forgery related to health care. · Prescription diversion, which occurs when a Member obtains a prescription from a Provider
for a condition that they do not suffer from and the Member sells the medication to someone else.
Review of Provider Claims and Claims System
Molina Healthcare Claims Examiners are trained to recognize unusual billing practices and to detect fraud, waste and abuse. If the Claims Examiner suspects fraudulent, abusive or wasteful billing practices, the billing practice is documented and reported to the Compliance Department.
The Claims payment system utilizes system edits and flags to validate those elements of Claims are billed in accordance with standardized billing practices; ensure that Claims are processed accurately and ensure that payments reflect the service performed as authorized.
Molina Healthcare performs auditing to ensure the accuracy of data input into the Claims system. The Claims department conducts regular audits to identify system issues or errors. If errors are identified, they are corrected and a thorough review of system edits is conducted to detect and locate the source of the errors.
Provider Profiling
Molina performs claims audits to detect potential external health care fraud, waste, or abuse. These audits of provider billings are based on objective and documented criteria. Molina uses a
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fraud, waste, and abuse detection software application designed to score and profile provider and member billing behavior and patterns. The software utilizes a fraud finder engine to identify various billing behaviors, billing patterns, known schemes, as well as unknown patterns by taking into consideration a provider or member's prior billing history. The software statistically identifies what is expected based on prior history and specialty norms, including recognition of pattern changes from those identified in profiled historical paid claims data and ongoing daily claims batches. If a score reaches a certain parameter or threshold, the provider or member is placed on a list for further review.
Molina will inform the provider of the billing irregularities and request an explanation of the billing practices. The Compliance department, with the aid of the Special Investigation Unit, may conduct further investigation and take action as needed.
Provider/Practitioner Education
When Molina identifies through an audit, provider profile or other means a situation with a provider (e.g. coding, billing) that is either inappropriate or deficient, the Compliance Officer may determine that a provider/practitioner education visit is appropriate.
The Compliance Department and/or the Special Investigation Unit will contact the provider/ practitioner's Molina Provider Services Representative regarding the education issue. The Provider Services Representative will be informed that an on-site meeting at the provider's office is required in order to educate the provider on certain issues identified as inappropriate or deficient.
Prepayment Fraud, Waste, and Abuse Detection Activities
Through implementation of Claims edits, Molina's Claims payment system is designed to audit Claims concurrently, in order to detect and prevent paying Claims that are inappropriate.
Molina has a pre-payment Claims auditing process that identifies frequent correct coding billing errors ensuring that Claims are coded appropriately according to State and Federal coding guidelines. Code edit relationships and edits are based on guidelines from specific State Medicaid Guidelines, Centers for Medicare & Medicaid Services (CMS), Federal CMS guidelines, AMA and published specialty specific coding rules. Code Edit Rules are based on information received from the National Physician Fee Schedule Relative File (NPFS), the Medically Unlikely Edit table (MUE), the Medicaid National Correct Coding Initiative (NCCI) files and State-specific policy manuals and guidelines as specified by a defined set of indicators in the Medicare Physician Fee Schedule Data Base (MPFSDB).
Additionally, Molina may, at the request of a State program or at its own discretion, subject a Provider to prepayment reviews whereupon Provider is required to submit supporting source documents that justify an amount charged. Where no supporting documents are provided, or insufficient information is provided to substantiate a charge, the claim will be denied until such time that the Provider can provide sufficient accurate support.
Post-payment Recovery Activities
The terms expressed in this section of this Provider Manual are incorporated into the Provider Agreement, and are intended to supplement, rather than diminish, any and all other rights and remedies that may be available to Molina under the Provider Agreement or at Law or equity.
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In the event of any inconsistency between the terms expressed here and any terms expressed in the Provider Agreement, the parties agree that Molina shall in its sole discretion exercise the terms that are expressed in the Provider Agreement, the terms that are expressed here, its rights under Law and equity, or some combination thereof.
Provider will provide Molina, governmental agencies and their representatives or agents, access to examine, audit, and copy any and all records deemed by Molina, in Molina's sole discretion, necessary to determine compliance with the terms of the Provider Agreement, including for the purpose of investigating potential fraud, waste and abuse. Documents and records must be readily accessible at the location where Provider provides services to any Molina Members. Auditable documents and records include, but are not limited to, medical charts; patient charts; billing records; and coordination of benefits information. Production of auditable documents and records must be provided in a timely manner, as requested by Molina and without charge to Molina. In the event Molina identifies fraud, waste or abuse, Provider agrees to repay funds or Molina may seek recoupment.
If a Molina auditor is denied access to Provider's records, all of the claims for which Provider received payment from Molina is immediately due and owing. If Provider fails to provide all requested documentation for any claim, the entire amount of the paid Claim is immediately due and owing. Molina may offset such amounts against any amounts owed by Molina to Provider. Provider must comply with all requests for documentation and records timely (as reasonably requested by Molina) and without charge to Molina. Claims for which Provider fails to furnish supporting documentation during the audit process are not reimbursable and are subject to charge back.
Provider acknowledges that HIPAA specifically permits a covered entity, such as Provider, to disclose protected health information for its own payment purposes (see 45 CFR 164.502 and 45 CFR 154.501). Provider further acknowledges that in order to receive payment from Molina, Provider is required to allow Molina to conduct audits of its pertinent records to verify the services performed and the payment claimed, and that such audits are permitted as a payment activity of Provider under HIPAA and other applicable privacy Laws.
Claim Auditing
Molina shall use established industry claims adjudication and/or clinical practices, State and Federal guidelines, and/or Molina's policies and data to determine the appropriateness of the billing, coding, and payment.
Provider acknowledges Molina's right to conduct pre and post-payment billing audits. Provider shall cooperate with Molina's Special Investigations Unit and audits of claims and payments by providing access at reasonable times to requested claims information, all supporting medical records, provider's charging policies, and other related data as deemed relevant to support the transactions billed. Providers are required to submit, or provide access to, medical records upon Molina's request. Failure to do so in a timely manner may result in an audit failure and/or denial, resulting in an overpayment.
In reviewing medical records for a procedure, Molina may select a statistically valid random sample, or smaller subset of the statistically valid random sample. This gives an estimate of the
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proportion of claims that Molina paid in error. The estimated proportion, or error rate, may be projected across all claims to determine the amount of overpayment.
Provider audits may be telephonic, an on-site visit, internal claims review, client-directed/ regulatory investigation and/or compliance reviews and may be vendor assisted. Molina asks that you provide Molina, or Molina designee, during normal business hours, access to examine, audit, scan and copy any and all records necessary to determine compliance and accuracy of billing.
If Molina Special Investigations Unit suspects that there is fraudulent or abusive activity, Molina may conduct an on-site audit without notice. Should you refuse to allow access to your facilities, Molina reserves the right to recover the full amount paid or due to you.
Medical Records
In accordance with your contract with Molina, which allows for the review of claims, please submit complete medical records for all of the members indicated for the dates of service provided. This includes, but is not limited to the following:
· Patient information sheets (completed by patient, parent, or guardian) · Financial records including superbills, copayments, copies of identification cards, and
patient intake forms · Provider orders · Diagnostic test results · Referral/authorization requests and forms · Physician progress notes · Medication records · Graphic reports · Emergency room records · History and physical notes · Operative reports · Lab requisitions and lab reports
Please photocopy each record. Make sure all copies are complete and legible and contain both sides of each page, including page edges. Complete copies should include specific records to support the services provided and be separated by patient in chronological order.
All records should be sent via a trackable manner (e.g., certified mail). Please return a copy of the records request letter with the medical records to the following address:
Molina Healthcare, Inc. Attn: Special Investigation Unit 200 Oceangate, Suite 100 Long Beach, CA 90802
Molina must be in receipt of the requested document within 15 calendar days from the receipt of this letter. Failure to submit requested documentation could result in the retrospective denial of claims and other sanctions.
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Provider Appeal Procedures
If you are in disagreement with any of the results of any audit conducted by the Special Investigation Unit at Molina, you have the right to file an appeal within 30 days from the data of the issued audit findings letter. In order for the appeal to be considered, the following must be enclosed:
· The written letter of appeal must be clearly labeled "Appeal Regarding SIU Audit Results;" · A copy of the issued audit findings letter must be attached to the written letter of appeal; · The written letter of appeal must contain all necessary information, such as the original
claim(s), medical record(s), prior authorization letter(s) or form(s), and any new information pertinent to the appeal, which was not originally submitted and/or reviewed by the SIU during the audit process.
Please send the written letter of appeal and supporting documentation to:
Molina Healthcare, Inc. Attn: Special Investigation Unit PO Box 22625 Long Beach, CA 90802
Provider Education
When Molina Healthcare identifies through an audit or other means a situation with a Provider (e.g., coding, billing) that is either inappropriate or deficient, Molina Healthcare may determine that a Provider education visit is appropriate.
Molina Healthcare will notify the Provider of the deficiency and will take steps to educate the Provider, which may include the Provider submitting a corrective action plan to Molina Healthcare addressing the issues identified and how it will cure these issues moving forward.
Cooperating with Special Investigation Unit Activities
Molina Healthcare's Special Investigation Unit may conduct prepayment, concurrent, or postpayment review. Providers will cooperate with Special Investigation Unit activities, and will provide requested documentation to the unit following the time lines indicated in such requests. Failure to cooperate may result in further action, up to and including termination of the provider contract.
Reporting Fraud, Waste and Abuse
If you suspect cases of fraud, waste, or abuse, you must report it by contacting the Molina Healthcare Alert Line. Alert Line is an external telephone and web based reporting system hosted by Global Compliance, a leading provider of compliance and ethics hot line services. Alert Line telephone and web based reporting is available 24 hours a day/seven days a week, 365 days a year. When you make a report, you can choose to remain confidential or anonymous. If you choose to call Alert Line, a trained professional at Global Compliance will note your concerns and provide them to the Molina Healthcare Compliance Department for follow-up. If you elect to use the web-based reporting process, you will be asked a series of questions concluding with the submission of your report. Reports to Alert Line can be made from anywhere within the United States with telephone or internet access.
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Molina Healthcare Alert Line can be reached toll free at (866) 606-3889 or you may use the service's website to make a report at any time at MolinaHealthcare.AlertLine.com.
You may also report cases of fraud, waste or abuse to Molina's Compliance Department. You have the right to have your concerns reported anonymously without fear of retaliation.
Molina Healthcare of South Carolina Attn: Compliance PO Box 40309
North Charleston, SC 29423-0309
Remember to include the following information when reporting:
· Nature of complaint · The names of individuals and/or entity involved in suspected fraud and/or abuse including
address, phone number, Medicaid ID number and any other identifying information · Suspected fraud and abuse may also be reported directly to the state at:
South Carolina Department of Health and Human Services Medicaid Fraud and Abuse Hotline Toll Free Phone: (888) 364-3224 By Email: fraudres@scdhhs.gov South Carolina Attorney General Medicaid Fraud Unit
By Phone: (803) 734-3660 or Toll Free (888) 662-4325
HIPAA (Health Insurance Portability & Accountability Act)
Applicable Laws
Providers/practitioners must understand all state and federal health care privacy laws applicable to their practice and organization. Currently, there is no comprehensive regulatory framework that protects all health information in the United States; instead there is a patchwork of laws that providers/practitioners must comply with. In general, most health care providers/practitioners are subject to various laws and regulations pertaining to privacy of health information including, without limitation, the following:
1. Federal Laws and Regulations
· HIPAA · The Health Information Technology for Economic and Clinical Health Act (HITECH) · 42 C.F.R. Part 2 · Medicare and Medicaid Laws · The Affordable Care Act
2. Applicable State Laws and Regulations Providers/practitioners should be aware that HIPAA provides a floor for patient privacy but that state laws should be followed in certain situations, especially if the state law is more stringent than HIPAA. Providers/practitioners should consult with their own legal counsel to address their specific situation.
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Uses and Disclosures of PHI
Member and patient PHI should only be used or disclosed as permitted or required by applicable law. Under HIPAA, a provider/ practitioner may use and disclose PHI for their own treatment, payment, and health care operations activities (TPO) without the consent or authorization of the patient who is the subject of the PHI. Uses and disclosures for TPO apply not only to the provider/ practitioner's own TPO activities, but also for the TPO of another covered entity. Disclosure of PHI by one covered entity to another covered entity, or health care provider, for the recipient's TPO is specifically permitted under HIPAA in the following situations:
1. A covered entity may disclose PHI to another covered entity or a health care provider for the payment activities of the recipient. Please note that "payment" is a defined term under the HIPAA Privacy Rule that includes, without limitation, utilization review activities, such as pre-authorization of services, concurrent review, and retrospective review of "services."
2. A covered entity may disclose PHI to another covered entity for the health care operations activities of the covered entity that receives the PHI, if each covered entity either has or had a relationship with the individual who is the subject of the PHI being requested, the PHI pertains to such relationship, and the disclosure is for the following health care operations activities:
· Quality Improvement · Disease Management · Care Management and Care Coordination · Training programs · Accreditation, licensing, and credentialing
Importantly, this allows providers/practitioners to share PHI with Molina for our health care operations activities, such as HEDIS® and quality improvement.
Confidentiality of Substance Use Disorder Patient Records
Federal Confidentiality of Substance Use Disorder Patients Records regulations apply to any entity or individual providing federally- assisted alcohol or drug abuse prevention treatment. Records of the identity, diagnosis, prognosis, or treatment of any patient which are maintained in connection with substance use disorder treatment or programs are confidential and may be disclosed only as permitted by 42 CFR Part 2. Although HIPAA protects substance use disorder information, the Federal Confidentiality of Substance Use Disorder Patients Records regulations are more restrictive than HIPAA and they do not allow disclosure without the Member's written consent except as set forth in 42 CFR Part 2.
Inadvertent Disclosures of PHI
Molina may, on occasion, inadvertently misdirect or disclose PHI pertaining to Molina Member(s) who are not the patients of the Provider. In such cases, the Provider shall return or securely destroy the PHI of the affected Molina Members in order to protect their privacy. The Provider
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agrees to not further use or disclose such PHI, and further agrees to provide an attestation of return, destruction and non-disclosure of any such misdirected PHI upon the reasonable request of Molina.
Written Authorizations
Uses and disclosures of PHI that are not permitted or required under applicable law require the valid written authorization of the patient. Authorizations should meet the requirements of HIPAA and applicable state law.
Patient Rights
Patients are afforded various rights under HIPAA. Molina providers/practitioners must allow patients to exercise any of the below- listed rights that apply to the provider/practitioner's practice:
1. Notice of Privacy Practices Providers/practitioners that are covered under HIPAA and that have a direct treatment relationship with the patient should provide patients with a Notice of Privacy Practices that explains the patient's privacy rights and the process the patient should follow to exercise those rights. The provider/practitioner should obtain a written acknowledgment that the patient received the Notice of Privacy Practices.
2. Requests for Restrictions on Uses and Disclosures of PHI Patients may request that a health care provider/practitioner restrict its uses and disclosures of PHI. The provider/practitioner is not required to agree to any such request for restrictions.
3. Requests for Confidential Communications Patients may request that a health care provider/practitioner communicate PHI by alternative means or at alternative locations. Providers/practitioners must accommodate reasonable requests by the patient.
4. Requests for Patient Access to PHI Patients have a right to access their own PHI within a provider/practitioner's designated record set. Personal representatives of patients have the right to access the PHI of the subject patient. The designated record set of a provider/practitioner includes the patient's medical record, as well as billing and other records used to make decisions about the member's care or payment for care.
5. Request to Amend PHI Patients have a right to request that the provider/practitioner amend information in their designated record set.
6. Request Accounting of PHI Disclosures Patients may request an accounting of disclosures of PHI made by the provider/ practitioner during the preceding six year period. The list of disclosures does not need to include disclosures made for treatment, payment, or health care operations or made prior to April 14, 2003.
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HIPAA Security
Providers/practitioners should implement and maintain reasonable and appropriate safeguards to protect the confidentiality, availability, and integrity of member PHI. Providers/practitioners should recognize that identity theft is a rapidly growing problem and that their patients trust them to keep their most sensitive information private and confidential.
In addition, medical identity theft is an emerging threat in the health care industry. Medical identity theft occurs when someone uses a person's name and sometimes other parts of their identity such as health insurance information without the person's knowledge or consent to obtain health care services or goods. Medical identity theft frequently results in erroneous entries being put into existing medical records. Providers should be aware of this growing problem and report any suspected fraud to Molina.
HIPAA Transactions and Code Sets
Molina strongly supports the use of electronic transactions to streamline health care administrative activities. Molina providers/practitioners are encouraged to submit claims and other transactions to Molina using electronic formats. Certain electronic transactions are subject to HIPAA's Transactions and Code Sets Rule including, but not limited to, the following:
· Claims and encounters · Member eligibility status inquiries and responses · Claims status inquiries and responses · Authorization requests and responses · Remittance advices
Molina is committed to complying with all HIPAA Transaction and Code Sets standard requirements. Providers/practitioners who wish to conduct HIPAA standard transactions with Molina should refer to Molina's website at MolinaHealthcare.com for additional information. Click on the tab titled "Providers," select a state, click the tab titled "HIPAA" and then click on the tab titled "TCS readiness."
Code Sets
HIPAA regulations require that only approved code sets may be used in standard electronic transactions. For Claims with dates of service prior to October 1, 2015, ICD-9 coding must be used. For Claims with dates of service on or after October 1, 2015, Providers must use the ICD-10 code sets.
National Provider Identifier (NPI)
Provider/practitioners must comply with the National Provider Identifier (NPI) Rule promulgated under HIPAA. The provider/ practitioners must obtain an NPI from the National Plan and Provider Enumeration System (NPPES) for itself or for any subparts of the provider/practitioner. The provider/practitioner must report its NPI and any subparts to Molina and to any other entity that requires it. Any changes in its NPI or subparts information must be reported to NPPES within 30 days and should also be reported to Molina within 30 days of the change. Provider/practitioners
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must use its NPI to identify it on all electronic transactions required under HIPAA and on all claims and encounters (both electronic and paper formats) submitted to Molina.
Additional Requirements for Delegated Providers/Practitioners
Providers/practitioners that are delegated for claims and utilization management activities are the "business associates" of Molina. Under HIPAA, Molina must obtain contractual assurances from all business associates that they will safeguard member PHI. Delegated providers/ practitioners must agree to various contractual provisions required under HIPAA's Privacy and Security Rules.
Section 13. Cybersecurity Requirements
Nonpublic Information Cybersecurity Attachment
Note: This section (Nonpublic Information Cybersecurity Attachment) is only applicable to providers who are a delegated provider and delegated a health plan function.
1. Provider shall comply with the following requirements and permit Molina to audit such compliance as required by law or any regulatory agency.
2. Provider shall implement appropriate administrative, technical, and physical measures to protect and secure the Information Systems and Nonpublic Information that are accessible to, or held by, the provider.
3. Definitions:
i. "Cybersecurity Event" means an event resulting in unauthorized access to or the disruption or misuse of an information system or information stored on an information system. The term "Cybersecurity Event' does not include the unauthorized acquisition of encrypted nonpublic information if the encryption, process or key is not also acquired, released or used without authorization. The term "Cybersecurity Event' also does not include an event with regard to which provider has determined that the nonpublic information accessed by an unauthorized person has not been used or released and has been returned or destroyed.
ii. "Information Systems" means a discrete set of electronic information resources organized for the collection, processing, maintenance, use, sharing, dissemination or disposition of electronic information, as well as any specialized system such as industrial or process controls systems, telephone switching and private branch exchange systems, and environmental control systems.
iii. "Nonpublic Information" means information that is not publicly available information and is:
a. business related information of Molina the tampering with which, or unauthorized disclosure, access, or use of which, would cause a material adverse impact to the business, operations, or security of Molina;
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b. any information concerning a consumer which because of name, number, personal mark, or other identifier can be used to identify such consumer, in combination with any one or more of the following data elements:
i. social security number; ii. driver's license number or non driver identification card number; iii. account number, credit or debit card number; iv. security code, access code, or password that would permit access to a
consumer's financial account; or v. biometric records; c. any information or data, except age or gender, in any form or medium created by or derived from a health care provider or a consumer and that relates to:
i. the past, present, or future physical, mental or behavioral health or condition of a consumer or a member of the consumer's family;
ii. the provision of health care to a consumer; or iii. payment for the provision of health care to a consumer.
4. Molina agrees to comply with all applicable laws governing Cybersecurity Events, including notification requirements. Molina will decide on further action including, but not limited to, notification to affected individuals or government entities. Upon Molina's prior written request, Molina agrees to assume responsibility for informing all such individuals in accordance with applicable law.
5. In the event of a Cybersecurity Event, provider shall notify Molina's Chief Information Security Officer of such Cybersecurity Event by telephone and email as provided below (with followup notification by mail) as promptly as possible, but in no event later than 72 hours from a determination that a Cybersecurity Event has occurred.
Notification to Molina's Chief Information Security Officer shall be provided to:
Molina Chief Information Security Officer Telephone: (844) 821-1942 Email: CyberIncidentReporting@MolinaHealthcare.com
Molina Chief Information Security Officer Molina Healthcare of South Carolina, Inc. PO Box 40309 North Charleston, SC 29423-0309
6. Further, in the event of a Cybersecurity Event, provider must provide Molina any documentation required by Molina to complete an investigation, or, upon written request by Molina, complete an investigation pursuant to the following requirements:
a. determine whether a Cybersecurity Event occurred; b. assess the nature and scope of the Cybersecurity Event; c. identify Nonpublic Information that may have been involved in the Cybersecurity Event;
and
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d. perform or oversee reasonable measures to restore the security of the Information Systems compromised in the Cybersecurity Event to prevent further unauthorized acquisition, release, or use of Nonpublic Information in Molina or provider's possession, custody, or control.
7. Provider shall maintain records concerning all Cybersecurity Events for a period of at least five years from the date of the Cybersecurity Event or such longer period as required by applicable laws and produce those records upon demand of Molina.
8. In order for Molina to meet its reporting requirements pursuant to applicable law, provider must notify Molina no later than 24 hours after determining that a Cybersecurity Event has occurred.
9. Provider must provide Molina the required information in electronic form as directed by Molina. Provider shall have a continuing obligation to update and supplement the initial and subsequent notifications to Molina concerning the Cybersecurity Event. The information provided to Molina must include at least the following:
a. the date of the Cybersecurity Event; b. a description of how the information was exposed, lost, stolen, or breached, including the
specific roles and responsibilities of provider, if any; c. how the Cybersecurity Event was discovered; d. whether any lost, stolen, or breached information has been recovered and if so, how this
was done; e. the identity of the source of the Cybersecurity Event; f. whether provider has filed a police report or has notified any regulatory, governmental or
law enforcement agencies and, if so, when such notification was provided; g. a description of the specific types of information acquired without authorization, which
means particular data elements including, for example, types of medical information, types of financial information, or types of information allowing identification of the consumer; h. the period during which the Information System was compromised by the Cybersecurity Event; i. the number of total consumers in the State affected by the Cybersecurity Event; j. the results of any internal review identifying a lapse in either automated controls or internal procedures, or confirming that all automated controls or internal procedures were followed; k. a description of efforts being undertaken to re-mediate the situation which permitted the Cybersecurity Event to occur; l. a copy of provider's privacy policy and a statement outlining the steps provider will take to investigate and if requested by Molina, the steps that provider will take to notify consumers affected by the Cybersecurity Event; and m. the name of a contact person who is both familiar with the Cybersecurity Event and authorized to act on behalf of provider.
10. In the event provisions of this Attachment conflict with provisions of any other agreement between Molina and provider, including but not limited to any Business Associate Agreement, the stricter of the conflicting provisions will control.
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INFORMATION SECURITY
1. Network Security.
Contractor agrees at all times to maintain network security thatat a minimumincludes: network firewall provisioning, intrusion and threat detection, and regular (three or more annually) third party vulnerability assessments. Contractor agrees to maintain network security that conforms to generally recognized industry standards and best practices that Contractor shall apply to its own network (refer to "12. Industry Standards").
2. Application Security.
Contractor agrees at all times to provide, maintain, and support its software and subsequent updates, upgrades, and bug fixes such that the software is, and remains, secure from those vulnerabilities in accordance with industry practices or standards.
3. Data Security.
Contractor agrees to preserve the confidentiality, integrity and accessibility of Client data with administrative, technical and physical measures that conform to generally recognized industry standards and best practices that Contractor then applies to its own processing environment (refer to "12. Industry Standards"). Maintenance of a secure processing environment includes but is not limited to the timely application of patches, fixes and updates to operating systems and applications as provided by Contractor or open source support.
4. Data Storage.
Contractor agrees that any and all Client data will be stored, processed, and maintained solely on designated target servers and that no Client data at any time will be processed on or transferred to any portable or laptop computing device or any portable storage medium, unless that device or storage medium is in use as part of the Contractor's designated backup and recovery processes and encrypted (refer to "6. Data Encryption").
5. Data Transmission.
Contractor agrees that any and all electronic transmission or exchange of system and application data with Client and/or any other parties expressly designated by Client shall take place via secure means (using HTTPS or SFTP or equivalent) and solely in accordance with Federal Information Processing Standard Publication 140-2 ("FIPS PUB 140-2") and Section 7. Data Re-Use.
6. Data Encryption.
Contractor agrees to store all Client backup data as part of its designated backup and recovery processes in encrypted form, using a commercially supported encryption solution. Contractor further agrees that any and all Client data defined as personally identifiable information under current legislation or regulations stored on any portable or laptop computing device or any portable storage medium be likewise encrypted. Encryption solutions will be deployed with no less than a 128- bit key for symmetric encryption, a 1024 (or larger) bit key length for asymmetric encryption, and FIPS PIB 140-2.
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7. Data Re-Use.
Contractor agrees that any and all data exchanged shall be used expressly and solely for the purposes enumerated in the Current Agreement and this Addendum. Data shall not be distributed, re-purposed or shared across other applications, environments, or business units of the Contractor. Contractor further agrees that no Client data of any kind shall be transmitted, exchanged or otherwise passed to other Contractors or interested parties except on a case-by-case basis as specifically agreed to in writing by the Client.
8. End of Agreement Data Handling.
Contractor agrees that upon termination of this Agreement and upon Client's written approval it shall erase, destroy, and render unrecoverable all Client data and certify in writing that these actions have been completed within thirty (30) days of the termination of this Agreement or within seven (7) days of the request of an agent of the Client, whichever shall come first. At a minimum, a "Clear" media sanitization is to be performed according to the standards enumerated by the National Institute of Standards and Technology ("NIST") Guidelines for Media Sanitization (SP800-88, Appendix A).
9. Security Breach Notification.
Contractor agrees to comply with all applicable laws that require the notification of Client, in the event of an unauthorized disclosure or breach of information or other events requiring notification. Client will then decide on further action including, but not limited to, notification to affected individuals or government entities. In the event of a breach of any of Contractor's security obligations, or other events requiring notification under applicable law, Contractor agrees to:
a. Notify the Client Chief Information Security Officer by telephone and email of such an event within twenty-four (24) hours of discovery;
b. Upon Client's prior written request, assume responsibility for informing all such individuals in accordance with applicable law; and
c. Indemnify, hold harmless and defend Client and its trustees, officers, and employees from and against any claims, damages, or other harm related to such event.
10. Right to Audit.
The Client or a client-appointed audit firm ("Auditors") has the right to audit the Contractor and the Contractor's sub-contractors or affiliates that provide a service for the processing, transport or storage of Client's data. Client will announce their intent to audit the Contractor by providing at a minimum of ten (10) business days' notice to the Contractor. This notice will go to the Contractor that this contract is executed with. A scope document along with a request for deliverables will be provided at the time of notification of an audit. If the documentation requested cannot be removed from the Contractor's premises, the Contractor will allow the Client or Auditors access to their site or share on the desktop screen in an audio-video conference. Where necessary, the Contractor will provide a personal site guide for the Client or Auditors while on site. If site visit is necessary, the Contractor will provide a private workspace on site with electrical and internet connectivity for data review, analysis
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and meetings. The Contractor will make necessary employees or contractors available for interviews in person or on the phone during the time frame of the audit.
In lieu of the Client or its appointed audit firm performing their own audit, if the Contractor has an external, independent audit firm that performs a certified SOC or HITRUST review, the Client has the right to review the controls tested as well as the results, and has the right to request additional controls to be added to the certified SOC or HITRUST review for testing the controls that have an impact on Client data. Audits will be at the Client's sole expense, except where the audit reveals material noncompliance with contract specifications, in which case the cost will be borne by the Contractor.
11. Contractor Warranty.
Contractor (i) warrants that the services provided in this agreement will be in substantial conformity with the information provided in Contractor's response to the Client's Due Diligence/Security Assessment questionnaire; (ii) agrees to inform Client promptly of any material variation in operations from that reflected in the Contractor's response to the Client's Due Diligence/Security Assessment; and (iii) agrees that any material deficiency in operations from those as described in the Contractor's Response to the Client's Due Diligence/Security Assessment questionnaire will be deemed a material breach of this agreement.
12. Industry Standards.
Generally recognized industry standards include but are not limited to the current standards and benchmarks set forth and maintained by the:
a. Center for Internet Security - http://www.cisecurity.org b. Payment Card Industry/Data Security Standards ("PCI/DSS") -
http://www.pcisecuritystandards.org/ c. National Institute for Standards and Technology (NIST 800-53) - http://csrc.nist.gov d. ISO/IEC 27000-series - http://www.iso27001security.com/ e. HIPAA and HITECH f. Federal Risk and Authorization Management Program ("Fed Ramp")
13. Business Continuity ("BC") and Disaster Recovery ("DR"). As part of its Business Continuity Management Program, Client requires Contractors to have documented procedures in place to ensure continuity of the Contractors' business operations during an Incident that may otherwise disrupt the Contractor's delivery of services to the Client.
For the purposes of this Section 13, an "Incident" is defined as a situation that might be, or could lead to, a disruption, loss, emergency or crisis (Source: ISO 22300:2012 - Societal security Terminology).
a. Resilience Questionnaire
i. Contractors shall complete a questionnaire provided by the Client to establish the resilience capabilities of the Contractor.
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b. BC and DR Plans
i. The Contractor's procedures addressing continuity of business operations shall be collected and/or summarized in a documented business continuity plan ("BCP").
ii. Included within the BCP's content shall be identification of the service level agreement(s) established between the Contractor and Client.
iii. The BCP shall also indicate where the Client ranks among the Contractor's other customers in recovery priority.
iv. Contractors shall develop information technology disaster recovery or systems contingency plans consistent with the guidelines set forth in the National Institute of Standards and Technology ("NIST") Special Publication 800- 34 Revision 1 ("Contingency Planning Guide for Federal Information Systems"), or a similar standard.
v. The BC and DR plans may be separate documents, or may be consolidated into a single document.
vi. The Contractor's operating practices and BC and DR plan(s) must ensure compliance with the Security Rule of the Health Insurance Portability and Accountability Act ("HIPAA"), i.e., Title 45 of the Code of Federal Regulations, Parts 160, 162, and 164.
vii. The Contractor's operating practices, BC, and DR plan(s) shall also comply with the Health Information Technology for Economic and Clinical Health ("HITECH") Act, Subtitles A, B, and D.
c. BC and DR Plan Submission and Modification
i. Upon written request, Contractor shall promptly, but no later than five (5) business days after such request, provide the Client an electronic copy of its current BC and DR plan(s).
ii. In the event Contractor makes a material change to its BC and DR plan(s), Contractor shall give Client at least a fifteen (15) day notice prior to implementation of the change.
d. Contractor shall notify the Client as soon as practicable but not to exceed twenty-four (24) hours of Contractor's discovery of any BC or DR incident such as interruption of business operations that may interfere with the delivery of services to the Client or detrimentally affects Client's Information Systems or Nonpublic Information (as those terms are defined by 23 NYCRR 500).
i. BC and DR Testing
e. Contractor shall exercise its BC and DR plan(s) at least once each calendar year, and shall provide the Client a written report in electronic format upon request.
f. At a minimum, the test report shall include the date of the test, a description of activities performed, results of the activities, corrective actions identified, and modifications to plans based on results of the exercise(s).
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i. Preferred standards/guidelines for BC and DR include, but are not limited to:
a. International Organization for Standardization (ISO) 22301 "Societal security Business continuity management systems Requirements"
b. Disaster Recovery Institute International (DRI) Professional Practices c. National Institute of Standards and Technology (NIST) Special Publication 800-34
Revision 1 "Contingency Planning Guide for Federal Information Systems"
Nonpublic Information Cybersecurity Attachment
Note: This section is only applicable to providers who are a delegated provider and delegated a health plan function.
Provider shall comply with the following requirements and permit Molina to audit such compliance as required by law or any regulatory agency.
Provider shall implement appropriate administrative, technical, and physical measures to protect and secure the Information Systems and Nonpublic Information that are accessible to, or held by, the provider.
Definitions:
"Cybersecurity Event" means an event resulting in unauthorized access to or the disruption or misuse of an Information System or information stored on an Information System. The term "Cybersecurity Event" does not include the unauthorized acquisition of encrypted Nonpublic Information if the encryption, process or key is not also acquired, released or used without authorization. The term "Cybersecurity Event" also does not include an event with regard to which provider has determined that the Nonpublic Information accessed by an unauthorized person has not been used or released and has been returned or destroyed.
"Information Systems" means a discrete set of electronic information resources organized for the collection, processing, maintenance, use, sharing, dissemination or disposition of electronic information, as well as any specialized system such as industrial or process controls systems, telephone switching and private branch exchange systems, and environmental control systems.
"Nonpublic Information" means information that is not publicly available information and is: business related information of Molina the tampering with which, or unauthorized disclosure, access, or use of which, would cause a material adverse impact to the business, operations, or security of Molina; any information concerning a consumer which because of name, number, personal mark, or other identifier can be used to identify such consumer, in combination with any one or more of the following data elements: social security number; driver's license number or non driver identification card number; account number, credit or debit card number; security code, access code, or password that would permit access to a consumer's financial account; or biometric records; any information or data, except age or gender, in any form or medium created by or derived from a health care provider or a consumer and that relates to: the past, present, or future physical, mental or behavioral health or condition of a consumer or a member of the consumer's family; the provision of health care to a consumer; or payment for the provision of health care to a consumer.
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Molina agrees to comply with all applicable laws governing Cybersecurity Events, including notification requirements. Molina will decide on further action including, but not limited to, notification to affected individuals or government entities. Upon Molina's prior written request, provider agrees to assume responsibility for informing all such individuals in accordance with applicable law.
In the event of a Cybersecurity Event, provider shall notify Molina's Chief Information Security Officer of such Cybersecurity Event by telephone and email as provided below (with followup notification by mail) as promptly as possible, but in no event later than 72 hours from a determination that a Cybersecurity Event has occurred.
Notification to Molina's Chief Information Security Officer shall be provided to:
Molina Chief Information Security Officer Telephone: (844) 821-1942 Email: CyberIncidentReporting@MolinaHealthcare.com
Molina Chief Information Security Officer Molina Healthcare, Inc. 200 Ocean gate Blvd., Suite 100 Long Beach, CA 90802
· Further, in the event of a Cybersecurity Event, provider must provide Molina any documentation required by Molina to complete an investigation, or, upon written request by Molina, complete an investigation pursuant to the following requirements:
determine whether a Cybersecurity Event occurred; assess the nature and scope of the Cybersecurity Event; identify Nonpublic Information that may have been involved in the Cybersecurity Event; and perform or oversee reasonable measures to restore the security of the Information Systems compromised in the Cybersecurity Event to prevent further unauthorized acquisition, release, or use of Nonpublic Information in Molina or provider's possession, custody, or control.
· Provider shall maintain records concerning all Cybersecurity Events for a period of at least five (5) years from the date of the Cybersecurity Event or such longer period as required by applicable laws and produce those records upon demand of Molina.
Provider must provide Molina the required information in electronic form as directed by Molina. Provider shall have a continuing obligation to update and supplement the initial and subsequent notifications to Molina concerning the Cybersecurity Event. The information provided to Molina must include at least the following: the date of the Cybersecurity Event; a description of how the information was exposed, lost, stolen, or breached, including the specific roles and responsibilities of provider, if any; how the Cybersecurity Event was discovered; whether any lost, stolen, or breached information has been recovered and if so, how this was done; the identity of the source of the Cybersecurity Event; whether provider has filed a police report or has notified any regulatory, governmental or law enforcement agencies and, if so, when such notification was provided; a description of the specific types of information acquired without authorization, which means particular data elements including, for example, types of medical information, types of financial information, or
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types of information allowing identification of the consumer; the period during which the Information System was compromised by the Cybersecurity Event; the number of total consumers in the State affected by the Cybersecurity Event; the results of any internal review identifying a lapse in either automated controls or internal procedures, or confirming that all automated controls or internal procedures were followed; a description of efforts being undertaken to re-mediate the situation which permitted the Cybersecurity Event to occur; a copy of provider's privacy policy and a statement outlining the steps provider will take to investigate and if requested by Molina, the steps that Provider will take to notify consumers affected by the Cybersecurity Event; and the name of a contact person who is both familiar with the Cybersecurity Event and authorized to act on behalf of provider.
Section 14. Credentialing and Recredentialing
The purpose of the Credentialing Program is to assure Molina Healthcare and its subsidiaries (Molina) network consists of quality providers who meet clearly defined criteria and standards. It is the objective of Molina to provide superior health care to the community.
The decision to accept or deny a credentialing applicant is based upon primary source verification, secondary source verification and additional information as required. The information gathered is confidential and disclosure is limited to parties who are legally permitted to have access to the information under state and federal Law.
The Credentialing Program has been developed in accordance with state and federal requirements and the standards of the National Committee for Quality Assurance© (NCQA ©) The Credentialing Program is reviewed annually, revised, and updated as needed.
Non-Discriminatory Credentialing and Re-credentialing
Molina does not make credentialing and re-credentialing decisions based on an applicant's race, ethnic/national identity, gender, gender identity, age, sexual orientation, ancestry, religion, marital status, health status, or patient types (e.g. Medicaid) ) in which the practitioner specializes. This does not preclude Molina from including in its network practitioners who meet certain demographic or specialty needs; for example, to meet cultural needs of Members.
Type of Practitioners Credentialed & Re-credentialed
Practitioners and groups of practitioners with whom Molina contracts must be credentialed prior to the contract being implemented.
Providers that are licensed as organizations or facilities will be credentialed as an Organizational Provider (please refer to the policy titled Assessment of Organizational Providers).
Practitioner types requiring credentialing include but are not limited to:
· Acupuncturists · Addiction medicine specialists · Audiologists
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· Behavioral healthcare practitioners who are licensed, certified or registered by the state to practice independently
· Chiropractors · Clinical Social Workers · Dentists · Licensed/Certified Midwives (Non-Nurse) · Doctoral or master's level psychologists · Master's-level clinical social workers · Master's-level clinical nurse specialists or psychiatric nurse practitioners · Medical Doctors (MD) · Naturopathic Physicians · Nurse Midwives · *Nurse Practitioners · Occupational Therapists · Optometrists · Oral Surgeons · Osteopathic Physicians (DO) · Pharmacists · Physical Therapists · **Physician Assistants · Podiatrists · Psychiatrists and other physicians · Speech and Language Pathologists · Telemedicine Practitioners
Credentialing Turn-Around Time
Molina fully enrolls/on-boards initial practitioners within sixty (60) calendar days. The sixty (60) calendar days is measured by the number days between the day Molina receives a full and complete credentialing application and the day the Agency successfully receives the practitioner on Molina's Provider Network Verification (PNV) file. Molina will submit the date it receives a full and complete credentialing application to the Agency on the PNV file requested.
Molina shall take into account and make allowances for the time required to request and obtain primary source verifications and other information that must be obtained from third parties in order to authenticate the practitioner's credentials and shall make allowances for the scheduling of a final decision to meet the sixty (60) day turnaround time.
Criteria for Participation in the Molina Network
Molina has established criteria and the sources used to verify these criteria for the evaluation and selection of practitioners for participation in the Molina network. This policy defines the criteria
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that are applied to applicants for initial participation, re-credentialing and ongoing participation in the Molina network.
To remain eligible for participation, providers must continue to satisfy all applicable requirements for participation as stated herein and in all other documentations provided by Molina.
Molina reserves the right to exercise discretion in applying any criteria and to exclude practitioners who do not meet the criteria. Molina may, after considering the recommendations of the Professional Review Committee, waive any of the requirements for network participation established pursuant to these policies for good cause, if it is determined such waiver is necessary to meet the needs of Molina and the community it serves. The refusal of Molina to waive any requirement shall not entitle any Provider to a hearing or any other rights of review.
Practitioners must meet the following criteria to be eligible to participate in the Molina network. The practitioner shall have the burden of producing adequate information to prove they meet all criteria for initial participation and continued participation in the Molina network. If the Provider fails provide this information, the credentialing application will be deemed incomplete and it will result in an administrative denial or termination from the Molina network. Practitioners who fail to provide proof of meeting these criteria do not have the right to submit an appeal.
· Application - Provider must submit to Molina a complete credentialing application either from CAQH Pro View or other State mandated practitioner application. The attestation must be signed within one-hundred-twenty (120) days. Application must include all required attachments.
· License, Certification or Registration - Provider must hold a current and, valid and license, certification or registration to practice in their specialty in every State in which they will provide care and/or render services for Molina Members. Telemedicine practitioners are required to be licensed in the state where they are located and the State the member is located.
· DEA or CDS Certificate - Provider must hold a current, valid, unrestricted Drug Enforcement Agency (DEA) or Controlled Dangerous Substances (CDS) certificate. Provider must have a DEA or CDS in every State where the Provider provides care to Molina Members. If a practitioner has never had any disciplinary action taken related to their DEA and/or CDS and has a pending DEA/CDS certificate or chooses not to have a DEA and/ or CDS certificate, the practitioner must then provide a documented process that allows another practitioner with a valid DEA and/or CDS certificate to write all prescriptions requiring a DEA number. If a practitioner does not have a DEA or CDS because it has been revoked, restricted or relinquished due to disciplinary reasons, the practitioner is not eligible to participate in the Molina network.
· Education - Practitioner must have graduated from an accredited school with a degree in their designated specialty.
o Residency Training - Practitioners must have satisfactorily completed a residency program from an accredited training program in the specialties in which they are practicing. Molina only recognizes residency training programs that have been accredited by the Accreditation Council of Graduate Medical Education (ACGME)
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and the American Osteopathic Association (AOA) in the United States or by the College of Family Physicians of Canada (CFPC), the Royal College of Physicians and Surgeons of Canada. Oral Surgeons must complete a training program in Oral and Maxillofacial Surgery accredited by the Commission on Dental Accreditation (CODA). Training must be successfully completed prior to completing the verification. It is not acceptable to verify completion prior to graduation from the program. As of July 2013, podiatric residencies are required to be three (3) years in length. If the podiatrist has not completed a three (3) year residency or is not board certified, the podiatrist must have five (5) years of work history practicing podiatry. o Fellowship Training - If the practitioner is not board certified in the specialty in which they practice and has not completed a residency program in the specialty in which they practice, they must have completed a fellowship program from an accredited training program in the specialty in which they are practicing.
· Board Certification - Board certification in the specialty in which the practitioner is practicing but not required. Initial applicants who are not board certified will be considered for participation if they have satisfactorily completed a residency program from an accredited training program in the specialty in which they are practicing. Molina recognizes board certification only from the following Boards:
o American Board of Physicians o American Board of Medical Specialties (ABMS) o American Osteopathic Association (AOA) o American Board of Foot and Ankle Surgery (ABFAS) o American Board of Podiatric Medicine (ABPM) o American Board of Oral and Maxillofacial Surgery o College of Family Physicians of Canada (CFPC) o Royal College of Physicians and Surgeons of Canada (RCPSC) o Behavioral Analyst Certification Board (BACB) o National Commission on Certification of Physician Assistants (NCCPA)
· General Practitioners Practitioners who are not board certified and have not completed a training program from an accredited training program are only eligible to be considered for participation as a general practitioner in the Molina network. To be eligible, the practitioner must have maintained a primary care practice in good standing for a minimum of the most recent five years without any gaps in work history. Molina will consider allowing a practitioner who is/was board certified and/or residency trained in a specialty other than primary care to participate as a general practitioner, if the practitioner is applying to participate as a Primary Care Physician (PCP), Urgent Care or Wound Care. General practitioners providing only wound care services do not require five years of work history as a PCP.
· Nurse Practitioners & Physician Assistants In certain circumstances, Molina may credential a practitioner who is not licensed to practice independently. In these instances, it would also be required that the practitioner providing the supervision and/or oversight be contracted and credentialed with Molina.
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· Work History - Practitioner must supply most recent five years of relevant work history on the application or curriculum vitae. Relevant work history includes work as a health professional. If a gap in employment exceeds six months, the practitioner must clarify the gap verbally or in writing. The organization documents a verbal clarification in the practitioner's credentialing file. If the gap in employment exceeds one year, the practitioner must clarify the gap in writing.
· Malpractice History - Practitioner must supply a history of malpractice and professional liability claims and settlement history in accordance with the application.
· Professional Liability Insurance - Provider must supply a history of malpractice and professional liability claims and settlement history in accordance with the application. Documentation of malpractice and professional liability claims, and settlement history is requested from the practitioner on the credentialing application. If there is an affirmative response to the related disclosure questions on the application, a detailed response is required from the practitioner.
· State Sanctions, Restrictions on Licensure or Limitations on Scope of Practice Practitioner must disclose a full history of all license/certification/registration actions including denials, revocations, terminations, suspension, restrictions, reductions, limitations, sanctions, probations and non-renewals. Practitioner must also disclose any history of voluntarily or involuntarily relinquishing, withdrawing, or failure to proceed with an application in order to avoid an adverse action or to preclude an investigation or while under investigation relating to professional competence or conduct. If there is an affirmative response to the related disclosure questions on the application, a detailed response is required from the practitioner. Molina will also verify all licenses, certifications and registrations in every state where the practitioner has practiced. At the time of initial application, the practitioner must not have any pending or open investigations from any state or governmental professional disciplinary body. This would include Statement of Charges, Notice of Proposed Disciplinary Action or the equivalent.
· Medicare, Medicaid and other Sanctions and Exclusions Practitioner must not be currently sanctioned, excluded, expelled or suspended from any state or federally funded program including but not limited to the Medicare or Medicaid programs. Practitioner must disclose all Medicare and Medicaid sanctions. If there is an affirmative response to the related disclosure questions on the application, a detailed response is required from the practitioner. Practitioner must disclose all debarments, suspensions, proposals for debarments, exclusions or disqualifications under the non-procurement common rule, or when otherwise declared ineligible from receiving federal contracts, certain subcontracts, and certain federal assistance and benefits. If there is an affirmative response to the related disclosure questions on the application, a detailed response is required from the practitioner.
If a practitioner's application is denied solely because a practitioner has a pending Statement of Charges, Notice of Proposed Disciplinary Action, Notice of Agency Action or the equivalent from any state or governmental professional disciplinary body, the practitioner may reapply as soon as practitioner is able to demonstrate that any pending Statement of Charges, Notice of Proposed Disciplinary Action, Notice of Agency Action, or the equivalent from any state or governmental professional disciplinary body is resolved, even if the application is received less than one year from the date of original denial.
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o Medicare Opt Out Practitioners currently listed on the Medicare Opt-Out Report may not participate in the Molina network for any Medicare or Duals (Medicare/ Medicaid) lines of business.
o Social Security Administration Death Master File Practitioners must provide their Social Security number. That Social Security number should not be listed on the Social Security Administration Death Master File.
o Medicare Preclusion List Practitioners currently listed on the Preclusion List may not participate in the Molina network for any Medicare or Duals (Medicare/Medicaid) lines of business.
o Professional Liability Insurance Practitioner must have and maintain professional malpractice liability insurance with limits that meet Molina criteria. This coverage shall extend to Molina Members and the practitioners activities on Molina's behalf. Practitioners maintaining coverage under a federal tort or self-insured are not required to include amounts of coverage on their application for professional or medical malpractice insurance.
o Inability to Perform Practitioners must disclose any inability to perform essential functions of a practitioner in their area of practice with or without reasonable accommodation. If there is an affirmative response to the related disclosure questions on the application, a detailed response is required from the practitioner.
o Lack of Present Illegal Drug Use Practitioner must disclose if they are currently using any illegal drugs/substances.
o Criminal Convictions Practitioners must disclose if they have ever had any criminal convictions. Practitioners must not have been convicted of a felony or pled guilty to a felony for a health care related crime including but not limited to health care fraud, patient abuse and the unlawful manufacturing, distribution or dispensing of a controlled substance.
o Loss or Limitations of Clinical Privileges At initial credentialing, Practitioner must disclose all past and present issues regarding loss or limitation of clinical privileges at all facilities or organizations with which the practitioner has had privileges. If there is an affirmative response to the related disclosure questions on the application, a detailed response is required from the practitioner. At re-credentialing, Practitioner must disclose past and present issues regarding loss or limitation of clinical privileges at all facilities or organizations with which the practitioner has had privileges since the previous credentialing cycle.
· Hospital Privileges - Practitioners must list all current hospital privileges on their credentialing application. If the practitioner has current privileges, they must be in good standing.
· NPI - Practitioner must have a National Provider Identifier (NPI) issued by the Centers for Medicare and Medicaid Services (CMS).
If a practitioner's application is denied solely because a practitioner has a pending Statement of Charges, Notice of Proposed Disciplinary Action, Notice of Agency Action or the equivalent from any state or governmental professional disciplinary body, the practitioner may reapply as soon as practitioner is able to demonstrate that any pending Statement of Charges, Notice of Proposed
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Disciplinary Action, Notice of Agency Action, or the equivalent from any state or governmental professional disciplinary body is resolved, even if the application is received less than one year from the date of original denial.
Notification of Discrepancies in Credentialing Information & Practitioner's Right to Correct Erroneous Information
Molina will notify the practitioner immediately in writing in the event that credentialing information obtained from other sources varies substantially from that submitted by the practitioner. Examples include but are not limited to actions on a license, malpractice claims history, board certification, sanctions or exclusions. Molina is not required to reveal the source of information if the information is not obtained to meet organization credentialing verification requirements or if disclosure is prohibited by Law. Practitioners have the right to correct erroneous information in their credentials files. Practitioner's rights are published on the Molina website and are included in this Provider Manual.
The notification sent to the practitioner will detail the information in question and will include instructions to the practitioner indicating:
· Their requirement to submit a written response within ten (10) calendar days of receiving notification from Molina
· In their response, the practitioner must explain the discrepancy, may correct any erroneous information and may provide any proof that is available
· The practitioner response must be sent to Molina Healthcare, Inc. Attention: Credentialing Director at PO Box 2470 Spokane, WA 99210
Upon receipt of notification from the practitioner, Molina will document receipt of the information in the practitioner's credentials file. Molina will then re-verify the primary source information in dispute. If the primary source information has changed, correction will be made immediately to the practitioner's credentials file. The practitioner will be notified in writing that the correction has been made to their credentials file. If the primary source information remains inconsistent with the practitioner's information, the Credentialing department will notify the practitioner.
If the practitioner does not respond within ten (10) calendar days, their application processing will be discontinued and network participation will be administratively denied or terminated.
Practitioner's Right to Review Information Submitted to Support Their Credentialing Application
Practitioners have the right to review their credentials file at any time. Practitioner's rights are published on the Molina website and are included in this Provider Manual.
The practitioner must notify the Credentialing department and request an appointed time to review their file and allow up to seven (7) calendar days to coordinate schedules. A Medical Director and the Director responsible for Credentialing or the Quality Improvement Director will be present. The practitioner has the right to review all information in the credentials file except peer references or recommendations protected by Law from disclosure.
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The only items in the file that may be copied by the practitioner are documents, which the practitioner sent to Molina (e.g., the application and any other attachments submitted with the application from the Practitioner). Practitioners may not copy any other documents from the credentialing file.
Practitioner's Right to be Informed of Application Status
Practitioners have a right, upon request, to be informed of the status of their application by telephone, email or mail. Practitioner's rights are published on the Molina website and are included in this Provider Manual. Molina will respond to the request within two (2) working days. Molina will share with the practitioner where the application is in the credentialing process and note any missing information or information not yet verified.
Notification of Credentialing Decisions
Initial credentialing decisions are communicated to practitioners via letter or email. This notification is typically sent by the Molina Medical Director within two (2) weeks of the decision. Under no circumstance will notifications letters be sent to the practitioners later than sixty (60) calendar days from the decision. Notification of re-credentialing approvals are not required.
Re-credentialing
Molina re-credentials every practitioner at least every thirty-six (36) months.
Excluded Providers
Excluded provider means an individual provider, or an entity with an officer, director, agent, manager or individual who owns or has a controlling interest in the entity who has been convicted of crimes as specified in section 1128 of the SSA, excluded from participation in the Medicare or Medicaid program, assessed a civil penalty under the provisions of section 1128, or has a contractual relationship with an entity convicted of a crime specified in section 1128.
Pursuant to section 1128 of the SSA, Molina and its Subcontractors may not subcontract with an excluded provider/person. Molina and its Subcontractors shall terminate Subcontracts immediately when Molina and its Subcontractors become aware of such excluded provider/person or when Molina and its Subcontractors receive notice. Molina and its Subcontractors certify that neither it nor its provider is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any federal department or agency. Where Molina and its Subcontractors are unable to certify any of the statements in this certification, Molina and its Subcontractors shall attach a written explanation to this Agreement.
Ongoing Monitoring of Sanctions
Molina monitors the following agencies for provider sanctions and exclusions between recredentialing cycles for all provider types and takes appropriate action against providers when occurrences of poor quality are identified. If a Molina provider is found to be sanctioned or excluded, the provider's contract will immediately be terminated effective the same date as the sanction or exclusion was implemented.
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· The United States Department of Health & Human Services (HHS), Office of Inspector General (OIG) Fraud Prevention and Detection Exclusions Program - Monitor for individuals and entities that have been excluded from Medicare and Medicaid programs.
· State Medicaid Exclusions - Monitor for state Medicaid exclusions through each state's specific Program Integrity Unit (or equivalent).
· Medicare Exclusion Database (MED) - Molina monitors for Medicare exclusions through the Centers for Medicare & Medicaid Services (CMS) MED online application site.
· Medicare Preclusion List Monitor for individuals and entities that are reported on the Medicare Preclusion List.
· National Practitioner Database - Molina enrolls all credentialed practitioners with the NPDB Continuous Query service to monitor for adverse actions on license, DEA, hospital privileges and malpractice history between credentialing cycles.
· System for Award Management (SAM) - Monitor for Providers sanctioned with SAM. Molina also monitors the following for all provider types between the re-credentialing cycles:
· Member Complaints/Grievances · Adverse Events · Medicare Opt Out · Social Security Administration Death Master File Provider Appeal Rights In cases where the Credentialing Committee suspends or terminates a Provider's contract based on quality of care or professional conduct, a certified letter is sent to the Provider describing the adverse action taken and the reason for the action, including notification to the provider of the right to a fair hearing when required pursuant to Laws or regulations.
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Section 15. Delegation
This section contains information specific to Molina's delegation criteria. Molina may delegate certain administrative responsibilities upon meeting all of Molina's delegation criteria and execution of a Delegation of Services Agreement, as defined by Molina. Molina is accountable for all aspects of the Member's health care delivery, even when it delegates specific responsibilities to sub-contracted entities. Molina's Delegation Oversight Committee (DOC), or other designated committee, must approve all delegation and sub-delegation arrangements.
Delegation is a process that gives another entity the ability to perform specific functions on behalf of Molina. Molina may delegate:
1. Medical Management 2. Credentialing and Recredentialing 3. Sanction Monitoring for employees and contracted staff at all levels 4. Claims 5. Complex case management 6. CMS Preclusion List Monitoring 7. Other clinical and administrative functions
When Molina delegates any clinical or administrative functions, Molina remains responsible to external regulatory agencies and other entities for the performance of the delegated activities, including functions that may be sub-delegated. To become a delegate, the Provider/Accountable Care Organization (ACO)/vendor must be in compliance with Molina's established delegation criteria and standards. Molina's Delegation Oversight Committee (DOC), or other designated committee, must approve all delegation and sub-delegation arrangements. To remain a delegate, the Provider/ACO/vendor must maintain compliance with Molina's standards and best practices.
Disease Management
To be considered as a delegate for Disease Management functions, Medical Groups, IPAs and/or Vendors must meet the following criteria:
· Submit a written request to Molina to be considered for delegation. · Be certified by the National Committee for Quality Assurance (NCQA) for complex care
management and disease management programs. · Must be able to support South Carolina Department of Health and Human Services
(SCDHHS) disease management requirements that includes, but is not limited to, the following:
o Comply with physical and behavioral health Disease Management and Case Management /Coordination provisions
o Preventive and Rehabilitative Services for Primary Care Enhancement o Develop utilization review protocols-utilization review falls under the scope of UM
Delegation
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o Consult with the Department prior to implementation of the Contractor's protocols to ensure alignment with the intent of this service
· Monthly Disease Management Reporting Requirements o Submit a monthly report of all members that are receiving disease management services. o Member program eligibility and enrollment data, program engagement rates, and maintenance of NCQA compliant disease management care plans
· Quarterly program performance reporting · Undergo a delegation pre-assessment audit. The audit includes the following standards:
o Verification of NCQA certification o Assess program compliance for meeting South Carolina Department of Health and
Human Services (SCDHHS) contractual requirements for disease management · Honors timely requests for disease management files required for internal and external
audits · Comply with all applicable federal and state laws
Note: Molina does not allow disease management delegates to further sub-delegate disease management activities.
A Medical Group, IPA, or Vendor interested in a delegated Disease Management arrangement should contact Molina's Quality Improvement Compliance Department.
Credentialing
Credentialing functions may be delegated to Capitated or Non-Capitated entities, which meet National Committee for Quality Assurance (NCQA) criteria for credentialing functions. To be delegated for credentialing functions, Providers must:
· Pass Molina's credentialing pre-assessment, which is based on NCQA credentialing standards.
· Have a multi-disciplinary Credentialing Committee who is responsible for review and approval or denial/termination of practitioners included in delegation.
· Have an Ongoing Monitoring process in place that screens all practitioners included in delegation against OIG and SAM exclusion lists a minimum of every 30 days.
· Correct deficiencies within mutually agreed upon time frames when issues of noncompliance are identified by Molina.
· Agree to Molina's contract terms and conditions for credentialing delegates. · Submit timely and complete Credentialing delegation reports as detailed in the Delegated
Services Addendum to the applicable Molina contact. · Comply with all applicable federal and state Laws. · When key specialists, as defined by Molina, contracted with IPA or group terminate,
provide Molina with a letter of termination according to Contractual Agreements and the information necessary to notify affected Members.
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· Must employ a minimum of 100 practitioners. · Must have an NCQA compliant credentialing process that has been in operation for at
least three years.
Note: If the Provider is an NCQA Certified or Accredited organization, a modified pre-assessment audit may be conducted. Modifications to the audit depend on the type of Certification or Accreditation the Medical Group, IPA, or Vendor has, but will always include evaluation of applicable state requirements and Molina business needs.
If the Provider sub-delegates Credentialing functions, the sub-delegate must be NCQA accredited or certified in Credentialing functions or demonstrate an ability to meet all Health Plan, NCQA, and State and Federal requirements identified above. A written request must be made to Molina prior to execution of a contract, and a pre-assessment must be completed on the potential sub-delegate, and annually thereafter. Evaluation should include review of Credentialing policies and procedures, Credentialing and Re-credentialing files Credentialing Committee Minutes, Ongoing Monitoring documentation, and a process to implement corrective action if issues of non-compliance are identified.
An entity may request Credentialing delegation from Molina through Molina's Delegation Oversight Manager or through their Contract Manager. Molina will ask the potential delegate to submit a Credentialing Pre Delegation survey, policies and procedures for review and will schedule an appointment for pre-assessment. The results of the pre-assessment are submitted to the Delegation Oversight Committee (DOC) for review and approval. Final decision to delegate Credentialing responsibilities is based on the entity's ability to meet Molina, State and Federal requirements for delegation.
Delegation Reporting Requirements
Delegated entities contracted with Molina must submit monthly and quarterly reports determined by the function(s) delegated to the identified Molina Delegation Oversight Staff within the time line indicated by Molina. For a copy of Molina's current delegation reporting requirements, please contact your Molina Contract Manager.
Corrective Action Plans and Revocation of Delegated Activities
If it is determined that the delegate is out of compliance with Molina's guidelines or regulatory requirements, Molina may require the delegate to develop a corrective action plan designed to bring the delegate into compliance. Molina may also revoke delegated activities if it is determined that the delegate cannot achieve compliance or if Molina determines that is the best course of action.
If you have additional questions related to delegated functions, please contact your Molina Contract Manager.
CMS Preclusion List
All subcontractors delegated for Credentialing and/or Claims Administration must review their Provider network against the CMS Preclusion list. The CMS Preclusion list will be provided to the subcontractor on a monthly basis by Molina. Within five business days of receipt, the
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subcontractor must review the list and identify any Providers with a new preclusion since the last publication date. Within 15 calendar days of receipt of the list, the subcontractor must notify Molina of any identified Provider(s), including a report of all Molina Claims paid to the Provider in the previous 12 months. Depending on delegated expectations, subcontractors may also be responsible for sending the necessary Member notification at least 60 calendar days prior to the Preclusion effective date, informing the Member of the need to select a new Provider.
Note: Member notification responsibilities depend on the functions delegated and the services provided. Not all subcontractors are responsible for this piece, and in some cases, are required to send the appropriate information to Molina so that Molina can notify impacted Members. If there are questions about subcontractor responsibilities related to Member notification of precluded Providers, please contact your Molina Delegation Oversight contact.
Section 16. Appeals and Grievance Process
Molina members or members' personal representatives have the right to file a grievance and submit an appeal through a formal process. All grievances and appeals must first be submitted to Molina for resolution. Members also have access to the State Fair Hearing system if they are dissatisfied with Molina's final determination of an appeal.
Molina members and providers will not be penalized, discriminated against or otherwise retaliated against for filing a grievance or appeal. Members are informed of their grievance and appeal rights and their access to the State Fair Hearing system (for appeals) through various general communications including, but not limited to, the Member Handbook, and Disclosure, Member Newsletters and Molina's website: MolinaHealthcare.com.
This section addresses the identification, review and resolution of member grievances and appeals. Below is Molina's Member Grievance and Appeals Process.
Definitions
Adverse Benefit Determination: Adverse benefit determination means the denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or in part, of payment for a service; the failure to provide services in a timely manner; the failure to act within the time frames provided in State and Federal regulations regarding the standard resolution of grievances and appeals; for a resident of a rural area with only one MCO, the denial of a member's request to exercise his or her right to get services outside the Molina network; or the denial of a member's request to dispute a financial liability, including cost sharing, co-payments, premiums, deductibles, coinsurance, and other member financial liabilities.
Appeal: An appeal is a request for Molina to review an adverse benefit determination/decision made.
Clinical Peer: Clinical peer means a health care professional who is in the same profession and the same or similar specialty as the health care provider who typically manages the medical condition, procedures, or treatment under review.
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Expedited Appeal: An Expedited Appeal is a request for Molina to review an adverse benefit determination where the adverse benefit determination is related to a hospital admission, continued stay, or other health care services, when following the standard appeals time frame could seriously jeopardize the member's life or health or ability to attain, maintain, or regain maximum function.
Grievance: Grievance means any expression of dissatisfaction about a matter other than an adverse benefit determination. Possible subjects for grievances include, but are not limited to, the quality of care or services provided, aspects of personal relationships such as rudeness of a provider or employee or failure to respect a member's rights.
Second Opinion
If a member or member's authorized representative does not agree with their provider's plan of care, they have the right to request a second opinion from another provider. Members can call Member Services to find out how to get a second opinion, and under what circumstances a second option can be obtained/approved. If a member receives services from an out-of-network provider then prior approval will be required.
Providers may also request a second opinion for a member if certain clinical requirements are met. Providers should call Provider Services for additional information regarding Molina's Second Opinion Policy.
Member Grievance Process:
If a member is unhappy with the service from Molina or providers contracted with Molina, they may file a grievance by contacting Member Services toll-free at (855) 882-3901. They can also write to us at:
Molina Healthcare of South Carolina Attn: Member Appeals & Grievances
PO Box 40309 North Charleston, SC 29423-0309
Or via fax: (877) 823-5961
All grievances, whether oral or written, are documented and logged in all appropriate systems. Members may identify an individual in writing, including an attorney or provider, to serve as a personal representative to act on their behalf at any stage during the grievance and appeals process. If under applicable law, a person has authority to act on behalf of a member in making decision related to health care or is a legal representative of the member, Molina will treat such person as a personal representative. The member (or authorized representative) shall have the right to participate in the formal grievance proceedings.
When needed, members are given reasonable assistance in completing forms and taking other procedural steps, including translation services for members with limited English proficiency or other limitations, e.g., hearing impaired, requiring communication support.
Molina does not discriminate against, retaliate against, or take any other form of punitive action against members or members' representatives for utilizing the grievance process. Molina does not take punitive action of any kind against providers for assisting members in the grievance process.
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Any grievance regarding a potential quality of care issue is referred to the Quality Improvement Department for further investigation. Additionally, any identified issue related to the Privacy and Confidentiality of Protected Health Information (PHI) is referred to the Compliance Department.
Molina has an organized grievance process to ensure thorough, appropriate and timely resolution to member grievances. Grievance analysis is performed regularly to identify trends, concerns and opportunities for improvement.
Grievance Timelines
Grievances may be filed orally or in writing at any time from the date the member became aware of an issue. Oral grievances are acknowledged at the time of filing and written acknowledgment is issued within five business days for grievances filed in writing. Grievances may be submitted by members, a member's provider (with the member's consent) or member's authorized representative acting on behalf of the member with written consent from the member.
All grievances are resolved within 90 calendar days.
A member can ask Molina to extend the time frame to resolve a grievance by up to 14 calendar days. Molina can also extend the time frame to resolve a grievance by up to 14 calendar days if Molina thinks that the delay is in the member's best interest. If Molina extends the time frame, we must be able to explain to SCDHHS how the delay is in the member's best interest. We will call the member and a letter will be sent to the member informing him or her of the extension and why the delay is in their best interest. If Molina extends the time frame, the letter will also include information about the member's right to file a grievance about extending the time frame.
Appeals
An appeal is a request for Molina to review an adverse benefit determination/decision made regarding a request for services including the type, level, and duration of services. Appeals may be submitted by members, providers or their authorized representative acting on behalf of the member with written consent from the member. A provider can appeal on a Molina member's behalf if the member has agreed to treatment; Molina has received medical records from the provider; and/or there is a history of paid claims for services from the provider. When a requested health care service has been denied in whole or part, the members are sent a notice of the denied adverse benefit determination. The following is included in the notice:
· Their right to appeal the decision · The process by which the appeal is initiated · The Molina Customer Service phone number where more information regarding the appeal
process can be obtained · The availability of Molina to assist the member in filing an appeal if needed
All appeals that involve a denial based on clinical medical necessity will be reviewed by the Chief Medical Officer (CMO)/Medical Director who was not involved in any previous level of review or decision-making and has the appropriate clinical expertise. When appropriate, appeals will be sent out for an independent review to ensure it meets the NCQA guidelines of a clinical review by a "same or similar" specialty. A written appeal resolution letter will contain reasons for the
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determination including the medical or clinical criteria for the determination. The letter will also provide the member with their State Fair Hearing rights if the denial is upheld.
A member can ask Molina to extend the time frame to resolve an appeal by up to 14 calendar days. Molina can also extend the time frame to resolve an appeal by up to 14 calendar days if Molina thinks that the delay is in the member's best interest. If Molina extends the time frame, we must be able to explain to SCDHHS how the delay is in the member's best interest. We will call the member and a letter will be sent to the member informing him or her of the extension and why the delay is in their best interest. If Molina extends the time frame, the letter will also include information about the member's right to file a grievance about extending the time frame.
Members who are not satisfied with Molina's appeal determination may request a State Fair Hearing. A State Fair Hearing must be requested within 120 calendar days of the date on the notice of Appeal resolution.
Standard Appeals Process and Timeline
Standard appeals may be submitted orally or in writing. Oral appeals must be followed by a written appeal request. Standard appeals must be filed within 60 calendar days from the date of the notice of adverse benefit determination and may be submitted to:
Molina Healthcare of South Carolina Attn: Member Appeals & Grievances
PO Box 40309 North Charleston, SC 29423-0309
Or Via Fax: (877) 823-5961
Or Via Phone: (855) 882-3901
Molina will acknowledge receipt and notify the party filing the appeal of all information that is required to evaluate the appeal. Molina will render a decision on the appeal within 30 calendar days from the date of receipt of the appeal. The time frame to resolve an appeal may be extended another 14 days if the member/authorized representative or Molina think it would be in the member's best interest (for example, additional information is needed). A letter will be sent to the member informing them of the extension, why it was requested and that it was in the member's best interest if the plan requests the extension. If Molina extends the time frame, the letter will also include information about the member's right to file a grievance about extending the time frame.
Members, member's authorized representative, or any regulatory or oversight agencies may request copies of the documents used to review the appeal free of charge. Members may ask for copies of the benefit, guidelines, or any other criteria used to make the decision. Members may also request information regarding the qualifications and specialty of the doctors who looked at the appeal. If a Molina member would like a copy of their case file at any time, they may contact Member Services to make this request.
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Expedited Appeals Process and Timeline
Expedited appeals are available when following the standard appeals time frame could seriously jeopardize the member's life or health or ability to attain, maintain, or regain maximum function. Expedited appeals may be submitted orally or in writing. Expedited appeals can be filed within 60 calendar days from the date of notice of adverse benefit determination. If the expedited appeal is submitted orally, a written appeal request is not needed. Submit requests to:
Molina Healthcare of South Carolina Attn: Member Appeals & Grievances
PO Box 40309 North Charleston, SC 29423-0309
Or Via Fax: (877) 823-5961
Or Via Phone: (855) 882-3901
Upon receipt of an expedited appeal request, Molina will notify the party filing the appeal as soon as possible, and within no more than 24 hours after receipt, of all information that is required to evaluate the appeal. If the request to expedite is approved, Molina will notify the member of the limited time available to present evidence for the appeal and will render a decision within 72 hours of receipt of the appeal request, unless an extension is granted as mentioned above. If the request to process the appeal as expedited is denied, Molina will notify the member or authorized representative promptly via telephone of the result of the resolution process and the date it was completed. Within two calendar days of the decision, Molina will provide written notification of the decision to deny the processing of the appeal as expedited and inform the member that they can grieve the decision. The appeal will then be processed as a standard appeal.
Molina will attempt to provide oral notification to the member/member's representative of the appeal determination promptly after determination is made. Oral notification will be followed up by a written notice of determination. Where a service denial is reversed, the provider will be notified of the determination as promptly as possible. In all appeals, members can present evidence in person as well as in writing, and can request copies to examine the case file and other documents related to the appeal. Molina will provide these items to the member.
A member can ask Molina to extend the time frame to resolve an appeal by up to 14 calendar days. Molina can also extend the time frame to resolve an appeal by up to 14 calendar days if Molina thinks that the delay is in the member's best interest. If Molina extends the time frame, we must be able to explain to SCDHHS how the delay is in the member's best interest. We will call the member and a letter will be sent to the member informing him or her of the extension and why the delay is in their best interest. If Molina extends the time frame, the letter will also include information about the member's right to file a grievance about extending the time frame.
State Fair Hearing
The State Fair Hearing system is available to members after they have exhausted Molina's internal appeal process and are dissatisfied with the determination. Requests for a State Fair Hearing must be made no later than 120 calendar days from the date on the notice of Appeal.
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Molina will participate in the State Fair Hearing process by completing all required documents within the required time frame and providing to appeal information, including, but not limited to, medical records and claim payment records.
Continuation of Benefits
A member has the right to continue receiving services during the appeal process if requested in writing within ten calendar days from the date on the denial notice. If the final resolution of the appeal decision is made and it is not in the member's favor, they may be responsible for the cost of the care received during the appeal process.
Provider Claim Dispute/Claim Re-determination Request
Providers seeking a redetermination of a claim previously adjudicated must request such action within 90 calendar days of Molina's original remittance advice date. Additionally, the item(s) being resubmitted should be clearly marked as a redetermination and must include the following documentation:
· The item(s) being resubmitted should be clearly marked as a Claim Dispute/ Adjustment · Payment adjustment requests must be fully explained · The previous claim and remittance advice, any other documentation to support the
adjustment and a copy of the Referral/Authorization form (if applicable) must accompany the adjustment request · The claim number clearly marked on all supporting documents These requests shall be classified as a Claims Disputes/Adjustment and be sent to the following:
Molina Healthcare of South Carolina Attention: Claims Disputes / Adjustments
PO Box 40309 North Charleston, SC 29423-0309
Or Via Fax: (877) 901-8182
The provider will be notified of Molina's decision in writing within 30 business days of receipt of the Claims Dispute/ Adjustment request. Providers may request a claim dispute/adjustment when the claim was incorrectly denied as a duplicate or due to claims examiner or data-entry error.
Please note that Molina does not offer second level appeals.
Molina's Commitment to Patient Privacy
Protecting the privacy of members' personal health information is a core responsibility that Molina takes very seriously. Molina is committed to complying with all federal and state laws regarding the privacy and security of members' protected health information (PHI).
Provider/Practitioner Responsibilities
Molina expects that its contracted providers/practitioners will respect the privacy of Molina members and comply with all applicable laws and regulations regarding the privacy of patient and member PHI.
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Molina provides its Members with a privacy notice upon their enrollment in our health plan. The privacy notice explains how Molina uses and discloses their PHI and includes a summary of how Molina safeguards their PHI. Telehealth/Telemedicine Providers: Telehealth transmissions are subject to HIPAA-related requirements outlined under State and Federal Law, including:
· 42 C.F.R. Part 2 regulations · Health Information Technology for Economic and Clinical Health Act, ("HITECH Act") · In accordance with 42 CFR § 401.305 and MCL 400.111b(16), Medicaid providers are
required to self-report any overpayment received from Molina, return the overpayment to Molina, and notify Molina in writing for the reason of the overpayment. To self-report an overpayment, please see Chapter 4-Claims for more information. · In accordance with 42 CFR § 438.610 and 42 CFR Subpart 455, providers must not knowingly employ, contract, or be affiliated with, a director, officer, partner, managing employee or person with beneficial ownership of more than 5% of the provider's equity who has been or are currently debarred or suspended from participating from State and Federal health care programs. Providers must immediately terminate any individual or entity excluded from participation.
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Appendix
Molina Forms and Materials The following Molina forms and reference materials have been included for your use. Please feel free to make copies as needed.
· Pregnancy Notification Report · Disease Management/Care Management Referral Form · SBIRT Integrated Screening Tool · Abortion Statement · Surgical Justification Review for Hysterectomy · Transportation Brokers Grid · Neonatal Transfer Form · Health Education Referral Form To access additional forms, including the latest copy of the Consent for Sterilization Form, please visit the SCDHHS Provider Manual Forms section: https://www.scdhhs.gov/internet/ pdf/manuals/Physicians/Forms.pdf
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Pregnancy Notification Report
Thank you in advance for completing this form
Please complete all sections and fax within 7 day of the first prenatal visit and/or positive pregnancy test.
Today's Date:
/
/
DIRECTIONS FOR COMPLETION OF FORM:
Step 1: Complete all member information. Step 2: Complete the OB/GYN section with the name of the OB/GYN to whom the member was referred for
prenatal care. Step 3: Fax form to Molina Healthcare at 1 (866) 423-3889 Step 4: If you have any questions or need some assistance, please contact us at 1 (855) 237-6178
STEP 1: MEMBER INFORMATION
Member's Name:
Member ID/CIN:
Address:
CITY:
STATE: ZIP:
Member DOB:
/
/
Phone #: ( ) Alternate Ph.#: ( ) -
Date of Positive Pregnancy Test:
/
/
Preferred Language:
LMP:
EDC:
Gravida:
Para:
Number of Live Births:
High Risk Condition(s) (if known):
CURRENT PREGNANCY
PAST PREGNANCY N/A
Hypertension Excessive Nausea & Vomiting Hypertension
Diabetes
Diabetes
Pre-term labor
Pre-term labor
Pre-term delivery
Smoking
Multiple Gestation
No problems with Current Pregnancy
No problems with Current Pregnancy
Other:
Other:
STEP 2: OB/GYN INFORMATION
OB/GYN Practitioner's Name:
OB/GYN Practitioner's Phone Number: ( ) -
Date of First Prenatal Appointment:
/
/
Referring Practitioner:
Phone: ( ) -
STEP 3: FAX FORM TO MOLINA HEALTHCARE
Fax to Molina Healthcare Fax line at 1 (866) 423-3889
STEP 4: CALL MOLINA WITH QUESTIONS
If you have any questions or need assistance, please contact us at 1 (855) 237-6178
Thank you for taking such good care of our members!
[Original form to remain in member's chart] Pregnancy Notification Form_SC Version2_12 1 14
Case Management Referral Form
The Molina Case Management program is designed to assist you and our members to achieve optimal health care outcomes. Molina Case Management provides a comprehensive program with Transition of Care Coach-RNs, Case Managers, and Community Connectors. The team is available to provide in-home or hospital visitation and to assist members with how to navigate the care system and obtain necessary services that will adequately meet their medical needs. Molina members may be referred to Case Management if they are actively in treatment but are failing to meet care plan milestones, however all members are eligible for our Case Management program. If you would like to refer a Molina Healthcare member for this program, please fax completed form to: Molina Healthcare of South Carolina, Case Management Department at (843) 740-1773.
Member Name: Member Phone Number: Date Referred to Case Management: Name and Phone Number of Person/Provider Submitting Referral:
DOB: Certificate Number:
Reason for Case Management Referral High Risk Obstetrics-Gestational Age Less Than 35 Weeks
Previous preterm labor (20 to 37wks) Previous preterm delivery (20 to 37wks) Incompetent cervix Cerclage (date done): Placenta previa/abruption Current substance abuse (including smoking) - Type: Other (specify high-risk medical condition):
Transplant
Type:
Catastrophic Conditions (ADULT AND PEDIATRIC)
Catastrophic/complex diagnosis requiring coordination of care, connection to services, coordination of benefits Compounding psychosocial factors presenting actual or potential barriers to care Chronic conditions requiring:
Three or more hospitalizations within the past 6 months Nonhealing wound requiring active treatment for a duration greater than 3 months Member/Caregiver is requesting case management - Contact phone number: Behavioral care needs:
HIV/AIDS
HIV
AIDS
End Stage Renal Disease
Hemodialysis Peritoneal dialysis
Sickle Cell
Disease Trait
Continuity of Care Services (because of physician contract terminations or member insurance changes)
Does the member have a need for continuation of services?
Acute or chronic health care condition requiring completion of service to complete a course of treatment
Pregnancy
Terminal illness
Surgery
Newborn (birth to 36 months)
Comments:
What would you like Case Management to focus on?
Are medical records attached to this referral? Yes No
www.MolinaHealthcare.com
10252191SC0518
South Carolina
MEDICAID SBIRT INTEGRATED SCREENING TOOL
*Fax the COMPLETED form to the patient's plan and referral site and keep a copy in patient file
Absolute Total Care Fax: 877-285-3226
Advicare Fax: 888-781-4316
Blue Choice Health Plan Medicaid Fax: 855-580-2810
First Choice by Select Health Fax: 866-533-5493
Molina Fax: 866-423-3889
SCDHHS (Fee-For-Service) Fax: 803-255-8247
Wellcare Fax: 866-455-6562
Blue Cross Blue Shield of South Carolina & Blue Choice Health Plan Fax: 803-870-9884
Patient's last name:
First:
PATIENT INFORMATION
Middle:
Language:
Race:
Ethnicity:
Expected due date:
Phone no: ( )
Practice name:
Street address:
Member ID no:
Group NPI:
PROVIDER INFORMATION
Individual NPI:
Screening provider's name:
PATIENT SCREENING INFORMATION
Parents Did any of your parents have a problem with alcohol or drug use?
YES
Peers Do any of your friends have a problem with alcohol or other drug use?
YES
Partner Does your partner have a problem with alcohol or other drug use?
Violence Are you feeling at all unsafe in any way in your relationship with your current partner?
Emotional Health Over the last few weeks, has worry, anxiety, depression or sadness made it difficult for you to do your work, get along with people or take care of things at home?
Past In the past, have you had difficulties in your life due to alcohol or other drugs, including prescription medications?
Present In the past month, have you drunk any alcohol or used other drugs? 1.How many days per month do you drink? 2.How many drinks on any given day? 3.How often did you have 4 or more drinks per day in the last month? 4.In the past month have you taken any prescription drugs?
Smoking Have you smoked any cigarettes in the past three months?
Please provide additional details for any "yes" responses:
YES
Phone no: ( )
YES
YES YES YES
NO NO NO NO
YES
NO
NO
NO
NO
Review risk
Review domestic violence resources
Review substance use, set healthy goals
Consider mental evaluation
ADVICE FOR BRIEF INTERVENTION
Y
N
N/A
Did you State your medical concern?
Did you Advise to abstain or reduce use?
Did you Check patient's reaction?
Did you Refer for future assessment?
At Risk Drinking
Non-Pregnant Pregnant/Planning Pregnancy
7+ drinks/week 3+ drinks/day
Any Use is Risky Drinking
Patient referred to: (Check all that apply)
DMH
CONFIDENTIAL SBIRT REFERRAL INFORMATION
DAODAS
DHEC Quitline
Private provider (Name & NPI)
Fax: 800-483-3114
Domestic violence 803-256-2900
Date of referral appointment (DD/MM/YY): Date screened:
Patient refused referral Referral not warranted:
Patient requested assistance
Women's health can be affected by emotional problems, alcohol, tobacco, other drug use and domestic violence. Women's health is also affected when those same problems are presented in people close to us. By "alcohol," we mean beer, wine, wine coolers or liquor.
Physician's Signature:
*Adapted from Institute for Health & Recovery, (2015)
ABORTION STATEMENT
This certification meets FFP requirements and must include all of the aforementioned criteria. Patient's Name : Patient's Medicaid ID#: Patient's Address:
Physician Certification Statement
I,
certify that it was necessary to terminate the pregnancy of
for the following reason:
a. ( ) Physical disorder, injury, or illness (including a life-endangering condition caused or arising from pregnancy) placed the patient in danger of death unless abortion was performed. Name of condition:
b. ( ) The patient has certified to me the pregnancy was a result of rape or incest and the police report is attached.
c. ( ) The patient has certified to me pregnancy was a result of rape or incest and the patient is unable for physiological or psychological reasons to comply with the reporting requirements.
Physician's Signature
Date
*************************************************************************************************************** The patient's certification statement is only required in cases of rape or incest.
Patient's Certification Statement
I,
of rape or incest. (Patient's Name)
certify that my pregnancy was the result of an act
Patient's Signature
Date
Both the completed Abortion Statement and appropriate medical records must be submitted with the claim form.
SOUTH CAROLINA MEDICAID PROGRAM SURGICAL JUSTIFICATION REVIEW FOR HYSTERECTOMY
THIS COMPLETED FORM AND A SIGNED "ACKNOWLEDGMENT OF RECEIPT OF HYSTERECTOMY INFORMATION" FORM MUST BE RECEIVED 30 DAYS PRIOR TO SCHEDULED SURGERY.
PATIENT NAME
LAST
FIRST
BIRTH DATE MONTH/DAY/YEAR
GRAVITY
MEDICAID # MI
PARITY
PROCEDURE CODE:
DX CODE:
HOSPITAL
NAME
NPI (IF AVAILABLE)
PLANNED ADMISSION DATE
PLANNED SURGERY DATE
TYPE OF HYSTERECTOMY PLANNED
GYNECOLOGICAL HISTORY/PHYSICAL EXAM RELATING TO PRINCIPAL DIAGNOSIS:
HCT
HGB
CHECK ONE: PRE MENOPAUSAL
CONSERVATIVE TREATMENT/MEDICATION WITH DATES:
POST MENOPAUSAL
PRIOR GYN SURGERY/DIAGNOSTIC PROCEDURES (INCLUDE COPIES OF ALL REPORTS):
OFFICE NOTES AND ALL SUPPORTING DOCUMENTATION (e.g., ULTRASOUND OPERATIVE AND PATH REPORTS, ETC.) ARE REQUIRED FOR APPROVAL AND SHOULD BE ATTACHED TO THIS FORM.
ATTENDING PHYSICIAN'S NAME
LAST
FIRST
MI
NPI
ADDRESS
CONTACT PERSON
TELEPHONE(
)
FAX(
)
SIGNATURE
ATTENDING PHYSICIAN
DATE
APPROVALS ARE VALID FOR 180 DAYS FROM DATE OF ISSUE. Revised: 06/01/12
Health Education Referral Form
Complete all requested information (please print clearly). Member Information
Today's Date:
Last Name:
First Name:
Member ID/ CIN #:
Address:
City:
Zip Code:
Current Phone #:
Preferred Language:
DOB:
Diagnosis:
Full Name of Guardian (if member is under 18 years of age):
Best Time to Call Member:
OK to leave messages at home: YES
NO
PCP Information
Name:
Address:
Phone Number:
Ext:
Fax Number:
Referral for Educational Services
To refer a Molina member for the following health education services: 1. Fax or E-mail the completed referral form to Molina at (800) 642-3691 or MHIHealthEducationMailbox@MolinaHealthCare.Com. 2. Include required documentation with all referrals.
Asthma (2+ years old)
General Nutrition (not to be checked for weight management)
Pregnancy (EDC):
Depression (18+ years old)
Adult Weight Management (18+ years old): Telephonic weight management consultation with a Health Educator
Medical Nutrition Therapy (Consultation with Registered Dietitian) For all MNT referrals, please attach most recent progress notes and labs
Failure to Thrive
HIV/AIDS
Nutrition Assessment (specify need):
Liver Failure
Oncology
Other:
Multiple Food Allergies
Renal Failure
Resources for Providers
Educational materials are available in the listed topic areas below. Please visit the following links to download and/or print on demand: Health Education Materials and Clear and Easy Booklets.
Appropriate Use of Healthcare Services (i.e.: Make the most of your healthcare visit, how to take care of your sick family) Risk Reduction and Healthy Lifestyles (i.e.: Exercise, Stop Smoking, Kids and Healthy Weight, etc.) Self-Care and Management of Health Conditions (i.e.: Hypertension, Diabetes, Asthma, etc.) Pregnancy and Postpartum ( i.e.: Signs and Stages of Labor, Prenatal Care, Anemia, etc.) Behavioral Health Management (i.e.: Depression, Eating Disorders, Substance Abuse, etc.)
Transportation Broker Listing and Contact Information
Transportation is available for doctor appointments, dialysis, x-rays, lab work, drug store or other non-emergency medical appointments for Molina members. If a member needs a ride, they can call the Healthy Connections transportation broker between 8 a.m. and 5 p.m., local time. A ride must be requested at least three days before their appointment. If a member needs to cancel a ride, they must call at least twenty-four (24) hours in advance. Members may schedule or cancel a ride by calling one of the following toll-free numbers. They can also call Member Services for assistance. Toll-Free Phone Numbers: (866) 910-7688 (866) 445-6860 (866) 445-9954 For more information on LogistiCare, visit http://memberinfo.logisticare.com/scmember
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