Molina Healthcare of Illinois New Provider Orientation · 2020. 6. 26. · New Provider Orientation...
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Molina Healthcare of Illinois New Provider Orientation 2019
Transcript of Molina Healthcare of Illinois New Provider Orientation · 2020. 6. 26. · New Provider Orientation...
Molina Healthcare of Illinois New Provider Orientation2019
Table of ContentsMolina Healthcare of Illinois, pages 3-7
Program Overview, pages 8-20• HealthChoice Illinois and HealthChoice Illinois MLTSS, pages 9-14• Enrollment and PCP Changes, pages 15-16• Transition of Care, page 17• Credentialing and Effective Date, pages 18-19• Provider Changes, page 20
Covered Services, pages 21-28• Covered Services, page 22• Delegated Vendor Relationships, pages 23-24• Nurse Advice Line and Pharmacy, pages 25-26• MLTSS Benefits, page 27-28
Eligibility/Authorization/Claims, pages 29-39• Eligibility and Member Cost Sharing, pages 30-32• Referrals and Prior Authorization, pages 33-36• Claims Submissions, page 37• Provider Disputes/Adjustments, pages 38-39
Provider Resources, pages 40-44• Online Provider Resources, page 41• Provider Online Directory and Web Portal, pages 42-44
Quality Improvement, pages 45• Quality Improvement Program and Access Standards, pages 46-49
New Provider Orientation
Our Vision, Mission and Core Values
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MissionTo provide quality health care to people receiving government assistance
VisionWe envision a future where everyone receives quality health care
Core ValuesCaring – We care about those we serve and advocate on their behalf. We assume the best about people so that we can learn. Enthusiastic – We enthusiastically address problems and seek creative solutions. Respectful – We respect each other and value ethical business practices.Focused – We focus on our mission.Thrifty – We are careful with scarce resources. Little things matter and nickels add up. Accountable – We are personally accountable for our actions and collaborate to get results.Feedback – We strive to improve the organization and achieve meaningful change through feedback and coaching. Feedback is a gift. One Molina – We are one organization. We are a team.
New Provider Orientation
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Mission To provide quality health care to people receiving government assistance Vision We envision a future where everyone receives quality health care Core Values Caring – We care about those we serve and advocate on their behalf. We assume the best about people so that we can learn. Enthusiastic – We enthusiastically address problems and seek creative solutions. Respectful – We respect each other and value ethical business practices. Focused – We focus on our mission. Thrifty – We are careful with scarce resources. Little things matter and nickels add up. Accountable – We are personally accountable for our actions and collaborate to get results. Feedback – We strive to improve the organization and achieve meaningful change through feedback and coaching. Feedback is a gift. One Molina – We are one organization. We are a team.
What Makes Us Unique
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• Molina HealthCare of Illinois is accredited/rated by National Committee for Quality Assurance (NCQA), as are most Molina health plans
• 11 of our 15 plans (including IL) have earned the Multicultural Health Care Distinction from NCQA
• Ranked #152 on FORTUNE 500 list for 2018
New Provider Orientation
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Molina HealthCare of Illinois is accredited/rated by National Committee for Quality Assurance (NCQA), as are most Molina health plans 11 of our 15 plans (including IL) have earned the Multicultural Health Care Distinction from NCQA Ranked #152 on the FORTUNE 500 list for 2018
Presence in Key Medicaid Markets
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New Provider Orientation
Molina Healthcare of Illinois
New Provider Orientation
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Molina Healthcare has been happily serving its Illinois
members since 2013
Provider Network Medicaid MMP
Provider Type Count Count
Hospitals 200 159
Primary Care Providers 21,815 16,484
Specialist Physicians 54,719 38,398
WHCP 3,100 2,233
Behavioral Health 7,581 6,731
FQHC 358 258
Molina Healthcare of Illinois
New Provider Orientation
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Kim BlackwellAVP, Compliance
David VinklerVP, Government Contracts
Vijay ParthasarathyRegional Chief Financial Officer
Kris ClassenAVP, Healthcare Services
Matt WolfVP, Network and Operations
Karen Babos, DO, MBAChief Medical Officer
Pam Sanborn Plan President
Program Overview
HealthChoice Illinois
New Provider Orientation
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• HealthChoice Illinois is the state’s managed care program for the 3.2 million IL residents enrolled in Medicaid – The mandatory program provides health care coverage for Medicaid enrollees
previously under Family Health Plan (FHP) and Integrated Care Program (ICP) – Designed to help members reach health goals and stay well– Individuals who do not select a plan will be automatically assigned – Members also select primary care provider (PCP) or one will be assigned to
them by MCO• Molina will coordinate a full range of medical, dental, vision, behavioral
health and pharmacy benefits for members• Members can access case management services, health management
and disease management programs, a 24-hour nurse advice line, transportation and a network of hospitals and specialists
Presenter
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HealthChoice Illinois is the state’s managed care program for the 3.2 million IL residents enrolled in Medicaid The mandatory program provides health care coverage for Medicaid enrollees previously under Family Health Plan (FHP) and Integrated Care Program (ICP) Designed to help members reach health goals and stay well Individuals who do not select a plan will be automatically assigned Members also select primary care provider (PCP) or one will be assigned to them by MCO Molina will coordinate a full range of medical, dental, vision, behavioral health and pharmacy benefits for members Members can access case management services, health management and disease management programs, a 24-hour nurse advice line, transportation and a network of hospitals and specialists
HealthChoice Illinois
HealthChoice Illinois eligible population includes
• Families and children eligible for Medicaid through Title XIX or Title XXI • Affordable Care Act expansion Medicaid-eligible adults• Medicaid-eligible adults with disabilities (not eligible for Medicare)• Medicaid-eligible older adults (not eligible for Medicare)• Dual-eligible adults receiving long-term services and supports (LTSS) in
institutional care setting or through HCBS waiver• Children formerly under the care of Department of Children and Family
Services (DCFS) who have opted out of DCFS-specific managed care program
New Provider Orientation
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HealthChoice Illinois eligible population includes: Families and children eligible for Medicaid through Title XIX or Title XXI (Children's Health Insurance Program) Affordable Care Act expansion Medicaid-eligible adults Medicaid-eligible adults with disabilities who are not eligible for Medicare Medicaid-eligible older adults who are not eligible for Medicare Dual-Eligible Adults receiving long-term services and supports (LTSS) in an institutional care setting or through an HCBS waiver Children formerly under the care of Department of Children and Family Services (DCFS) who have opted out of the DCFS-specific managed care program
HealthChoice Illinois
Excluded populations include
• Dual-Eligible Adults enrolled in Medicare – Medicaid (MMP)• Dual-Eligible Adults not receiving nursing facility or waiver services• Participants who are American Indian/Alaskan Natives, unless they
voluntarily enroll in MCO• DCFS youth-in-care children• Participants only eligible with a spend-down• All Presumptive Eligibility categories• Participants who are incarcerated in a county jail, IL Department of
Corrections facility or federal penal institution• Participants in state facility operated as psychiatric hospital (as result of
forensic commitment)• Participants enrolled in partial/limited benefits programs • Participants with comprehensive third-party insurance
New Provider Orientation
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Excluded populations include Dual-eligible adults enrolled in Medicare – Medicaid (MMP) Dual-eligible adults not receiving nursing facility or waiver services Participants who are American Indian/Alaskan Natives, unless they voluntarily enroll in a MCO DCFS youth-in-care children Participants only eligible with a spend-down All Presumptive Eligibility categories Participants who are incarcerated in a county jail, IL Department of Corrections facility or federal penal institution Participants in a state facility operated as a psychiatric hospital as a result of a forensic commitment Participants enrolled in partial/limited benefits programs Participants with comprehensive third-party insurance
Managed Long Term Services and Supports (MLTSS)
• HealthChoice Illinois also covers Medicaid Long Term Services and Supports (MLTSS) enrollees who qualify for Medicaid and Medicare, but have opted out of Medicare-Medicaid Alignment Initiative
• MLTSS includes Long-Term Care (LTC) and Home and Community Based Services (HCBS) – LTC is for an individual living in a facility-based care setting (such as nursing
home or intermediate care facility) – Home and community-based services provide supportive services in
community so individuals can continue to live in their home and empower them to take active role in their health care
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New Provider Orientation
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HealthChoice Illinois also covers Medicaid Long Term Services and Supports (MLTSS) enrollees who qualify for Medicaid and Medicare, but have opted out of the Medicare-Medicaid Alignment Initiative MLTSS includes both Long-Term Care (LTC) and Home and Community Based Services (HCBS) Long-Term Care is for an individual living in a facility-based care setting (such as a nursing home or intermediate care facility) Home and community-based services provide supportive services in the community so that individuals can continue to live in their home and empower them to take an active role in their health care
Managed Long Term Services and Supports (MLTSS)
• Molina offers services to members of the following waiver groups– Persons who are elderly– Persons with disabilities– Persons with HIV/AIDS– Persons with brain injury– Supportive living facility
• Molina’s MLTSS program covers certain Medicaid services including non-Medicare long term services and supports, non-Medicare behavioral health and non-emergency transportation
• All medical benefits traditionally covered by Medicare would be submitted to member’s primary payer
New Provider Orientation
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Molina offers services to members of the following waiver groups Persons who are elderly Persons with disabilities Persons with HIV/AIDS Persons with brain injury Supportive living facility Molina’s MLTSS program covers certain Medicaid services which include non-Medicare long term services and supports, non-Medicare behavioral health and non-emergency transportation All medical benefits traditionally covered by Medicare would be submitted to member’s primary payer
HealthChoice Illinois and HealthChoice Illinois MLTSS Sample Member Identification Card
New Provider Orientation
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Front BackHealthChoice Illinois
HealthChoice Illinois MLTSS
Enrollment
New Provider Orientation
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• Eligible individuals may enroll in a HealthChoice IL program by contacting IL Client Enrollment Services
• IL Client Services Enrollment will - Ensure impartial choice education- Conduct client enrollment activities, including mailing education/ enrollment
materials, and providing information on each health plan - Assist enrollees with selection of health plan and PCP - Process requests to change health plan
• Members may visit Client Enrollment Services website at www.EnrollHFS.Illinois.gov- Plan comparison information - Answers to frequently asked questions - General information
• Or call Client Services, (877) 912-8880; TTY, (866) 565-8576
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Eligible individuals may enroll in an HealthChoice Illinois program by contacting Illinois Client Enrollment Services. Illinois Client Services Enrollment will: Ensure impartial choice education Conduct all client enrollment activities, including mailing education and enrollment materials and providing information on each health plan Assist enrollees with the selection of a health plan and Primary Care Provider (PCP) in an unbiased manner Process requests to change health plan Members may visit the Client Enrollment Services website at www.EnrollHFS.Illinois.gov to access plan comparison information, answers to frequently asked questions and general information regarding managed care. Enrollees may also call Client Services at (877) 912-8880 (TTY: (866) 565-8576).
PCP Changes
New Provider Orientation
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• Members can change their PCP at any time • New PCP will take effect on the first day of the month following the date of
the member’s request• PCP assignment does not affect claims payment within Molina network
- PCP-to-PCP referrals are not necessary
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Members can change their PCP at any time New PCP will take effect on the first day of the month following the date of the member’s request PCP assignment does not affect claims payment within Molina network PCP-to-PCP referrals are not necessary
Transition of Care
• Non-contracted providers can continue to see Molina Medicaid or MMP members with prior authorization for the first 90 days following member’s effective date with Molina – Provider must be active in Illinois Medicaid Program Advanced Cloud
Technology (IMPACT)– Must have a service plan from previous MCO/HFS– Allows for continuity of care
New Provider Orientation
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Non-contracted providers can continue to see Molina Healthcare Medicaid members with prior authorization for the first 90 days following a member’s effective date with Molina Provider must be active in Illinois Medicaid Program Advanced Cloud Technology (IMPACT) Must have a service plan from previous MCO/HFS Allows for continuity of care
Simplified Credentialing Process
• Registering with HFS’ online provider enrollment program (IMPACT) is the only requirement to begin a relationship with Molina
• Once application is approved by HFS, provider is considered credentialed with Molina
• Two important features1. Process applies to Medicaid and MMP2. Although providers will be credentialed through IMPACT, they must complete and
submit the IAMHP Universal Roster to Provider Information Management Team, [email protected]
• Credentialing alone does not mean a provider and health plan will be doing business together
• Provider and plans must still enter into contractual relationships and satisfy all necessary operational requirements
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New Provider Orientation
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Registering with the HFS’ online provider enrollment program (IMPACT) will be the only requirement to begin developing a relationship with Molina Healthcare Once an application is approved by HFS, the provider is considered credentialed with Molina Healthcare Two important features The process applies to Medicaid and MMP Although providers will be credentialed through IMPACT, they must complete and submit the IAMHP Universal Roster to Provider Information Management Team, [email protected] Credentialing on its own does not mean a provider and a health plan will be doing business together Provider and plans must still enter into contractual relationships and satisfy all necessary operational requirements
Provider Effective Date
A provider’s effective date as a participating provider under the HealthChoice Illinois program is noted as the following.
Molina will load a provider’s effective date at the later of:• The execution date of Molina and provider’s contract • The date the provider submits to Molina a complete and accurate IAMHP
roster form for the provider in the format approved by HFS• The provider’s effective date contained within HFS provider enrollment
subsystem with the IMPACT system─ Provider may submit to Molina the IAMHP roster at the same time that the
provider submits an enrollment application to HFS through IMPACT
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Senate bill 1321, explain how providers are loaded
Provider Changes
• Use the Universal IAMHP Roster Template to– Add – Terminate or– Update a provider– Universal IAMHP Roster Template
• This process applies to– Pay To information– Servicing location– Rendering Provider
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New Provider Orientation
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Use the Universal IAMHP Roster Template to Add Terminate or Update a provider Universal IAMHP Roster Template This process applies to Pay To information Servicing location Rendering Provider
Covered Services
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HealthChoice IL Covered Medical Services
• Alcohol/substance abuse treatment• Audiology• Behavioral health• Chiropractic• Dental• Durable and non-durable medical
equipment and supplies• Emergency services• Family planning• Home health care• Hospice• Hospital inpatient and outpatient• Immunizations• Laboratory services
• Mammograms• Maternity care• Pharmacy• Physician services• Physical, occupational and speech
therapy• Podiatry• Preventive services• Skilled nursing facility• Transplant services (non-experimental)• Transportation (emergent and non-
emergent)• Vision services• Whole blood and blood products• X-ray services
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New Provider Orientation
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Here is a list of some of the medical services and benefits covered by HealthChoice IL.
Delegated Vendor Relationships
Transportation Services• Molina provides non-emergent medical transportation for members • Secure Transportation is Molina’s transportation vendor• Transportation can be scheduled on a recurring basis ahead of time
– Patients needing service should call Secure Transportation to schedule a ride
– Members should schedule transportation 72 hours in advance of appointments
– Rides for hospital discharge require 3 hours notice– Members can arrange for a ride to the pharmacy
• After a medical appointment • With advanced notification at any time
HealthChoice Illinois: (844) 644-6354MMP Duals: (844) 644-6353
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New Provider Orientation
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Transportation Services Molina Healthcare of Illinois provides non-emergent medical transportation for our members. Secure Transportation is Molina’s transportation vendor. Transportation can be scheduled on a recurring basis ahead of time. If your patients are in need of this service, please have them call Secure Transportation to schedule a ride. It is important to have members call 72 hours in advance of the appointments to schedule transportation. Rides for hospital discharge require 3 hours notice. Members can arrange for a ride to the pharmacy: After a medical appointment With advanced notification at any time HealthChoice Illinois: (844) 644-6354 MMP Duals: (844) 644-6353
Delegated Vendor Relationships
Dental Services• Routine dental services are coordinated through Molina’s Dental vendor, Avesis• For medical/surgical services, refer to Molina for direct reimbursement• Contact information, dentist and oral surgeon locator or to schedule appointment
Medicaid: (866) 857-8124MMP: (855) 704-0433Online: www.avesis.com
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Vision Services• MARCH Vision provides routine vision services/optical supplies to members • For medical/surgical services, refer to Molina for direct reimbursement• Contact information, vision provider locator or to schedule appointment
Member Services at (855) 687-7861Online: www.marchvision.com
New Provider Orientation
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Presentation Notes
Dental Services Routine dental services are coordinated through Molina’s Dental vendor, Avesis. For medical/surgical services, refer to Molina for direct reimbursement. Contact information, dentist and oral surgeon locator or to schedule an appointment: Medicaid: (866) 857-8124 MMP: (855) 704-0433 Online at: www.avesis.com Vision Services MARCH Vision provides routine vision services and optical supplies to Molina members. For medical/surgical services, refer to Molina for direct reimbursement. Contact information, to locate an Optometrist or Ophthalmologist or schedule an appointment: Member Services at (855) 687-7861 Online at: www.marchvision.com
24-Hour Nurse Advice Line
New Provider Orientation
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• Molina provides 24-Hour Nurse Advice Line • Members can call when they have symptoms or need health information • Registered nurses are available to assess medical/behavioral health
symptoms and help direct members to care they need • The Nurse Advice Line numbers listed on back of member ID cards
English: (888) 275-8750TTY: (866) 735-2929
Spanish: (866) 648-3537TTY: (866) 833-4703
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Presentation Notes
Molina Healthcare provides a 24-Hour nurse advice Line. Members may call any time they are experiencing symptoms or need health care information. Registered nurses are available 24 hours a day, seven days a week to assess medical and behavioral health symptoms and help direct Members where they can get the care they need. The Nurse Advice Line phone numbers are listed on the back of Member ID cards.
Pharmacy
New Provider Orientation
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• In-network pharmacy list available at www.MolinaHealthcare.com• Molina’s drug formulary helps manage pharmacy benefit quality
– Formulary is cornerstone of a managed care pharmacotherapy program– Created to ensure members receive high quality, cost-effective, rational drug
therapy • Medications requiring prior authorization, most injectable medications or
non-formulary medications may be approved when medically necessary and when formulary alternatives are ineffective – Prior Authorization Request Form is available at www.MolinaHealthcare.com
Medicaid Pharmacy: (855) 866-5462 Fax: (855) 365-8112
Presenter
Presentation Notes
Prescription drugs are covered through Molina Healthcare. A list of in-network pharmacies is available online at www.MolinaHealthcare.com. The Molina Healthcare Drug Formulary was created to help manage the quality of our Members’ pharmacy benefit. The formulary is the cornerstone for a progressive program of managed care pharmacotherapy, and was created to ensure that our Members receive high quality, cost-effective, rational drug therapy. Medications requiring prior authorization, most injectable medications or medications not included on the formulary may be approved when medically necessary and when formulary alternatives have demonstrated ineffectiveness. The Prior Authorization Request Form is available at www.MolinaHealthcare.com. Medicaid Pharmacy: (855) 866-5462 Fax: (855) 365-8112
Managed Long Term Services and Supports (MLTSS)Benefits and Approved Services – Waiver
• Adult day service• Adult day health transportation• Environmental accessibility
adaptations • Environmental accessibility
adaptations• Home delivered meals• Homemaker• Personal emergency response
system (PERS)• Respite• Nurse training• Family training
• Skilled nursing services RN/LPN• Specialized medical equipment• Supported employment• Personal care services• Home health aide• Nursing, intermittent• Therapies• Prevocational services• Placement maintenance counseling• Medically supervised day care• Assisted living
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* HealthChoice Illinois members, who are not part of MLTSS, may also qualify for waiver benefits
New Provider Orientation
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Here is a list of Managed Long Term Services and Supports (MLTSS) Benefits and Approved Services – Waiver.
Managed Long Term Services and Supports (MLTSS) Benefits and Approved Services – Non-Waiver
• Behavioral health services• Custodial long-term care• Non-emergent transportation
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New Provider Orientation
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Presentation Notes
Here is a list of Managed Long Term Services and Supports (MLTSS) Benefits and Approved Services – Non-Waiver.
Eligibility, Authorization and Claims
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Verifying Member Eligibility
New Provider Orientation
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• Molina offers various tools to verify member eligibility – Providers may use self-service Web Portal, IVR system, eligibility rosters
or call Provider Services, (855) 866-5462• Providers can also verify eligibility/health plan assignment for HFS
recipients through Medical Electronic Data Interchange (MEDI) • Provider’s responsibility to verify member eligibility before rendering
services • At no time should a member be denied services because his/her
name does not appear on Molina member roster • If member does not appear on roster, contact Molina for further
verification
Web Portal: https://provider.molinahealthcare.com/provider/loginProvider Services: (855) 866-5462
Presenter
Presentation Notes
Molina offers various tools to verify member eligibility Providers may use self-service Web Portal, IVR system, eligibility rosters or call Provider Services, (855) 866-5462 Providers can also verify eligibility/health plan assignment for HFS recipients through Medical Electronic Data Interchange (MEDI) Provider’s responsibility to verify member eligibility before rendering services At no time should a member be denied services because his/her name does not appear on Molina member roster If member does not appear on roster, contact Molina for further verification Web Portal: https://provider.molinahealthcare.com/provider/login Provider Services: (855) 866-5462
Member Cost Sharing – Medicaid
New Provider Orientation
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• Molina members never have a co-payment for covered services
• Providers may not balance bill members for covered services for any reason
• Molina’s Provider Agreement requires providers to verify eligibility and obtain approval for services that require prior authorization
• If payment is denied, providers should look solely to Molina for compensation for services rendered
Presenter
Presentation Notes
Molina Healthcare Members never have a co-payment for covered services, with the exception of Medicare Part D co-payments for prescription drugs. Providers may not balance bill members for covered services for any reason. The Molina Healthcare of Illinois Provider Agreement requires Provider offices to verify eligibility and obtain approval for those services that require prior authorization. In the event of a denial of payment, providers shall look solely to Molina Healthcare of Illinois for compensation for services rendered.
Member Cost Sharing – MMP
New Provider Orientation
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• Molina members may have a co-payment for covered services
• Providers may only balance bill members for copayments/deductibles
• Molina’s Provider Agreement requires providers to verify eligibility and obtain approval for services that require prior authorization
Presenter
Presentation Notes
Molina members may have a co-payment for covered services. Providers may only balance bill members for copayments/deductibles. Molina’s Provider Agreement requires providers to verify eligibility and obtain approval for services that require prior authorization.
Referrals and Prior Authorization
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• Referrals made when medically necessary services are beyond scope of PCP’s practice
• Referrals to in-network specialists do not require authorization from Molina • Information should be exchanged between PCP and specialist to coordinate
care • Prior authorization is request for prospective review to
- Create collaborative approach to determine appropriate level of member care - Identify case management and disease management opportunities- Improve coordination of care
• Requests for services listed in the Prior Authorization Guide are evaluated by licensed nurses and clinicians
• Services requiring prior authorization can be found at www.MolinaHealthcare.com under the Forms tab
• Service requests may be submitted via Web Portal or faxed in to numbers below Web Portal: https://provider.molinahealthcare.com/provider/loginPrior Authorization Fax: (866) 617-4971
New Provider Orientation
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Presentation Notes
Referrals made when medically necessary services are beyond scope of PCP’s practice Referrals to in-network specialists do not require authorization from Molina Information should be exchanged between PCP and specialist to coordinate care Prior authorization is request for prospective review to Create collaborative approach to determine appropriate level of member care Identify case management and disease management opportunities Improve coordination of care Requests for services listed in the Prior Authorization Guide are evaluated by licensed nurses and clinicians Services requiring prior authorization can be found at www.MolinaHealthcare.com under the Forms tab Service requests may be submitted via Web Portal or faxed in to numbers below Web Portal: https://provider.molinahealthcare.com/provider/login Prior Authorization Fax: (866) 617-4971
Requests for Authorization
New Provider Orientation
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• Provide supporting clinical documentation with elective service authorization requests – Information required generally includes
• Current (up to 6 months) patient history related to requested services• Physical examination that addresses the problem• Lab or radiology results to support request (including MRI, CT, lab or X-ray)• PCP or specialist progress notes/consultations• Any information or data specific to request
• Molina will process routine requests within 4 days of initial request – Urgent requests processed within 48 hours – If more information is required, we will pend the case and notify you
• Providers may review Prior Authorization Codification List for HCPCS codes requiring prior authorization, https://www.molinahealthcare.com/providers/il/medicaid/forms/Pages/fuf.aspx
Presenter
Presentation Notes
Provide supporting clinical documentation with elective service authorization requests Information required generally includes Current (up to 6 months) patient history related to requested services Physical examination that addresses the problem Lab or radiology results to support request (including MRI, CT, lab or X-ray) PCP or specialist progress notes/consultations Any information or data specific to request Molina will process routine requests within 4 days of initial request Urgent requests processed within 48 hours If more information is required, we will pend the case and notify you Providers may review Prior Authorization Codification List for HCPCS codes requiring prior authorization, https://www.molinahealthcare.com/providers/il/medicaid/forms/Pages/fuf.aspx
Requesting Prior Authorization
Prior Authorization Request Options• Web Portal: Use Molina Web Portal for prior authorization submission
– Instructions are available on Web Portal • Fax: Prior authorization form can be faxed to Molina, (866) 617-4971
New Provider Orientation
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Presenter
Presentation Notes
Prior Authorization Request Options Web Portal: Use Molina Web Portal for prior authorization submission Instructions are available on Web Portal Fax: Prior authorization form can be faxed to Molina, (866) 617-4971
Request for Authorization
New Provider Orientation
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• Providers requesting prior authorization can review criteria used to make final decision – Providers may speak to Medical Director who made determination – Molina clinical policies available for provider review at
https://www.molinahealthcare.com/providers/il/medicaid/resource/Pages/Molina-Medical-Coverage-Guidelines.aspx
• Upon receipt of prior authorization, Molina will provide unique authorization number (use on claims related to service authorized)
• Goal is to ensure members are receiving right services at right time and in right place
• Help us meet this goal by sending information to support member’s need for services
• Contact Molina with questions/concerns• Prior Authorization (PA) form is available at,
http://www.molinahealthcare.com/providers/il/medicaid/forms/Pages/fuf.aspx
Presenter
Presentation Notes
Providers requesting prior authorization can review criteria used to make final decision Providers may speak to Medical Director who made determination Molina clinical policies available for provider review at https://www.molinahealthcare.com/providers/il/medicaid/resource/Pages/Molina-Medical-Coverage-Guidelines.aspx Upon receipt of prior authorization, Molina will provide unique authorization number (use on claims related to service authorized) Goal is to ensure members are receiving right services at right time and in right place Help us meet this goal by sending information to support member’s need for services Contact Molina with questions/concerns Prior Authorization (PA) form is available at, http://www.molinahealthcare.com/providers/il/medicaid/forms/Pages/fuf.aspx
Claims SubmissionsNew Provider Orientation
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• Molina is contractually required to process 90% of clean claims within 30 calendar days (99% of clean claims processed within 90 work days)
• Claims Submission Options– EDI Clearinghouse – Change Healthcare is Molina’s gateway clearinghouse
• Providers may submit claims directly to EDI clearinghouse (Payer ID 20934)– Molina’s Provider Portal – Molina’s Provider Portal is available at no cost
• Submit corrected claims, void claims, check claims status and receive claims status notifications
• Electronic Funds Transfer (EFT)– Molina partners with Alegeus ProviderNet for electronic Funds Transfer (EFT)
and Electronic Remittance Advice– Access is free– Go to https://providernet.adminisource.com to register after getting first Molina
check • Call (877) 389-1160 or email [email protected] with
questions about registration process
Presenter
Presentation Notes
Molina Healthcare is contractually required to process 90% of clean claims received within 30 calendar days, and 99% of clean claims are processed within 90 working days. Claims Submission Options EDI Clearinghouse – Change Healthcare is Molina’s gateway clearinghouse. Change Healthcare is contracted with hundreds of other clearinghouses. Providers may submit claims directly to their EDI clearinghouse for submission. Molina’s Provider Portal – Molina’s Provider Portal is available to providers at no cost. The online provider tool offers easy submission of attachments. Providers also may submit corrected claims, void claims, check claims status and receive notifications regarding claims status. Electronic Funds Transfer (EFT) Molina Healthcare has partnered with Alegeus ProviderNet for electronic Funds Transfer (EFT) and Electronic Remittance Advice. Access is free for participating Providers Go to https://providernet.adminisource.com to register after getting first check from Molina Healthcare. Call (877) 389-1160 or send an email to [email protected] if you have questions about the registration process
Provider Disputes and Adjustments
New Provider Orientation
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• Providers seeking a redetermination of previously adjudicated claim must request action within 90 days of Molina’s original remittance advice date
• Item(s) being resubmitted should be clearly marked as a redetermination and include– Claims Dispute Request Form,
https://www.molinahealthcare.com/providers/il/PDF/Medicaid/Claims_Dispute_Request_Form.pdf
– Item(s) being resubmitted should be marked as Claim Dispute/Adjustment – Payment adjustment requests must be fully explained– Previous claim and remittance advice, any other documentation to support
adjustment and copy of referral/authorization form (if applicable) must accompany adjustment request
– Claim number clearly marked on supporting documents • Providers should allow 60 days to process the request
Presenter
Presentation Notes
Providers seeking a redetermination of a claim previously adjudicated must request such action within 90 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: Claims Dispute Request Form, https://www.molinahealthcare.com/providers/il/PDF/Medicaid/Claims_Dispute_Request_Form.pdf 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 Providers should allow 60 days to process the request.
Provider Disputes
New Provider Orientation
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Claims Dispute Request Form Submission Options• Web Portal: Providers are strongly encouraged to use Molina Web Portal
to submit Claims Dispute Request Forms• Fax: Claims Dispute Request Form can be faxed to Molina,
(855) 502-4962
Presenter
Presentation Notes
Claims Dispute Request Form Submission Options Web Portal: Providers are strongly encouraged to use the Molina Web Portal to submit Claims Dispute Request Forms. Fax: The Claims Dispute Request Form can be faxed to Molina at: (855) 502-4962.
Provider Resources
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Online Provider Resources
• Provider manual• Provider online directories• Web portal• Frequently used forms• Preventive & clinical care
guidelines• Prior authorization information• Advanced directives• Model of Care training• Pharmacy information• HIPAA
• Fraud, Waste & Abuse information
• Communications & newsletters• Member rights & responsibilities• Contact information• News & updates• Service area maps
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New Provider Orientation
Training Webinars
• Visit www.MolinaHealthcare.com, Communications tab, for Webinar & Event information
• Online webinars are held on a variety of topics including– Billing– Claims– Redetermination
42
New Provider Orientation
Presenter
Presentation Notes
Visit www.MolinaHealthcare.com, Communications tab, for Webinar & Event information Online webinars are held on a variety of topics including Billing Claims Redetermination
Provider Directory
New Provider Orientation
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• To find a Provider, visit www.MolinaHealthcare.com, select Find a Doctor or Pharmacy, and click– Find a Provider – Find a Hospital/Facility – Find a Pharmacy
• Molina providers may request a provider directory by calling Provider Services at (855) 866-5462
Presenter
Presentation Notes
To find a Provider, visit us at www.MolinaHealthcare.com, select Find a Doctor or Pharmacy, then click Find a Provider or Find a Hospital or Find a Pharmacy Molina providers may request a provider directory by calling Provider Services at (855) 866-5462.
Web Portal
New Provider Orientation
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• Why register for Molina’s Provider Web Portal?– Easy-to-use online tool designed to meet your needs
• Web Portal features– Search for member details, including eligibility status and covered benefits– Create, submit, correct and void claims; submit attachments and receive
notifications of status changes– Check current claim status and print claims– Submit disputes online– Create, submit and print Service Requests with notifications of status changes– View Service Request approval status– Track required HEDIS services for members and compare your scores with
national benchmarks– View member Personal Health Record– Access account information, manage and add users and update your profile– Update provider demographics
Presenter
Presentation Notes
Why register for Molina’s Provider Web Portal? Molina’s Provider Web Portal is an easy-to-use online tool designed to meet your needs. Web Portal Features: Easily search for member details, including eligibility status and covered benefits Create, submit, correct and void claims; plus submit attachments and receive notifications of status changes Inquire on current claim status and print your claims Create, submit and print Service Requests with notifications of status changes View Service Request approval status Track required HEDIS services for members and compare your scores with national benchmarks View Member Personal Health Record Access account information, manage and add users and update your profile
Quality Improvement
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Quality Incentive Program
New Provider Orientation
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• To achieve the highest levels of quality, Molina offers a Quality Incentive Program (QIP) for performance in NCQA HEDIS® measures- Bonus payments calculated per roster member, per month on annualized basis
when provider group reaches performance goals- Bonus payments made to the group practice as a whole, in accordance with
HEDIS guidelines• Eligible members are enrolled in HealthChoice and populations for each
measure meet NCQA criteria• To assist providers in determining eligible members, Molina will make
reasonable efforts to ensure accurate member rosters and provide regular Missing Services Reports
• For more information on the Quality Incentive Program’s measures, parameters and payment schedule, visit MolinaHealthcare.com
Presenter
Presentation Notes
To achieve the highest levels of quality, Molina offers a Quality Incentive Program (QIP) for performance in NCQA HEDIS® measures Bonus payments calculated per roster member, per month on annualized basis when provider group reaches performance goals Bonus payments made to the group practice as a whole, in accordance with HEDIS guidelines Eligible members are enrolled in HealthChoice and populations for each measure meet NCQA criteria To assist providers in determining eligible members, Molina will make reasonable efforts to ensure accurate member rosters and provide regular Missing Services Reports For more information on the Quality Incentive Program’s measures, parameters and payment schedule, visit MolinaHealthcare.com
Quality ImprovementNew Provider Orientation
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• Quality is a Molina core value, and ensuring members receive right care in right place at right time is everyone’s responsibility
• Molina’s Quality Improvement Department maintains key processes/initiatives to ensure measurable improvements are made in member care and service
• Clinical and service quality are measured, evaluated and monitored through– Healthcare Effectiveness Data and Information Set (HEDIS)– Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS)– Provider satisfaction surveys
• Additional information about Molina’s Quality Improvement initiatives available at www.MolinaHealthcare.com
Presenter
Presentation Notes
Quality is a Molina core value, and ensuring members receive right care in right place at right time is everyone’s responsibility Molina’s Quality Improvement Department maintains key processes/initiatives to ensure measurable improvements are made in member care and service Clinical and service quality are measured, evaluated and monitored through Healthcare Effectiveness Data and Information Set (HEDIS) Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS) Provider satisfaction surveys Additional information about Molina’s Quality Improvement initiatives available at www.MolinaHealthcare.com
Access StandardsNew Provider Orientation
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Molina monitors compliance and conducts ongoing evaluations regarding the availability and accessibility of services to members.
Please ensure adherence to these regulatory standards.
Appointment Type Wait Time Standards
Urgent Care Within 24 hours of the request
Office Wait Time Should not exceed 30 minutes from appointment time
Primary Care Provider (PCP) or Prenatal C are
Emergency Care Immediately
Routine Care (non-urgent) Within three weeks of the request
Preventive Care Within five weeks of the request
Prenatal – First Trimester Within two weeks of request
Second Trimester Within one week of request
Third Trimester Within three days of request
Follow up Discharge Within seven days of discharge
Specialty Care Provider
Routine Care (non-urgent) Within 10 working days of the request
Behavioral Health
Non-Life Threatening Emergency Care Within six hours of request
Urgent Care Within 24 hours of request
Routine Care Within 10 working days of request
Presenter
Presentation Notes
Molina Healthcare monitors compliance and conducts ongoing evaluations regarding the availability and accessibility of services to members. Please ensure adherence to these regulatory standards.
After Hours Access
New Provider Orientation
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• All physicians must have back-up coverage after hours or during absence/ unavailability
• Molina requires providers to maintain a 24-hour telephone service, 7 days a week – Access may be via an answering service– Voicemail alone is not acceptable
• The after-hours answering service must instruct the member– If this is a life-threatening emergency, hang up
and call 911
Presenter
Presentation Notes
All physicians must have back-up coverage after hours or during absence/ unavailability. Molina Healthcare requires providers to maintain a 24-hour telephone service, seven days a week. Access may be via an answering service and voicemail alone is not acceptable. The after-hours answering service must instruct the member as follows: If this is a life-threatening emergency, hang up and call 911.
In Conclusion
TrainingNew Provider Orientation
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• Model of Care– Model of Care training,
https://www.molinahealthcare.com/providers/common/medicare/PDF/2019-MOC-Provider-Training.pdf
– Model of Care attestation, https://www.molinahealthcare.com/providers/common/medicare/PDF/2019_MOC-Attestation_IL.pdf
– Model of Care reference guide, https://www.molinahealthcare.com/providers/common/medicare/PDF/2019-Provider-Training-QRG.pdf
Presenter
Presentation Notes
Providers are required to complete training, including Model of Care
Contact Molina
New Provider Orientation
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Important Numbers / Contact InformationMember Eligibility Verification (855) 866-5462 Non Emergent Transportation (844) 644-6354 Provider Services (855) 866-5462Member Services (855) 687-7861
Main Fax (630) 571-1220
Prior Authorization Fax (866) 617-4971
Pharmacy Prior Authorization Fax (855) 365-8112
Molina Healthcare of Illinois1520 Kensington Rd., Suite 212
Oak Brook, IL 60523Business Hours: 8 a.m. to 5 p.m. Monday - Friday
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