Molina Healthcare Provider Guide

Utilization Management

1. Will Molina have on-site case managers who conduct the medical review of nursing facility (NF) residents?
The Molina Prior Authorization Nurse will review the member's condition applying Title 22 criteria for medical necessity, but will not be on-site. Please refer to the Directory: Utilization Management Department (Appendix 5) specific to your county or region on how to submit prior authorization requests. Requests may be submitted via fax or via the Molina Provider Portal. One of Molina's Ambulatory Case Managers will be on-site to conduct the Cal MediConnect (CMC) required face-to-face Health Risk Assessment (HRA). As part of the visit to the facility, the case manager will meet with the member, review the Minimum Data Set (MDS) and other information in the member's chart, and talk with facility staff about the member's condition. The case manager will share this information with the Molina Long Term Care (LTC) Nurse, particularly as it relates to Title 22 Nursing Facility Level of Care criteria. As needed, the case manager may make recommendations to the Molina Prior Authorization Nurse about the type and/or length of the authorization.

2. If not on-site, will specific case managers be assigned to each facility?
As Molina identifies how many members are residing in each facility, and the geographic distribution of members and facilities within a region, Molina will make assignments to specific case management staff.

3. How long will authorizations be effective?
Molina will authorize custodial care for up to six (6) months, with exceptions (shorter or longer authorizations) based on medical review. See question 13 below for information on how to request an extension of a Molina authorization.

4. Is there a different process for "skilled" level of care compared to "custodial" level of care?
Yes. See authorization requirements in Appendix 1 for skilled versus custodial level of care.

5. What documents are required to submit for authorization and what is the process to submit them?
Please refer to the Authorization Detail Information Grid (Appendix 1) for more detailed information. The Authorization Request Form and supporting documentation must be faxed within the indicated timeframes to Molina at:

• (800) 811-4804 for Medi-Cal covered services
• (866) 472-6303 for Medicare covered services

• Molina contracted providers must follow the Medi-Cal/Medicare Prior Authorization/Pre-Service Review Guide to determine which services require prior authorization.
• Providers that are not contracted with Molina must request prior authorization for all services by submitting the Medi-Cal/Medicare Prior Authorization Request Form.

Utilization Management (Continued)

6. Is the authorization documented electronically and immediately available to the nursing facilities (NFs)?
Yes. Nursing facilities (NF) have access to this information in the Molina Provider Portal.

7. Is the authorization electronically tied to the claims processing system?
Yes. The nursing facility (NF) must include the authorization number on the claim form. See section on claims submission.

8. Does the health plan need supporting documents from the nursing facility (NF) in order to pay a claim?
The nursing facility does not need to submit supporting documentation with a claim for an authorized service. The nursing facility must include the authorization number on the claim form. Submission of a hard copy of the authorization should not be required to pay the claim. See section on claims submission.

9. Does the health plan delegate authorization to other groups, such as IPAs? If so, are the IPA authorizations tied to the health plan claims systems?
Molina has delegated skilled services to groups managed by Heritage Provider Network and Davita Healthcare Partners. Please refer to the Delegation of Skilled and Custodial Care Section on page 10 for more detailed information as they relate to delegation.

10. In the case where initial skilled level of care is delegated to the IPA, who is responsible for authorization and payment when the member reverts to custodial level of care? Who resolves disputes between the IPA and the health plan for responsibility of payment?
In designated regions, Molina has delegated skilled services to groups managed by Heritage Provider Network and Davita Healthcare Partners. For example, Heritage Provider Network would be responsible for rendering service authorizations and payments on behalf of Molina members who are assigned to one of their providers. When a member improves to custodial level of care, that member will be un-assigned from Heritage Provider Network and will be assigned back to the health plan. From that time onward, Molina would take over the authorization and payment for such custodial patients. Please refer to the Delegation of Skilled and Custodial Care Section on page 10 for more detailed information as they relate to delegation.

11. Are the IPAs required to provide copies of the authorizations immediately to the nursing facility (NF)? We have heard that some IPAs will not provide them until the member is discharged.
All delegated IPAs are required to follow the Cal MediConnect Program requirements when it comes to providing authorization to facilities as follows:

12. What training is available on authorization procedures?
Molina staff is available to provide orientations and trainings to all contracted nursing facilities. Please refer to the Directory: Utilization Management Department (Appendix 3).

13. How can I obtain an extension to a member's original Molina Custodial Care authorization?
To request an extension for a Molina authorization, please fax your request to the Molina Prior Authorization Department at (800) 811-4804.
The table below lists the documents required for an extension review. We ask that you allow five (5) business days for a faxed response. Molina contracted providers may also submit requests for extensions and check for status using the Molina Provider Portal.

Utilization Management - Sub-Acute Services

1. Does the health plan recognize that nursing facilities (NFs) may provide skilled, custodial and sub-acute services all within the same facility?
Yes.

2. Are all of the points above applicable to a nursing facility (NF) that provides Medi-Cal sub-acute services?
Please refer to the Authorization Detail Information Grid (Appendix 1) for more information.

Claims Management

Claims Submission

1. A facility may submit claims as frequently as desired.
2. Molina issues payment checks on Mondays, Wednesdays and Fridays.
3. When submitting a nursing facility (NF) claim, you must:
   
   • Bill on an 837 EDI claim (Molina payer ID 38333).
   • Use UB-04 claim form for paper submissions.
   • Submit through the Molina Provider Portal.
4. Billed services for any claim should not overlap two (2) consecutive calendar months.
5. Medicare claims must be submitted within 365 days after date of service (DOS).
6. Medi-Cal claims must be submitted within 180 days after date of service (DOS).
7. Bill type 21x.

Claims Value Codes

1. Use value code 23 in field 39a and enter Share of Cost (SOC) in the amount field.
2. Use value code 24 in field 40a and enter Accommodation code in the amount field.
3. Use value code 66 in field 41a and enter non-covered services (NCS) in the amount field.
   
   • Consistent with Johnson v. Rank, Medi-Cal recipients, not their providers can elect to use their SOC funds to pay for non-covered services.
4. Use value code 80 in field 39b and enter number of days of care in the amount field.

Case Management

Molina Healthcare Case Management

1. Who are Molina's case managers?
Molina primarily employs registered nurses (RN) and social workers who are licensed (LSW) or who have a master's degree in social work (MSW) as case managers. Staff is based in regional Molina offices in each of our service areas in Los Angeles, Riverside, San Bernardino, and San Diego counties.

2. What is the purpose of case management for the long-term care membership?
Case managers work to ensure Molina members are at the appropriate level of care and have timely access to needed covered benefits, carved out services and community resources. The State also requires that case managers assess for the members' willingness and ability to return to community living, as well as help facilitate that transition, if needed.

3. How can a nursing facility (NF) find out which case manager is assigned to a member?
To find out if a Molina member has an assigned case manager, please contact Molina with the member's full name and date of birth via any of the following methods:

• Phone: (800) 526-8196 Ext 127604
• Fax: (562) 499-6105
• Email: MHCCaseManagement@MolinaHealthcare.com

4. Who is the Molina point person in case management?
The assigned case manager will be your contact and can assist you in coordinating care for the member. If an issue requires escalation to a supervisor, please see the county-specific assignments in Appendix 6 of this guide. Please note that case managers and case management supervisors may not be able to immediately answer your questions related to authorizations, claims, billing, contracting, etc. Please see the relevant sections in this guide for the procedures and point persons for utilization management, claims, etc.

5. When should a facility contact the case manager?
Please contact the case manager for questions related to a member's Health Risk Assessment (HRA), care plan, or issues about their transition back to the community. Please notify the NF Specialist RN providing the authorizations as soon as possible for the following situations:

• There is a change in the member's physical or mental health and/or has a change in the level of care needed.
• The member goes to the ER or is admitted to the hospital.
• The member relocates or passes away.
• Bed holds

Case Management - Health Risk Assessment

1. When and how will a member's health risk assessment (HRA) be conducted?
a. The regulations state that Cal MediConnect and full-scope Medi-Cal members who reside in a long-term care facility must be assessed with a state-approved comprehensive HRA.
b. Cal MediConnect and full-scope Medi-Cal members will be assessed at least annually. Reassessments using the HRA may also be done following a member's change in condition or in anticipation of a transition to another setting or level of care.
c. Members whose primary coverage is with Medicare Fee-for-Service or other non-Molina insurance do not require a health risk assessment (HRA). This is most common with members who opted out of or were not eligible for Cal MediConnect. Instead, per DHCS All Plan Letter 14-010, Molina is required to review the NF's assessment to determine if any further coordination of services for the member is appropriate.

2. What do the HRA and NF assessment review entail?
a. The HRA for Cal MediConnect and full-scope Medi-Cal members is a bio/medical/psycho/social/functional assessment. The case manager will interview the member, and/or their representative, and seek information from the member's facility records (MDS, H&P, and nursing notes) in order to gather information about the member's clinical history, behavioral health status, sensory and I/ADL deficits, cultural/linguistic needs, etc. The survey tool Molina uses has been approved by the State and the Centers for Medicare and Medicaid Services (CMS).
b. The NF assessment review is for members who have Molina only for secondary/long term care coverage. It looks to determine whether the member has additional care coordination needs, including but not limited to, services to optimize health and functioning, to coordinate interdisciplinary communication and collaboration, and to determine contact frequency or reassessment.

3. Once the HRA or NF assessment review is complete, how often will the case manager be on-site or be in contact with the nursing facility?
a. The HRA and NF assessment review results will indicate the frequency and intensity of case management services. Stable Cal MediConnect and full-scope Medi-Cal members will receive at least a quarterly follow-up by phone. We found that this is sufficient for the majority of the long-term care members.
b. Members who are not stable often require more frequent contact, by phone and/or in person. Common scenarios include members who recently transitioned from a skilled level of care to custodial, or a member with recent or frequent admission to an acute setting.
c. Members who are willing and able to return to a community setting will also require more a more intense case management.

Case Management - Individualized Care Plan

1. What is an individualized care plan (ICP)?
a. For Cal MediConnect and full-scope Medi-Cal members, an individualized care plan (ICP) is the responsibility of Molina and is separate and distinct from a member's medical or treatment plan created and maintained by the primary care physician or other treating clinicians. The ICP takes information gathered via the HRA and documents a plan of action (interventions and goals) to address any unmet needs. It will also document non-Molina services the member may receive or for which they are eligible (e.g. Regional Center, California Community Transitions Project).
Care plans are required to be member-centric and it will be discussed with and agreed- upon by the member and/or his/her designated representative. For stable custodial members, the Molina care plan often reflects the same elements that are contained in their NF care plan.
Molina will send the facility a copy of the ICP. Please review it and let the case manager know of any recommendations or concerns. Place a copy of the Molina ICP in the member's medical record.
b. For members who have Molina as their secondary coverage (e.g. opt out from Cal MediConnect), per DHCS regulations (APL 14-010), Molina is not required to develop a full ICP as described above. However, Molina must retain and compile a copy of each care plan created on the member's behalf through the nursing facility. Molina must review the NF care plans to determine if any further coordination of care or delivery of services for the member is appropriate.

Delegation of Skilled and Custodial Care

1. Do IPA members automatically remain with the IPA during coordinated care initiative (CCI) transition?
Molina, upon receipt of files from the State of California, will use established processes to appropriately assign members to Medical Groups/IPAs. Medical Groups/IPAs will receive monthly e-lists (enrollment files) for the program from Molina, as well as ad-hoc communication if there are enrollment changes throughout the month.

2. To which medical groups/independent physician associations (IPAs) has Molina delegated for custodial and nursing facility services? Do these applicable delegated groups have risk for both professional and facility services?
Effective October 1, 2015, in addition to Heritage Provider Network; DaVita Healthcare Partners will also have both professional and facility risk for "skilled” services. Neither Heritage Provider Network nor DaVita Healthcare Partners will have risk for "custodial” care. Risk for "custodial" care will continue to remain Molina's responsibility. For all other Molina in-network Medical Groups/IPAs, the risk for both skilled and custodial care remains Molina's responsibility.
For Molina members in your facilities that are assigned to either Heritage Provider Network or DaVita Healthcare Partners, you will need to contact Heritage Provider Network or DaVita Healthcare Partners and follow their prior authorization guidelines for skilled services only. For members in your facilities who are receiving custodial care, please follow Molina's prior authorization guidelines. Please note, once a Heritage Provider Network- or DaVita Healthcare Partners-assigned member goes to custodial care, Molina will dis-enroll this member from these groups and assign them to a Molina-specific provider to ensure appropriate follow-up, care coordination and continuity of medical care. Custodial care is not delegated to Heritage Provider Network, DaVita Healthcare Partners or any other Molina contracted medical group or IPA; it is strictly Molina's responsibility.
For all other Molina members (non-Heritage Provider Network members and non-DaVita Healthcare Partners), please follow Molina's prior authorization guidelines for skilled and custodial care services (please refer to initial NF FAQ). It can be accessed at: http://www.molinahealthcare.com/providers/ca/duals/manual/Pages/provd.aspx.
Molina does not delegate custodial care or payment of custodial services to any medical group or IPA, including Heritage Provider Network and DaVita Healthcare Partners. Please follow Molina's prior authorization guidelines - face sheet, History & Physical (H&P) and authorization are needed. Molina requires submission of Medi-Cal Long-Term Care Facility Admission and Discharge Notification MC171, but not the Pre-Admission Screening and Resident Review (PASRR).

3. When a member transitions from skilled to custodial, who is responsible for authorization or payment of services?
As previously mentioned, Molina does not delegate custodial care or payment of custodial services to any medical group or IPA, including Heritage Provider Network and DaVita Healthcare Partners. Please follow Molina's prior authorization guidelines (refer to initial NF FAQ and the Molina Healthcare website for prior authorization documents and form).

4. How is Molina addressing NF concerns when it comes to delegated entities that are in the Coordinated Care Inititive (CCI) project?
Molina has been working closely with both Heritage Provider Network and DaVita Healthcare Partners and will continue to do so over the coming months to ensure that concerns raised by nursing facilities (NFs) are being addressed and that all applicable entities are providing members with the right care, at the right time, and in the right setting. Molina has also been working closely with these partners to educate them on the Coordinated Care Initiative (CCI) project, its applicable policies and procedures (including continuity of care) and health plan expectations. For all of our other medical groups or IPAs to which Molina do not delegate skilled services or custodial care, the risk remains with Molina and Molina is responsible for the member's authorization, case management and claims payment.

Delegation of Skilled and Custodial Care (Continued)

5. Will GeriNet be expanding to cover all nursing facilities (NFs) in the Inland Empire (IE)?
At this time, GeriNet Medical Associates will not be expanding to cover NFs in the Inland Empire. However, Molina will work with each facility in the IE to negotiate or get contracts in place with the physicians that round at those facilities. Please contact Molina's contracting department to provide information on any and all providers that your facility utilizes to provide professional services, including rounding and specialty care services to residents.

6. Is a separate authorization required for a bed hold and another one for when the patient returns from bed hold?
Separate authorization is needed for a bed hold but when patient returns to the facility, they return to the previous authorization number that was given to facility.

7. If the patient is authorized for NF care and goes on hospice, who requests the hospice notification?
The hospice provider is responsible for submitting and obtaining authorization from Molina. The NF is advised to notify Molina.

8. Does the provider making the rounds at the nursing facility (NF) need to be contracted and credentialed by Molina?
In the initial months, some of the providers making rounds at the nursing facilities (NFs) might not be contracted and/or credentialed by Molina. Molina's goal is to work closely with the facilities to get such providers contracted and credentialed. In the interim, we encourage the providers currently rounding the facilities to continue to do so to ensure continuity of care is maintained for the members under their care. Even without a contract, Molina will pay the physicians for the care provided to the members at mutually agreed upon rates.
At this time for Riverside, San Bernardino, Los Angeles and San Diego counties, Molina will work with each facility to get contracts in place with the physicians that round at those facilities. Please contact Molina's contracting department to provide information on any and all providers that your facility utilizes to provide professional services, including rounding and specialty care services to residents. Please refer to the Provider Contracting Team Contact list (Appendix 6) to identify the appropriate contracting team member information for your region.

9. Our facility uses electronic medical records. Can we grant Molina access to view the electronic medical records?
Yes. Please call our manager of Concurrent Review, Kelly Frost at (888) 562-5442, Ext. 117816 and she can help to coordinate the process.

Appendix

(1) Authorization Detail Information Grid

Appendix 2: Bed Hold and Leave of Absence

Appendix 2: Adult NF Codes

Appendix 2: Adult Sub-Acute (SA) Codes

Appendix 2: Pediatric Sub-Acute (SA) Codes

Appendix 3: Utilization Management Department Directory

Appendix 5: Prior Authorization Department

Appendix 5: Case Management Department

Appendix 5: Case Management Department (Continued)

Appendix 5: Provider Services Department

Appendix 5: Provider Services Department (Continued)

Appendix 6: Provider Contracting Department

Appendix 6: Pharmacy Contact Information

Appendix 7: Revision History

Provider Portal: https://provider.molinahealthcare.com/Provider/Login