PROVIDER MANUAL Molina Healthcare of Texas, Inc. (Molina Healthcare or Molina) Molina Marketplace . 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 . www.MolinaHealthcare.com. Last Updated: 02/2021
PROVIDER MANUAL Molina Healthcare of Texas, Inc.
(Molina Healthcare or Molina) Molina Marketplace 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 www.MolinaHealthcare.com. Last Updated: 02/2021
Table of Contents 1. Addresses and Phone Numbers........................................................................................ 2 2. Provider Responsibilities ................................................................................................... 7 3. Cultural Competency and Linguistic Services ...................................................................15 4. Member Rights and Responsibilities.................................................................................20 5. Eligibility, Enrollment, Disenrollment & Grace Period........................................................21 6. Benefits and Covered Services ........................................................................................27 7. Healthcare Services .........................................................................................................32 8. Quality ..............................................................................................................................49 9. Compliance ......................................................................................................................64 10. Claims and Compensation ...............................................................................................76 11. Complaints, Grievance and Appeals Process ...................................................................88 12. Credentialing and Recredentialing....................................................................................98 13. Delegation ......................................................................................................................107 14. Pharmacy.......................................................................................................................108 15. Risk Adjustment Management Program .........................................................................112
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1. Addresses and Phone Numbers
Molina Healthcare of Texas, Inc. 5605 N. MacArthur Blvd., Suite 400 Irving, TX 75038
Provider Services Department
The Provider Services department handles telephone and written inquiries from Providers regarding address and Tax-ID changes, Provider denied Claims review, 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: Fax:
(855) 322-4080 (877) 900-8452
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 8:00 a.m. 6:00 p.m. CST, Monday through Friday, excluding State holidays. Eligibility verifications can be conducted at your convenience via the Provider Portal.
Phone:
(888) 560-2025
TTY/TDD: 711
Claims Department
Molina strongly encourages Participating Providers to submit Claims electronically (via a clearinghouse or the Provider Portal) whenever possible. · Access the Provider Portal (https://provider.MolinaHealthcare.com) · EDI Payer ID 20554
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.
Address:
Molina Healthcare of Texas, Inc. PO Box 650823/Dept. 41205 Dallas, TX 75265
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Phone:
(866) 642-8999
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: Email:
(866) 606-3889 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.
Address:
Molina Healthcare of Texas, Inc. 84 NE Loop 410, Ste. 200 San Antonio, TX 78216
Phone: Fax:
(855) 322-4080 (855) 671-1277
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 Line: (888) 275-8750
Spanish Line: (888) 648-3537
TTY/TDD:
711 Relay
Healthcare Services Department
The Healthcare Services (formerly Utilization Management) department conducts concurrent review on inpatient cases and processes Prior Authorizations/Service
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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. · 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 Molina's
website for guidance.
Provider Portal: https://provider.MolinaHealthcare.com
Phone:
(855) 322-4080
Fax:
(866) 420-3639
Health Management
Molina's Health Management programs will be incorporated into the Member's treatment plan to address the Member's health care needs.
Weight Management and Smoking Cessations Programs
Phone: (866) 472-9483
Fax:
(562) 901-1176
Health Management Programs
Phone: (866) 891-2320
Fax:
(800) 642-3691
Behavioral Health
Molina manages all components of Covered Services for behavioral health. For Member behavioral health needs, please contact us directly at (800) 818-5837, 24 hours per day, 365 days per year.
Pharmacy Department
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Pharmacy services are covered through CVS Caremark. A list of in-network pharmacies is available on the www.MolinaHealthcare.com website, or by contacting Molina at (855) 322-4080.
Quality Improvement
Molina maintains a Quality department to work with Members and Providers in administering Molina's Quality Programs.
Phone: Fax:
(855) 322-4080 (210) 366-6540
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Molina Healthcare of Texas, Inc. Service Area
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2. Provider Responsibilities
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 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 HealthCare 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, Inc. Civil Rights Coordinator 200 Oceangate, Suite 100 Long Beach, CA 90802
Toll Free: (866) 606-3889 TTY/TDD: 711 On Line: 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).
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.
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Providers must validate the Provider Online Directory (POD) information at least quarterly 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, Tax ID 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 and correct most of your information. A convenient Provider web form can be found on the POD and on the Provider Portal at https://provider.MolinaHealthcare.com. You can also notify your Provider Services representative or complete and submit the Change of Information form located at www.MolinaHealthcare.com 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, faceto-face contact, fax and fax-back 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.
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 Requirements
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Molina requires Providers to utilize electronic solutions and tools whenever possible.
Molina requires 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, health plan access to electronic medical records (EMR), 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 includes 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 required to comply with Molina's Electronic Solution Policy by enrolling for EFT/ERA payments and registering for the Provider Portal 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 www.MolinaHealthcare.com.
Electronic Solutions/Tools Available to Providers
Electronic Tools/Solutions available to Molina Providers include: · Electronic Claims Submission Options · Electronic Payment: EFT with ERA · Provider Portal
Electronic Claims Submission
Molina strongly encourages Participating Providers to submit Claims electronically whenever possible. Electronic Claims submission provides significant benefits to the Provider including: · 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 enabling Claims to reach Molina faster.
Molina offers the following electronic Claims submission options: · Submit Claims directly to Molina via the Provider Portal. See the Provider Portal Quick
Reference Guide https://provider.MolinaHealthcare.com or contact your Provider Services Representative for registration and Claim submission guidance.
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· Submit Claims to Molina through your EDI clearinghouse using Payer ID 20554, refer to our website www.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.
Provider Portal Claims submission includes the 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 and Compensation Section of this Provider Manual.
Electronic Payment (EFT/ERA) Requirement
Participating Providers are required 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 remittance advice (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 processes.
Below is the link to register with Change Healthcare ProviderNet 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: www.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
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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 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.
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 amounts..
Member Rights and Responsibilities
Providers are required to comply with the Member Rights and Responsibilities as outlined in Molina's Member materials (such Member handbooks).
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 approved by Molina prior to use.
Please contact your Provider Services representative for information and review of proposed materials.
Member Eligibility Verification
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.
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Member Cost Share
Providers should verify the Molina Member's cost share status prior to requiring the Member to pay copayment 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 Case Management)
Providers are required to participate in and comply with Molina's Utilization Management 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 see the Healthcare Services section of this Provider Manual.
In Office Laboratory Tests
Molina'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 Provider's office is found on the Molina website at www.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 inoffice 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.
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Providers should direct Molina Members to health professionals, hospitals, laboratories, and other facilities and Providers which are contracted and credentialed (if applicable) with Molina. In the case of Emergency Services, Providers may direct Members to an appropriate service including but not limited to primary care, urgent care and 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.
PCPs are able to refer a Member to an in-network specialist for consultation and treatment without a prior authorization.
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.
Pharmacy Program
Providers are required to adhere to Molina's drug formularies and prescription policies. 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
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Molina requires that 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 and/or statement as needed. This includes the maintenance and retention of Member records for a period of not less than ten years 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 recredentialing criteria established by Molina and applicable accreditation, State and Federal requirements. This includes providing prompt responses to requests for information related to the credentialing or re-credentialing process.
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.
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3. Cultural Competency and Linguistic Services
Background
Molina works to ensure all Members receive culturally competent care across the service continuum to reduce health disparities and improve health outcomes. The Culturally and Linguistically Appropriate Services in Health Care (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 (LEP) and Members who are deaf, hard of hearing, non-verbal, have a speech impairment, or have an intellectual disability. Policies and procedures address how 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.
Additional information on cultural competency and linguistic services is available at www.MolinaHealthcare.com, from your local Provider Services representative and by calling Molina Provider Services at (855) 322-4080.
Non-discrimination of Health Care Service Delivery
Molina complies with the guidance set forth in the final rule for Section 1557 of the 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). 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 taglines 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.
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Members can also email the complaint to civil.rights@MolinaHealthcare.com.
Members can mail their complaint to Molina at: Molina Healthcare, Inc. Civil Rights Coordinator 200 Oceangate, Suite 100 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 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: https://www.federalregister.gov/documents/2020/06/19/202011758/nondiscrimination-in-health-and-health-education-programs-or-activitiesdelegation-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.
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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. 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 www.MolinaHealthcare.com and information delivered in digital form meet Section 508 accessibility requirements to support Members with visual impairments.
Key Member information, including Appeal 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 Contracted Providers to assess gaps in network demographics. · Revalidate data at least annually. · 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. · Collection of data and reporting for the Diversity of Membership HEDIS® measure. · Annual determination of threshold languages and processes in place to provide
Members with vital information in threshold languages. · Identification of specific cultural and linguistic disparities found within the plan's
diverse populations. · 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
Providers may request interpreters for Members whose primary language is other than English by calling Molina's Contact Center toll free at (888) 560-2025. If Contact Center
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Representatives are unable to interpret in the requested language, the Representative will immediately connect you and the Member to a qualified language service Provider.
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.
Documentation
As a contracted Molina Provider, your responsibilities for documenting Member language services/needs in the Member's medical record are as follows: · 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 notification of his or her right to have a qualified interpreter at no cost.
Members Who Are Deaf or Hard of Hearing
Molina provides a TTY/TDD connection accessible by dialing 711. This connection provides access to Member & Provider Contact Center, Quality, 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 are deaf or hard of hearing. 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, 7 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
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(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.
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4. Member Rights and Responsibilities
Providers must comply with the rights and responsibilities of Molina Members as outlined in the Molina Member Handbook.
State and Federal Law requires that health care Providers and health care facilities recognize Member rights while the Members 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 the Members.
For additional information, please contact Molina at (888) 560-2025, Monday through Friday, 8:00 a.m. 6:00 p.m. CST. TTY users, please call 711.
Second Opinions
If a Member 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. Second opinions may require Prior Authorization.
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5. Eligibility, Enrollment, Disenrollment & Grace Period
Enrollment
The Molina Marketplace is the program which implements the Health Insurance Marketplace as part of the Affordable Care Act. It is administered by the Federally Facilitated Marketplace (FFM).
To enroll with Molina, the Member, their representative, or their responsible parent or guardian must follow enrollment process established by the Molina Marketplace will enroll all eligible Members with the health plan of their choice.
No eligible Member shall be refused enrollment or re-enrollment, have their enrollment terminated, or be discriminated against in any way because of their health status, preexisting physical or mental condition, including pregnancy, hospitalization or the need for frequent or high-cost care.
Effective Date of Enrollment
Coverage shall begin as designated by the Marketplace Exchange on the first day of a calendar month. If the enrollment application process is completed by the 15th of the month, the coverage will be effective on the first day of the next month. If enrollment is completed after the 15th of the month, coverage will be effective on the first day of the second month following enrollment or as determined by the Exchange.
Newborn Enrollment
When a Molina Marketplace Subscriber or their Spouse gives birth, the newborn is automatically covered under the Subscriber's policy with Molina for the first 31 days of life. In order for the newborn to continue with Molina coverage past this time, the infant must be enrolled through the Marketplace Exchange with Molina on or before 60 days from the date of birth.
PCP's are required to notify Molina via the Pregnancy Notification Report immediately after the first prenatal visit and/or positive pregnancy test for any Molina Member presenting themselves for health care services.
Inpatient at time of Enrollment
With Member assistance, Molina may reach out to any prior Insurer (if applicable) to determine the Member's prior Insurer's liability for payment of Inpatient Hospital Services through discharge of any Inpatient admission. If there is no transition of care provision through Member's prior Insurer or Member did not have coverage through an Insurer at the time of admission, Molina would assume responsibility for Covered Services upon the effective date of Member's coverage with Molina, not prior.
Eligibility Verification
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Health Insurance Marketplace Programs
Payment for services rendered is based on enrollment status and coverage selected. The contractual agreement between Providers and Molina places the responsibility for eligibility verification on the Provider of services.
Eligibility Listing for Molina Marketplace Programs
Providers who contract with Molina may verify a Member's eligibility for specific services and/or confirm PCP assignment by checking the following: · Provider Portal https://provider.MolinaHealthcare.com. · Molina Provider Services automated IVR system at (855) 322-4080
Possession of a Marketplace ID Card does not mean a recipient is eligible for Marketplace services. A Provider should verify a recipient's eligibility each time the recipient presents to their office for services. The verification sources can be used to verify a recipient's enrollment in a Molina Marketplace plan.
Identification Cards
Molina Sample Member ID card
Card Front
Card Back
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Members are reminded in their Agreement 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 Medical 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 terminate coverage for any reason at any time. However, beyond the open-enrollment period, if a Member elects to terminate coverage with Molina Marketplace, they are not eligible to re-enroll with another health plan until the following year's open-enrollment period unless there is a life event, and they qualify for a Special Enrollment Period (SEP) or if they are American Indian or Alaska Native. Members may discontinue Molina coverage by contacting the Marketplace Exchange.
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 the Marketplace Exchange guidelines, Members may be involuntarily disenrolled from a Molina Marketplace program. With proper written documentation and approval by Molina Enrollment Accounting or its Agent; the following are acceptable reasons for which Molina may submit Involuntary Disenrollment requests to Molina Enrollment Accounting: · Delinquency of payment, past defined grace period(s). · Member has moved out of the Service Area. · Member death. · Member's utilization of services is fraudulent. · Member ages out of coverage (e.g., dependent child age > 26, child only age > 21).
PCP Assignment
Molina will offer each Member a choice of Primary Care Providers (PCPs). After making a choice, each Member will have a single PCP. Molina will assign a PCP to those Members who did not choose a PCP at the time of Molina selection. 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, ZIP code location, keeping Children/Adolescents within the same family together, age (adults versus Children/Adolescents) and gender (OB/GYN). 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.
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PCP Changes
Members can change their PCP at any time.
Grace Period
Definitions
APTC Member: A Member who receives advanced premium tax credits (premium subsidy), which helps to offset the cost of monthly premiums for the Member.
Non-APTC Member: A Member who is not receiving any advanced premium tax credits and is therefore solely responsible for the payment of the full monthly premium amount.
Member: An individual, including any dependents, enrolled in Molina Marketplace. This term includes both APTC Members and Non-APTC Members.
Summary
The Affordable Care Act mandates that all qualified health plans offering insurance through the Health Insurance Marketplace provide a grace period of three consecutive months to APTC Members who fail to pay their monthly premium by the due date. Molina Marketplace also offers a grace period in accordance with State Law to Non-APTC Members who fail to pay their monthly premium by the due date. To qualify for a grace period, the Member must have paid at least one full month's premium within the benefit year. The grace period begins on the first day of the first month for which the Member's premium has not been paid. The grace period is not a "rolling" period. Once the Member enters the grace period, they have until the end of that period to resolve the entire outstanding premium balance; partial payment will not extend the grace period.
Grace Period Timing
Non-APTC Members
Non-ATPC Members are granted a 31 day grace period, during which they may be able to access some, or all services covered under their benefit plan. If the full past-due premium is not paid by the end of the grace period, the Non-APTC Member will be retroactively terminated to the last day of the last month for which the premium was paid.
APTC Members
APTC Members are granted a three month grace period. During the first month of the grace period Claims and authorizations will continue to be processed, including Pharmacy Claims. Services, authorization requests and Claims may be denied or have certain restrictions during the second and third months of the grace period. If the APTC Member's full past-due premium is not paid by the end of the third month of the grace period, the APTC Member will be retroactively terminated to the last day of the first month of the grace period.
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Eligibility Messages
When a Member is in the grace period, Molina Healthcare, Inc. ("Molina") will include an eligibility message on the Provider Portal, interactive voice response (IVR) and in the call centers. This alert message will provide information about the Member's grace period status, including which month of the grace period that the Member is in the grace period (second or third) as well as information about how authorizations and Claims will be processed during this time. Providers should verify both the eligibility status AND any service messages when checking a Member's eligibility. For additional information about how authorizations and Claims will be processed during this time, please refer to the Member Evidence of Coverage, or contact Molina's Provider Services department at (855) 322-4080.
Notification
All Members will be notified upon entering the grace period. Additionally, when an APTC Member enters the grace period, their eligibility status becomes available on the Provider Portal. The online eligibility notification will inform Providers as follows: · Members who receive APTC and have entered the first month of the grace period will
not have any service restrictions. Therefore, the message that Providers will see upon checking the provider portal will read as follows: No Enrollment Restrictions. · Providers will be notified and are able to check that the APTC Member entered the second or third months of the grace period. · All Providers and specifically, Providers who have submitted Claims for the APTC Member in the two months prior to the start of the grace period will be notified and are able to check that the APTC Member entered the second or third months of the grace period. · Providers will be notified and are able to check if the APTC Member is in the second or third months of the grace period before services are rendered and before submitting claims.
The online eligibility notification will advise Providers that services rendered during the second and third months of the grace period may be denied if the premium is not paid in full prior to the expiration of the third month of the grace period.
Prior Authorizations
All authorization requests will be reviewed based on Medical Necessity and will expire at the end of the date of the authorization date span, when the authorized visits or unites are exhausted, or when the member's eligibility terminates. Providers should verify eligibility prior to service delivery. If a request for a prior authorization is made, the provider will receive the following disclaimer:
"Prior Authorization is a review of medical necessity and is not a guarantee of payment for services. Payment will be made in accordance with a determination of the member's eligibility on the date of service (for Molina Marketplace members, this includes grace period status), benefit
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limitations/exclusions and other applicable standards during the claim review, including the terms of any applicable provider agreement. If permitted under state law, Molina Healthcare will pend claims for services provided to Marketplace members in months two and three (2 and 3) of the Federally-required grace period until such time as all outstanding premiums due are received or the grace period expires, whichever occurs first. For additional information on a Marketplace member's grace period status, please contact Molina Healthcare."
APTC Members
If the APTC Member pays the full premium payment prior to the expiration of the three month grace period, Providers may then seek authorization for services. If the APTC Member received services during the second or third month of the grace period without a prior authorization, the Provider may request a retro-authorization for those services already rendered. All authorization requests will be reviewed based on Medical Necessity.
Non-APTC Members
Authorization requests received during a Non-APTC Member's grace period will be processed according to Medical Necessity standards.
Claims Processing
APTC Members
First Month of Grace Period: Clean Claims received for services rendered during the first month of a grace period will be processed using Molina's standard processes and in accordance with State and Federal statutes and regulations and within established turnaround-times.
Second/Third Month of Grace Period: Clean Claims received while the APTC Member is in the grace period for services rendered during the second and third months of an APTC Member's grace period will be processed according to Molina's standard processes, within established turn-around-times, and in accordance with State and Federal statutes and regulations. In the event that the APTC Member is terminated for non-payment of the full premium prior to the end of the grace period, Molina will retroactively deny Claims for services rendered in the second and third months of the grace period and will issue a recoup notice to the Provider(s) if appropriate. Pharmacy Claims will be processed based on program drug utilization review and formulary edits; the APTC Member will be charged 100% of the discounted cost for prescriptions filled during the second and third months of the grace period.
Non-APTC Members
Clean Claims received for services rendered during the grace period will be processed using Molina's standard processes and in accordance with State and Federal statutes and regulations and within established turn-around-times.
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6. Benefits and Covered Services
Molina covers the services described in the Summary of Benefits and Coverage and Schedule of Benefits documentation for each Molina Marketplace plan type. If there are questions as to whether a service is covered or requires prior authorization, please contact Molina at (855) 322-4080, Monday through Friday, 8:00 a.m. 5:00 p.m.
Member Cost Sharing
Cost Sharing is the Copayment that Members must pay for Covered Services provided under their Molina Marketplace plan. The Cost Sharing amount Members will be required to pay for each type of Covered Service is summarized on the Member's ID card. Additional detail regarding cost sharing listed in the Schedule of Benefits. Cost Sharing applies to all Covered Services except for preventive services included in the Essential Health Benefits (as required by the Affordable Care Act). Cost Sharing towards Essential Health Benefits may be reduced or eliminated for certain eligible Members, as determined by Marketplace's rules.
It is the Provider's responsibility to collect the copayment and other Member Cost Share from the Member to receive full reimbursement for a service. The amount of the copayment and other Cost Sharing will be deducted from the Molina payment for all Claims involving Cost Sharing.
Link to Benefit Documents
The following web link provides access to the Summary of Benefits and Coverage documents for Molina Marketplace products offered in Texas.
https://www.molinamarketplace.com/marketplace/tx/en-us/MemberForms.aspx
Detailed Benefit Information
Detailed information about benefits and services can be found in the Schedule of Benefits made available to Molina Marketplace Members via the Molina Member Portal. Providers can access Schedule of Benefits documents via the Provider Portal. EOCs are available to Providers via the Provider Portal Link: https://provider.MolinaHealthcare.com
Obtaining Access to Certain Covered Services
Prescription Drugs
Prescription drugs are covered by Molina, via our pharmacy vendor, CVS Caremark. A list of in-network pharmacies is available on the www.MolinaHealthcare.com website, or by contacting Molina. Members must use their Molina ID card to get prescriptions filled. Additional information regarding the pharmacy benefits, and its limitations, is available by contacting Molina at (855) 322-4080 or at www.Molinamarketplace.com.
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Non-Formulary Drug Exception Request Process
There are two types of requests for Formulary exception: · "Expedited Exception Request" for urgent circumstances that may seriously
jeopardize life, health or ability to regain maximum function, or for undergoing current treatment using non-Drug Formulary drugs. · "Standard Exception Request"
The Member and/or Member's representative and the prescribing Provider will be notified of Molina 's decision no later than: · 24 hours following receipt of request for Expedited Exception Request. · 72 hours following receipt of request for Standard Exception Request.
If the initial request is denied, an external review may be requested. The Member and/or Member's representative and the prescribing Provider will be notified of the external review decision no later than: · 24 hours following receipt of the request for external review of the Expedited Exception
Request. · 72 hours following receipt of the request for external review of the Standard Exception
Request.
Injectable and Infusion Services
Many self-administered and office-administered injectable products require Prior Authorization (PA). In some cases they will be made available through a vendor, designated by Molina. More information about our Prior Authorization process, including a link to the PA request form, is available in the Pharmacy section of this Provider Manual.
Family planning services related to the injection or insertion of a contraceptive drug or device are covered at no cost.
Access to Mental Health and Substance Abuse Services
Members in need of Mental Health or Substance Abuse Services can be referred by their PCP for services or Members can self-refer by calling Molina's Behavioral Health department at (888) 560-2025.
Molina's Nurse Advice Line is available 24 hours a day, 7 days a week for mental health or substance abuse needs. The services Members receive will be confidential. Additional detail regarding Covered Services and any limitations can be obtained in the EOCs, or by contacting Molina. All outpatient professional mental health and substance abuse services will be charged the primary care copay equivalent.
Emergency Mental Health or Substance Abuse Services
Members are directed to call 911 or go to the nearest emergency room if they need Emergency mental health or substance abuse services. Examples of Emergency mental health or substance abuse problems are:
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· 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 Providers are directed to do the following: · Go to the nearest hospital or facility. · 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.
Obtaining Mental Health or Substance Abuse Services
Please call the appropriate Member Services or Provider Services number or the Behavioral Health Department to find a mental health or substance abuse Provider.
Emergency 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.
Non-Emergency Medical Transportation
Molina covers non-routine, non-Emergency Medically Necessary ground transportation, when Molina determines such transportation is needed within Molina's Service Area to transfer the Member from one medical facility to another. Examples of this are from one hospital to another hospital, from a hospital to a skilled nursing facility or hospice. NonEmergency medical transportation is provided by wheelchair lift equipped vehicle, litter/stretcher van or non-Emergency ambulance (both advanced life support and basic life support). When non-Emergency medical transportation is needed, Molina will arrange for the transportation to be provided by one of our Participating Provider transportation vendors. Please note, this is not a service for which Members can self-refer and any services not arranged by Molina will not be covered.
Telehealth and Telemedicine Services
You may obtain covered services by Participating Providers, through the use of Telehealth and Telemedicine services. Not all Participating Providers offer these services. For more information, please refer to Telehealth and Telemedicine services in the definitions section. The following additional provisions that apply to the use of Telehealth and Telemedicine services:
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· 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. · Member cost sharing associates to the Schedule of Benefits, based upon the
Participating Provider's designation for covered services. (i.e., Primary Care, Specialist or Other Practitioner). · Covered Services provided through Store and Forward technology, must include an in-person office visit to determine diagnosis or treatment.
Upon at least ten 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 information on Telehealth and Telemedicine Services Claims and billing, please refer to the Claims and Compensation section of this Provider Manual.
Preventive Care
Preventive Care Guidelines are located on the Molina Website. Please use the link below to access the most current guidelines: http://www.MolinaHealthcare.com/providers/common/marketplace/resource/Pages/hlthg uide.aspx
Emergency Services
Emergency Services means: health care services provided in a hospital emergency facility, freestanding emergency medical care facility, or comparable emergency facility to evaluate and stabilize medical conditions of a recent onset and severity, including severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that the individual's condition, sickness, or injury is of such a nature that failure to get immediate medical care could: · Place the individual's health in serious jeopardy; · Result in serious impairment to bodily functions; · Result in serious dysfunction of any bodily organ or part; · Result in serious disfigurement; or, · For a pregnant woman, result in serious jeopardy to the health of the fetus.
Emergent Services are covered by Molina without an authorization. This includes noncontracted Providers inside or outside of Molina's service area.
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Nurse Advice Line
Members may call the Nurse Advise Line 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/TDD: 711 Relay or (866) 735-2929 (English), (866) 833-4703 (Spanish)
Molina is committed to helping our Members: · Prudently use the services of your office · Understand how to handle routine health 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 specially 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.
Health Management Programs
Molina's health management programs provide patient education information to Members and facilitate Provider access to chronic disease programs and services.
For additional information on health management programs please refer to the Healthcare Services section of this Provider Manual.
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7. Healthcare Services
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 of network Providers.
Utilization Management
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. · 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. · Ensuring that UM decision making tools are appropriately applied in determining
medical necessity decision.
Key Functions of the UM Program
The table below outlines the key functions of the UM program. All prior authorizations are based on a specific standardized list of services.
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Eligibility and Oversight Resource Management
Eligibility verification
Prior Authorization and
referral management
Benefit administration and interpretation Ensure authorized care correlates to Member's medical necessity need(s) & benefit plan Verifying current Physician/hospital contract status Delegation oversight
Pre-admission, Admission and Inpatient Review Post service/post claim audits
Referrals for Discharge Planning and Care Transitions Staff education on consistent application of UM functions
Quality Management Satisfaction evaluation of the UM program using Member and Provider input Utilization data analysis
Monitor for possible overor under-utilization of clinical resources
Quality oversight
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.
Medical Groups/IPAs and delegated entities who assume responsibility for UM must adhere to Molina's UM Policies. Their programs, policies and supporting documentation are reviewed by Molina at least annually.
UM Decisions
A decision is any determination (e.g., an approval or denial) made by Molina or the delegated Medical Group/IPA or other delegated entity 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.
Molina follows a hierarchy of medical necessity decision making with Federal and State regulations taking precedence. Molina covers all services and items required by State and Federal regulations.
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.
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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) 322-4080 to obtain Molina's UM Criteria.
Medical Necessity
"Medically Necessary" or "Medical Necessity" means health care services determined by a provider, in consultation with Molina Healthcare, to be clinically appropriate or clinically significant, in terms of type, frequency, event, site, according to any applicable generally accepted principles and practices of good medical care or practice guidelines developed by the federal government, national or professional medical societies, boards and associations, or any applicable clinical protocols or practice guidelines developed by Molina Healthcare consistent with such federal, national, and professional practice guidelines, for the diagnosis or direct care and treatment of a physical, behavioral, or mental health condition, illness, injury or disease.
This is for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms. Those services must be deemed by Molina to be: 1. In accordance with generally accepted standards of medical practice. 2. Clinically appropriate and clinically significant, in terms of type, frequency, extent,
site and duration. They are considered effective for the patient's illness, injury or disease. 3. Not primarily for the convenience of the patient, physician, or other health care Provider. The services must not be more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease.
For these purposes, "generally accepted standards of medical practice" means standards that are based on credible scientific evidence published in peer-reviewed medical literature. This literature is generally recognized by the relevant medical community, physician specialty society recommendations, the views of physicians practicing in relevant clinical areas and any other relevant factors.
The fact that a Provider has prescribed, recommended or approved medical or allied goods or 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
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notification/concurrent review, or retrospectively. 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.
Levels of Administrative and Clinical 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.
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 apprised of service requests and of the service provided to the
Member by other Providers.
All UM requests that may lead to a denial are reviewed by a licensed health care 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; physician emergency department notes, inpatient history/physical exams, discharge summaries, physician progress notes, physician office notes, physician orders, nursing notes, results of laboratory or imaging studies, therapy evaluations and therapist notes. Molina does not accept clinical summaries, telephone summaries or inpatient case
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manager criteria reviews as meeting the clinical information requirements unless State or Federal regulations allows such documentation to be acceptable.
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. Molina prior authorization documents are customarily updated quarterly, but may be updated more frequently as appropriate, and are posted on the Molina website at www.MolinaHealthcare.com.
Providers are notified of any additions to the prior authorization requirements no less than 60 days prior to the effective date. Prior authorization deletions require a notice no less than 5 days prior to the effective date.
Providers are encouraged to use the Texas Standard Prior Authorization Request Form provided on the Molina website. 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.
Services performed without authorization may not be eligible for payment. Services provided emergently (as defined by Federal and State Law) are excluded from the 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.
Molina makes UM decisions in a timely manner to accommodate the urgency of the situation as determined by the Member's clinical situation. The definition of expedited/urgent is when the situation where the standard time frame or decision making process could seriously jeopardize the life or health of the enrollee, 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 enrollee's ability to regain maximum function. Supporting documentation is required to justify the expedited request.
For expedited requests involving emergency post stabilization treatment, Molina will make a determination within one hour of receiving the request. Providers must call (855) 322-
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4080 to request an expedited authorization for emergency post stabilization treatment. After hours calls are facilitated by Molina's 24-hour Nurse Advice Line at (888) 275-8750. Please note: Emergency Department services and stabilization do not require authorization, regardless if the provider is contracted with Molina.
For urgent authorization, a determination is made as promptly as the member's health requires and no later than 72 hours after we receive the initial request for service in the event a provider indicates, or if we determine that a standard authorization decision timeframe could jeopardize a member's life or health. For a standard authorization request, Molina makes the determination and provides notification within 3 calendar days.
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 (855) 322-4080.
Upon approval, the requestor will receive an authorization number. The number may be provided by telephone or fax. If a request is denied, the requestor and the Member will receive a letter explaining the reason for the denial and additional information regarding the grievance and appeals process. Denials also are communicated to the Provider by telephone if at all possible or by fax with confirmation of receipt if telephonic communication fails.
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.
For additional information regarding the prior authorization of specialized clinical services, please refer to the Prior Authorization tools located on the www.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 available on the Provider Portal. The benefits of submitting your prior authorization request through the Provider Portal are: · Create and submit prior authorization requests. · Check status of authorization requests. · Receive notification of change in status of 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) 420-3639.
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Phone: Prior authorizations can be initiated by contacting Molina's Healthcare Services department at (855) 322-4080. It may be necessary to submit additional documentation before the authorization can be processed.
Mail: Prior authorization requests and supporting documentation can be submitted via U.S. Mail at the following address: Molina Healthcare of Texas, Inc. Attn: Healthcare Services/UM Dept. 5605 N. MacArthur Blvd., Suite 400 Irving, TX 75038
Emergency Services
Emergency Services means: health care services provided in a hospital emergency facility, freestanding emergency medical care facility, or comparable emergency facility to evaluate and stabilize medical conditions of a recent onset and severity, including severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that the individual's condition, sickness, or injury is of such a nature that failure to get immediate medical care could: · Place the individual's health in serious jeopardy; · Result in serious impairment to bodily functions; · Result in serious dysfunction of any bodily organ or part; · Result in serious disfigurement; or, · For a pregnant woman, result in serious jeopardy to the health of the fetus.
Emergency Medical Condition or Emergency means: means the sudden onset of what reasonably appears to be a medical condition that manifests itself by symptoms of sufficient severity. Including severe pain, which the absence of immediate medical attention could reasonably be expected by a reasonable layperson, to result in jeopardy to the person's health, serious impairment of bodily functions, serious dysfunction of any bodily organ or part, or disfigurement to the person; or in the case of a pregnant woman, serious jeopardy to the health of the fetus.
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
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participating facility. Services provided after stabilization in a non-participating facility are not covered and the Member will be responsible for payment. Member payments to the non-participating facility will not apply to the Member's deductible or annual out-of-pocket maximum.
Members over-utilizing the emergency department will be contacted by Molina Case Managers to provide assistance whenever possible and determine the reason for using Emergency Services.
Case 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.
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 24 hours or by the following 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 within 24 hours of admission or by the following business day. Molina recognizes that hospital stays after emergent care may be successfully completed with observation care. Unless an inpatient authorization is specifically requested with the notification, Molina considers the inpatient authorization request to begin when clinical information is submitted with indication that the member is in an inpatient level of care. Notification of admission and clinical information 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 inpatient admission will result in a denial of authorization for the inpatient stay.
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 to ensure medical necessity of ongoing inpatient services, adequate progress of treatment and development of appropriate discharge plans. Performing these functions requires timely clinical information updates
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from inpatient facilities. Molina will request updated clinical records from inpatient facilities at regular intervals during a member's inpatient stay. Molina requires that requested clinical information updates be received by Molina from the inpatient facility within 24 hours of the request. Failure to provide timely clinical information updates may result in a denial of authorization for the remainder of the inpatient stay dependent on the Provider contract terms and agreements.
Molina will authorize hospital care as an inpatient, when the clinical record supports the medical necessity for the need for continued hospital stay. It is the expectation that observation has been tried in those patients that require a period of treatment or assessment, pending a decision regarding the need for additional care, and the observation level of care has failed. 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, and disposition.
Inpatient Status Determinations
Molina's UM staff follow CMS guidelines to determine if the collected clinical information for requested services are "reasonable and necessary for the diagnosis or treatment of an illness or injury, or to improve the functioning of malformed body member" by meeting all coverage, coding and medical necessity requirements (refer to the Medical Necessity Standards section of this manual).
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.
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 and State regulations.
Molina will conduct readmission reviews for participating hospitals when both admissions occur at the same acute inpatient facility within the state regulatory requirement dates. There are two situations for Readmissions: Readmissions occurring within 24 hours from discharge (same or similar diagnosis); 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.
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When a subsequent admission to the same facility occurs within 2-30 days of discharge, and it is determined that the subsequent readmission is related to the first admission (readmission) 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 the following circumstances: o Premature or inadequate discharge from the same hospital; o Issues with transition or coordination of care from the initial admission; o For an acute medical complication plausibly related to care that occurred during the initial admission.
· Readmissions that are excluded from consideration as preventable readmissions include: o Planned readmissions associated with major or metastatic malignancies, multiple trauma, and burns. o Neonatal and obstetrical Readmissions. o Initial admissions with a discharge status of "left against medical advice" because the intended care was not completed. o Behavioral Health readmissions o 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. 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 and its delegated contractors 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
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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 Medical Groups/IPAs and 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) 322-4080 during normal business hours, Monday through Friday (except for Holidays) from 8:00 a.m. to 5:00 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.
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 for 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
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temporarily outside the service area, without prior authorization or as otherwise required by Federal or State Laws or regulations.
Except for Emergency Services and out-of-area Urgent Care Services, Marketplace Members must receive covered services from Participating Providers; otherwise, the services are not covered. Marketplace Members will be 100% responsible for payment and the payments will not apply to towards Deductibles or Annual Out-of-Pocket Maximums.
Coordination of Care and Services
Molina HCS staff work with Providers to assist with coordinating referrals, services and benefits for Members who have been identified for Molina's Integrated Care Management (ICM) program via assessment, or referral, such as self-referral, caregiver or Provider referrals, 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 addressing 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 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 or its delegated Medical Group/IPA. · High risk of second or third trimester 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 additional information regarding continuity of care and transition of Members, please contact Molina at (855) 322-4080.
Continuity and Coordination of Provider Communication
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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:
Child Abuse
Texas Department of Family and Protective Services (DFPS) Phone: 1-800-252-5400 Website: www.txabusehotline.org
Adult Abuse
Texas Department of Family and Protective Services (DFPS) Phone: 1-800-252-5400 Website: www.txabusehotline.org
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.
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Molina will track, analyze, and report aggregate information regarding abuse reporting to the Utilization Management 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 case manager provides the PCP with the Members' 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.
Case Manager Responsibilities
The case manager collaborates with the Member and any additional participants as directed by the Member to develop an ICP that includes recommended interventions from the Member's ICT as applicable. ICP interventions include the appropriate information to address medical and psychosocial needs and/or barriers to accessing care, care coordination to address Member's health care goals, health education to support selfmanagement goals, and a statement of expected outcomes. Jointly, the case manager, and the Member are responsible for implementing the plan of care. Additionally, the case manager: · Assesses the Member to determine if the Member's needs warrant care management. · Monitors and communicates the progress of the implemented ICP to the Member's
ICT, as Member needs warrant. · Serves as a coordinator and resource to the Member, their representative and ICT
participants throughout the implementation of the ICP and revises to the plan as suggested and needed. · Coordinates appropriate education and encourages the Member's role in selfmanagement . · Monitors progress toward the Member's achievement of ICP goals in order to determine an appropriate time for the Member's graduation from the ICM program.
Health Management
Molina's Health Management programs may be incorporated into the Member's ICP to address the Member's health care needs. Molina offers programs to help our Members and their families manage a diagnosed health condition. You as a Provider also help us identify Members who may benefit from these programs. Members can request to be enrolled or dis-enrolled in these programs at any time. Our programs include: · Asthma Management · Diabetes Management · High Blood Pressure Management · Cardiovascular Disease (CVD) management/Congestive Heart Disease · Chronic Obstructive Pulmonary Disease (COPD) Management · Depression Management · Obesity
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· Weight Management · Smoking Cessation · Organ Transplant · Serious and Persistent Mental Illness (SPMI) and Substance Use Disorder · Maternity Screening and High Risk Obstetrics
Member Newsletters
Member Newsletters are posted on the www.MolinaHealthcare.com website at least once a year. The articles are about topics asked by Members. The tips are aimed to help Members stay healthy.
Member Health Education Materials
Members can access our easy-to-read materials 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 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. · External referrals from Provider(s), caregivers or community-based organizations. · Internal Molina referrals from Nurse Advice Line, Medication Management or Utilization Management. · Member self-referral due to general plan promotion of program through Member newsletter or other Member communications.
Provider Participation
Contracted Providers are notified as appropriate, when the Member is 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.
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· 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. · Preventive Health Guidelines.
Additional information on Health Management programs is available from your local Molina Healthcare Services department toll free at (855) 322-4080.
Case Management (CM)
Molina provides a comprehensive ICM program to all Members who meet the criteria for services. The ICM program focuses on coordinating the care, services, and resources needed by Members throughout the continuum of care. Molina adheres to Case Management Society of America Standards of Practice Guidelines in its execution of the program.
The Molina case managers may be licensed professionals and are educated, trained and experienced in Molina's ICM program. The ICM 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 ICM program is individualized to accommodate a Member's needs with collaboration and input from the Member's PCP. The Molina case 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 case manager is responsible for assessing the Member's appropriateness for the ICM program and for notifying the PCP of ICM program enrollment,, as well as facilitating and assisting with the development of the members' 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 ICM program. The case manager works collaboratively with the Member and all participants of the ICT when warranted, including the PCP, and specialty Providers such as, discharge planners, ancillary Providers or other community resources when identified. The referral source should be prepared to provides the case 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 ICM 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, End Stage Renal Disease) · Comorbid chronic illnesses (e.g., asthma, diabetes, COPD, CHF, etc. ). · Preterm Infants · High-technology home care requiring more than two weeks of treatment
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· Member accessing Emergency Department services inappropriately
Referrals to the ICM program may be made by contacting Molina at: Phone: (866) 409-0039 Fax: (866) 409-3269
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8. Quality
Maintaining Quality Improvement Processes and Programs
Molina works with Members and Providers to maintain a comprehensive Quality Improvement Program. You can contact the Molina Quality department toll free at (855) 322-4080, or fax (210) 366-6524.
The address for mail requests is: Molina Healthcare of Texas, Inc. Quality Department 84 NE Loop 410, Suite 180 San Antonio, TX 78216
This Provider Manual contains excerpts from the Molina Quality Improvement Program. For a complete copy of Molina's Quality Improvement Program you can contact your Provider Services representative or call the telephone number above to receive a written copy.
Molina has established a Quality Improvement Program that complies with regulatory requirements and accreditation standards. The Quality Improvement Program provides structure and outlines specific activities designed to improve the care, service and health of our Members. In our quality program description, we describe how our program governance, scope, goals, measurable objectives, structure and responsibilities.
Molina does not delegate Quality Improvement 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 Quality Improvement 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 Practitioner 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. · Allow access to Molina Quality personnel for site and medical record review processes.
Patient Safety Program
Molina's Patient Safety Program identifies appropriate safety projects and error avoidance for Molina Members in collaboration with their Primary Care Providers. Molina continues to support safe personal health practices for our Members through our safety program, pharmaceutical management and care management/disease management
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programs and education. Molina monitors nationally recognized quality index ratings for facilities including adverse events and hospital acquired conditions as part of a national strategy to improve health care quality mandated by the Patient Protection and Affordable Care Act (ACA), Health and Human Services (HHS) is to identify areas that have the potential for improving health care quality to reduce the incidence of events.
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."
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. 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 .
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 Improvement and HIPAA compliance.
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· 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.
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. · Prescribed medications, including dosages and dates of initial or refill prescriptions; · Medication reconciliation within 30 days of an inpatient discharge should include
evidence of current and discharge medication reconciliation and the date performed. · Allergies and adverse reactions (or notation that none are known). · Documentation that Advance 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).
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· 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 medial information
for facilitation of medical care.
Retrieval
· The medical record is available to 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. · 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 ten years from the last date of treatment or for a minor, one year past their 20th birthday but, never less than ten 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 an 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; and,
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· Education and training for all staff on handling and maintaining protected healthcare information.
Additional information on medical records is available from your local Molina Quality department. For additional information regarding the HIPAA, please see the Compliance section of this Provider Manual.
Access to Care
Molina maintains access to care standards and processes for ongoing monitoring of access to health care (including behavioral health care) provided by contracted primary PCPs (adult and pediatric) and participating specialist (to include OB/GYN, behavioral health providers, and high volume and high impact specialists). Providers are required to conform to the Access to Care appointment standards listed below to ensure that health care services are provided in a timely manner. The standards are based on 90% availability for Emergency Services and 90% or greater for all other services. The PCP or their designee must be available 24 hours a day, 7 days a week to Members.
Appointment Access
All Providers who oversee the Member's health care are responsible for providing the following appointments to Molina Members in the timeframes noted:
Medical Appointment
Appointment Types Routine, asymptomatic Routine, symptomatic Urgent Care After Hours Care Specialty Care (High Volume) Specialty Care (High Impact) Urgent Specialty Care
Standard Within 60 calendar days. Within 14 calendar days. Within 24 hours. 24 hours/day; 7 day/week availability. Within 30 calendar days. Within 30 calendar days. Within 24 hours.
Behavioral Health Appointment
Appointment Types Life Threatening Emergency Non-life Threatening Emergency Urgent Care Initial Routine Care Visit Follow-up Routine Care Visit
Standard Immediately Within 6 hours. Within 48 hours. Within 10 business days. Within 30 calendar days.
Additional information on appointment access standards is available from your local Molina Quality department.
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Office Wait Time
For scheduled appointments, the wait time in offices should not exceed 60 minutes. All PCPs are required to monitor waiting times and adhere to this standard.
After Hours
All Providers must have back-up (on call) coverage after hours or during the Provider's absence or unavailability. Molina requires Providers to maintain a 24 hour phone service, 7 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.
Women's Health Access
Molina allows Members the option to seek obstetric and gynecological care from an innetwork 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. Gynecological services must be provided when requested regardless of the gender status of the Member.
Additional information on access to care is available from your local Molina Quality 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,
afterhours 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.
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Quality of Provider Office Sites
Molina Providers are to maintain office-site and medical record keeping practices standards. Molina continually monitors Member appeals and complaints/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.
Administration & Confidentiality of Facilities
Facilities contracted with Molina must demonstrate an overall compliance with the guidelines listed below: · Office appearance demonstrates that housekeeping and maintenance are performed
appropriately on a regular basis, the waiting room is well-lit, office hours are posted and parking area and walkways demonstrate appropriate maintenance. · Accessible parking is available, the building and exam rooms are accessible with an incline ramp or flat entryway, and the restroom is accessible with a bathroom grab bar. · Adequate seating includes space for an average number of patients in an hour and there is a minimum of two office exam rooms per physician. · Basic emergency equipment is located in an easily accessible area. This includes a pocket mask and Epinephrine, plus any other medications appropriate to the practice. · At least one CPR certified employee is available · Yearly OSHA training (Fire, Safety, Blood-borne Pathogens, etc.) is documented for offices with ten or more employees.
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· A container for sharps is located in each room where injections are given. · Labeled containers, policies, and contracts evidence hazardous waste management. · Patient check-in systems are confidential. Signatures on fee slips, separate forms,
stickers or labels are possible alternative methods. · Confidential information is discussed away from patients. When reception areas are
unprotected by sound barriers, scheduling and triage phones are best placed at another location. · Medical records are stored away from patient areas. Record rooms and/or file cabinets are preferably locked. · A CLIA waiver is displayed when the appropriate lab work is run in the office. · Prescription pads are not kept in exam rooms. · Narcotics are locked, preferably double-locked. Medication and sample access is restricted. · System in place to ensure expired sample medications are not dispensed and injectables and emergency medication are checked monthly for outdates. · Drug refrigerator temperatures are documented daily.
Advance Directives (Patient Self-Determination Act)
Molina complies with the advance directive requirements of the States in which the organization provides services. Responsibilities include ensuring Members receive information regarding advance directives and that contracted Providers and facilities uphold executed documents.
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.
When There Is No Advance Directive: The Member's family and Provider 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 (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.
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.
Services to Enrollees Under 21 Years of Age
Molina maintains systematic and robust monitoring mechanisms to ensure all Enrollees under 21 years of age are timely according to required preventive health guidelines. All Enrollees under 21 years of age should receive screening examinations including appropriate childhood immunizations at intervals as specified by the by the preventive health guidelines located on the Molina Provider Website (www.MolinaHealthcare.com) and referenced in the Benefits and Covered Services section of this Provider Manual.
Well Child/Adolescent Visits
Visits consist of age-appropriate components, that include but are not limited to: · Comprehensive health and developmental history. · 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 blood level assessment appropriate for age and
risk factors. · Periodic developmental and behavioral screening using a recognized, standardized
developmental screening tool. · Vision and hearing tests. · Dental assessment and services.
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· Health education (including anticipatory guidance such as child development, healthy lifestyles, and accident and disease prevention).
Diagnostic services, treatment, or services Medically Necessary to correct or ameliorate defects, physical or mental illnesses, and conditions discovered during a screening or testing must be provided or arranged for either directly or through referrals. 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 should be referred to an appropriate source of care for any required services that are not Covered Services.
Molina shall have no obligation to pay for services that are not Covered Services.
Monitoring for Compliance with Standards
Molina monitors compliance with the established performance standards as outlined above at least annually. Within 30 calendar days of the review, a copy of the review report and a letter will be sent to the medical group notifying them of their results. Performance below Molina's standards may result in a Corrective Action Plan (CAP) with a request the Provider submit a written corrective action plan to Molina within 30 calendar days. Followup to ensure resolution is conducted at regular intervals until compliance is achieved. The information and any response made by the Provider are included in the Provider's permanent credentials file. If compliance is not attained at follow-up, an updated CAP will be required. Providers who do not submit a CAP may be terminated from network participation or closed to new Members.
Quality Improvement Activities and Programs
Molina maintains an active Quality Improvement Program. The Quality Improvement Program 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.
Health Management and Care Management
The Molina Health Management and Care Management Programs provides for the identification, assessment, stratification, and implementation of appropriate interventions for Members with chronic diseases.
For additional information, please see the Health Management and Care Management headings in the Healthcare Services section of this Provider Manual.
Clinical Practice Guidelines
Molina adopts and disseminates Clinical Practice Guidelines (CPGs) to reduce interProvider variation in diagnosis and treatment. CPG adherence is measured at least monthly. All guidelines are based on scientific evidence, review of medical literature
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and/or appropriately established authority. Clinical Practice Guidelines are reviewed at least annually, and more frequently as needed when clinical evidence changes and are approved by the Quality Improvement Committee.
Molina Clinical Practice Guidelines include the following: · Acute Stress and Post-Traumatic Stress Disorder (PTSD) · Anxiety/Panic Disorder · Asthma · Attention Deficit Hyperactivity Disorder (ADHD) · Bipolar Disorder · Chronic Kidney Disease · Chronic Obstructive Pulmonary Disease (COPD) · Depression · Detoxification and Substance Abuse Treatment · Diabetes · Heart Failure · Hypertension · Obesity · Opioid Management · Perinatal/Prenatal/Postnatal Care · Sickle Cell Disease
The adopted CPGs are distributed to the appropriate Providers, Provider groups, staff model facilities, delegates and Members by the Quality, Provider Services, Health Education and Member Services departments. 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.
Preventive Health Guidelines
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: · Care for children up to 24 months old · Care for children 2 to 19 years old · Care for adults 20 to 64 years old · Care for adults 65 years and older · Immunization schedules for children and adolescents · Immunization schedules for adults
All Clinical Practice Guidelines are updated at least annually and more frequently as needed when clinical evidence changes and are approved by the Quality Improvement Committee. On an annual basis, Preventive Health Guidelines are distributed to Providers
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via www.MolinaHealthcare.com and the Provider Manual. Notification of the availability of the Preventive Health Guidelines is published in the Molina Provider Newsletter.
Cultural and Linguistic Services
Molina works to ensure all Members receive culturally competent care across the service continuum to reduce health disparities and improve health outcomes. For additional information about Molina's program and services, please see the Cultural Competency and Linguistic Services section of this Provider Manual.
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®) · Qualified Health Plan (QHP) Enrollee Experience Survey · Behavioral Health Survey · Provider Satisfaction Survey · Effectiveness of Quality Improvement Initiatives Molina evaluates continuous performance according to, or in comparison with objectives, measurable performance standards and benchmarks at the national, regional and/or at the local/health plan level.
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.
Molina's most recent results can be obtained from your local Molina Quality department or by visiting our website at www.MolinaHealthcare.com.
Healthcare Effectiveness Data and Information Set (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 cardiovascular disease.
HEDIS® results are used in a variety of ways. The results are the measurement standard for many 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.
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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.
Behavioral Health Survey
Molina obtains feedback from Members about their experience, needs, and perceptions of accessing behavioral health care. This feedback is collected at least annually to understand how our Members rate their experiences in getting treatment, communicating with their clinicians, receiving treatment and information from the plan, and perceived improvement in their conditions, among other areas.
Qualified Health Plan (QHP) Enrollee Experience Survey
The QHP Enrollee Experience Survey is a consumer experience survey that assesses enrollee experience with QHPs offered through Marketplaces. The QHP Enrollee Survey is fielded nationally by HHS-approved survey vendors using a standardized protocol to facilitate QHP comparison both within and across Marketplaces.
The QHP Enrollee Experience Survey was designed to collect accurate and reliable information from consumers about their experience with the health care they received through Health Insurance Marketplace QHPs. The survey includes a set of core questions that address key areas of care and service, with some questions grouped to form composites.
QHP Enrollee Survey topics include: · Access to Care · Access to Information · Care Coordination · Cost · Cultural Competence · Doctor's Communication · Plan Administration · Prevention ·
Provider Satisfaction Survey
Recognizing that HEDIS® and CAHPS®/Qualified Health Plan Enrollee Experience Survey both focus on Member experience with health care 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 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 outcomes 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.
Quality Rating System
Based on Section 1311(c)(3) of the Affordable Care Act, CMS developed the Quality Rating System (QRS) to: · Provide comparable and useful information to consumers about the quality of health
care services provided by QHPs. · Facilitate oversight of QHP issuer compliance with Marketplace quality standards. · Provide actionable information for improving quality and performance.
Quality ratings are calculated for each eligible QHP product using clinical quality and enrollee experience survey data. Based on results, CMS will calculate and produce quality performance ratings for each health plan on a 1 to 5- star rating scale.
Measures are organized into a hierarchical structure designed to make the QRS scores and ratings more understandable. They include, but are not limited, to the following domains: · Clinical Effectiveness · Patient Safety · Prevention · Access and Coordination · Doctor and Care · Efficiency and Affordability · Plan Service
What Can Providers Do?
· Ensure patients are up-to-date with their annual physical exam and preventive health screenings, including related lab orders and referrals to specialists, such as ophthalmology.
· Review the HEDIS® preventive care listing of measures for each patient to determine if anything applicable to your patients' age and/or condition has been missed.
· Check that staff is properly coding all services provided. · Be sure patients understand what they need to do.
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Molina has additional resources to assist Providers and their patients. For access to tools that can assist, please visit the Provider Portal. There is a variety of resources, including HEDIS® CPT/CMS-approved diagnostic and procedural code sheets. To obtain a current list of HEDIS® and CAHPS®/Qualified Health Plan Enrollee Survey Star Ratings measures, contact your local Molina Quality department.
HEDIS® and CAHPS® are registered trademarks of the National Committee for Quality Assurance (NCQA).
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9. Compliance
Fraud, Waste, and Abuse
Introduction
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 addresses how Molina will uphold and follow state and federal statutes and regulations pertaining to fraud, waste, and abuse. The program also addresses fraud, waste and abuse prevention and detection along with and the education of appropriate employees, vendors, Providers and associates doing business with Molina.
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 reporting these findings to the appropriate regulatory and/or Law enforcement agency.
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 program to prevent, investigate, and report suspected health care fraud, waste and abuse in order to reduce health care cost and to promote quality health care.
Regulatory Requirements
Federal False Claims Act
The False Claims Act is a Federal statute that covers fraud involving any Federally funded contract or program. 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
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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 whistleblowers.
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 lawsuit against the organization/individual accused of violating the False Claims Act. The whistleblower may also file a lawsuit independently. Cases found in favor of the government will result in the whistleblower receiving a portion of the amount awarded to the government.
Whistleblower 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.
Affected entities who fail to comply with the Law will be at 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-Kickback 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 Practitioners, 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.
Definitions
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Fraud: means 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: means health care spending that can be eliminated without reducing the quality of care. Quality waste includes overuse, underuse, and ineffective use. Inefficiency waste includes redundancy, delays, and unnecessary process complexity. An example would be the attempt to obtain reimbursement for items or services where there was no intent to deceive or misrepresent, however the outcome resulted in poor or inefficient billing methods (e.g. coding) causing unnecessary costs to the Marketplace program.
Abuse: means Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary costs to the Marketplace 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 Marketplace programs. (42 CFR § 455.2)
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 Member 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 Molina Member for covered services. This includes asking the
Member to pay the difference between the discounted and 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 Marketplace benefits. · Conspiracy to defraud the Marketplace. · 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 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 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.
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.
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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 (MUE) table, the National Correct Coding Initiative (NCCI) files, Local Coverage Determination/National Coverage Determination (LCD/NCD), 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.
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
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for which Provider fails to furnish supporting documentation during the audit process are not reimbursable and are subject to chargeback.
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 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, clientdirected/regulatory investigation and/or compliance reviews and may be vendor assisted. Molina asks that you provide Molina, or Molina's 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, 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.
Provider Education
When Molina identifies through an audit or other means a situation with a Provider (e.g. coding, billing) that is either inappropriate or deficient, Molina may determine that a Provider education is appropriate.
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Molina 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 (CAP) to Molina addressing the issues identified and how it will cure these issues moving forward.
Reporting Fraud, Waste and Abuse
If you suspect fraud, waste, or abuse, you must report it by contacting the Molina AlertLine. AlertLine is an external telephone and web-based reporting system hosted by NAVEX Global, a leading Provider of compliance and ethics hotline services. AlertLine telephone and web-based reporting is available 24 hours a day, 7 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 AlertLine, a trained professional at NAVEX Global will note your concerns and provide them to the Molina 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 AlertLine can be made from anywhere within the United States with telephone or internet access.
Molina AlertLine 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 https://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 Texas, Inc. Attn: Compliance 5605 N. MacArthur Blvd., Suite 400 Irving, TX 75038
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, Marketplace ID number and any other identifying information.
Suspected fraud and abuse may also be reported directly to the State at: Texas Department of Insurance Attn: Fraud Unit MC 109-3A P.O. Box 149336 Austin, TX 78714-9336 Toll Free Phone: 1-800-252-3439 Email: FraudUnit@tdi.texas.gov
HIPAA Requirements and Information
HIPAA (The Health Insurance Portability and Accountability Act)
Molina's Commitment to Patient Privacy
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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 Responsibilities
Molina expects that its contracted Provider will 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. 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 HIPAArelated 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)
Applicable Laws
Providers 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 must comply with. In general, most health care Providers 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. State Medical Privacy Laws and Regulations. Providers 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 should consult with their own legal counsel to address their specific situation.
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 may use and disclose PHI for their own treatment, payment, and health care operations activities (TPO) without the consent or
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authorization of the patient who is the subject of the PHI. Uses and disclosures for TPO apply not only to the Provider's own TPO activities, but also for the TPO of another covered entity1. 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 preauthorization of services, inpatient review, and retrospective review of "services2."
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. · Case Management and Care Coordination. · Training Programs. · Accreditation, Licensing, and Credentialing.
Importantly, this allows Providers 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 agrees to not further use or disclose such PHI and further agrees
1See, Sections 164.506(c) (2) & (3) of the HIPAA Privacy Rule. 2See the definition of Payment, Section 164.501 of the HIPAA Privacy Rule
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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 must allow patients to exercise any of the below-listed rights that apply to the Provider's practice:
1. Notice of Privacy Practices Providers 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 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 restrict its uses and disclosures of PHI. The Provider is not required to agree to any such request for restrictions.
3. Requests for Confidential Communications Patients may request that a health care Provider communicate PHI by alternative means or at alternative locations. Providers 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'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 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 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 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.
HIPAA Security
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Providers must implement and maintain reasonable and appropriate safeguards to protect the confidentiality, availability and integrity of Molina Member and patient PHI. As more Providers implement electronic health records, Providers need to ensure that they have implemented and maintain appropriate cyber-security measures. Providers should recognize that identity theft both financial and medical is a rapidly growing problem and that their patients trust their health care Providers to keep their most sensitive information private and confidential.
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 are strongly encouraged to submit Claims and other transactions to Molina using electronic formats. Certain electronic transactions in health care 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 should refer to Molina's website at www.MolinaHealthcare.com for additional information regarding HIPAA standard transactions. 1. Click on the area titled "I'm a Health Care Professional" 2. Click the tab titled "HIPAA" 3. Click on the tab titled "HIPAA Transactions" or "HIPAA Code Sets"
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 must comply with the National Provider Identifier (NPI) Rule promulgated under HIPAA. The Provider must obtain an NPI from the National Plan and Provider Enumeration System (NPPES) for itself or for any subparts of the Provider. The Provider
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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. Providers must use their NPI to identify it on all electronic transactions required under HIPAA and on all Claims and Encounters submitted to Molina.
Additional Requirements for Delegated Providers
Providers 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 must agree to various contractual provisions required under HIPAA's Privacy and Security Rules.
Reimbursement for Copies of PHI
Molina does not reimburse Providers for copies of PHI related to our program Members. These requests may include, although are not limited to, the following purposes: · Utilization Management · Care Coordination and/or Complex Medical Care Management Services · Claims Review · Resolution of an Appeal and Grievance · Anti-Fraud Program Review · Quality of Care Issues · Regulatory Audits · Risk Adjustment · Treatment, Payment and/or Operation Purposes · Collection of HEDIS® medical records
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10. 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 been reasonably 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 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
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a) Total Knee Replacement b) Hip Replacement c) Iatrogenic Pneumothorax with Venous Catheterization
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
Participating Providers are required to submit Claims to Molina with appropriate documentation. Providers must follow the appropriate State and CMS Provider billing guidelines. Providers must utilize electronic billing though a clearinghouse or the Provider Portal whenever possible 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: 20554. For Members assigned to a delegated medical group/IPA that processes its own Claims, please refer to the Claim Submission instructions on the Member's Molina ID card.
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. · Billing-to/Pay-to Provider name and billing address.
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· Place of service and type (for facilities). · Disclosure of any other health benefit plans. · E-signature. · Service Facility location information.
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 30 calendar days from the change.
Electronic Claims 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 20554.
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.
Clearinghouse
Molina uses Change Healthcare as its gateway clearinghouse. Change Healthcare has relationships with hundreds of other clearinghouses. 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. It is important to track your electronic
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transmissions using your acknowledgement 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 acknowledgement from your clearinghouse. · You should also receive 277CA 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
Participating Providers should submit Claims electronically. If electronic submission is not possible, please submit paper Claims to the following address: Molina Healthcare of Texas, Inc. PO Box 22719 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.
Coordination of Benefits (COB) and Third Party Liability (TPL)
For Members enrolled in a Molina Marketplace plan, Molina and/or contracted Medical Groups/IPAs are financially responsible for the care provided to these Members. Molina Marketplace will pay Claims for Covered Services, however if COB/TPL is determined post payment, Molina Marketplace will attempt to recover any Overpayments.
Timely Claim Filing
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 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 95 calendar days after the discharge for inpatient services or the Date of Service for outpatient services. If Molina is not the primary payer under coordination of benefits or third party liability, Provider must submit Claims to Molina within 95 calendar days after final determination by the primary payer. Except as otherwise provided by Law or provided by Government Program requirements, any
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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). Furthermore, 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 Federal requirements as well as administers payment rules based on generally accepted principles of correct coding. These payment 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). If a professional organization has a more stringent/restrictive standard than a Federal MUE, the professional organization standard may be used. o Medicare National Coverage Determinations (NCD). o 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. · 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 Federal guidelines. · Molina policies based on the appropriateness of health care and medical necessity. · Payment policies published by Molina.
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.
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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.
National Correct Coding Initiative (NCCI)
CMS has directed all Federal agencies to implement NCCI as policy in support of Section 6507 of the Patient Affordable Care Act of March 23, 2010. Molina Healthcare, Inc. uses NCCI standard payment methodologies.
NCCI Procedure to Procedure edits prevent inappropriate payment of services that should not be bundled or billed together and to promote correct coding practices. Based on NCCI Coding Manual and CPT guidelines, some services/procedures performed in conjunction with an evaluation and management (E&M) code will bundle into the procedure when performed by same physician and separate reimbursement will not be allowed if the sole purpose for the visit is to perform the procedures. NCCI editing also includes Medically Unlikely Edits (MUEs) which prevent payment for an inappropriate number/quantity of the same service on a single day. An MUE for a HCPCS/CPT code is the maximum number of units of service under most circumstances reportable by the same Provider for the same patient on the same date of service. Providers must correctly report the most comprehensive CPT code that describes the service performed, including the most appropriate modifier when required.
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.
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· 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
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 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) 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.
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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-xxxxxx) as well as the NDC units and descriptors. Claims submitted without the NDC number will be denied.
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 ICD-10-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.
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.
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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, clientdirected/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.
Corrected Claims
Corrected Claims are considered new Claims for processing purposes. Corrected Claims must be submitted electronically with the appropriate fields on the 837I or 837P completed. 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 and include the original claim number.
Claims submitted without the correct coding will be returned to the Provider for resubmission.
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).
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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).
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 days after receipt of Clean Electronic Claims and 45 days after receipt of non-electronic clean claims.
The receipt date of a Claim is the date Molina receives notice of the Claim.
Electronic Claim Payment
Participating Providers are required to enroll for Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA). Providers who enroll in EFT payments will automatically receive ERAs as well. EFT/ERA services allow Providers to reduce paperwork, provides searchable ERAs, and Providers 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. Additional information about EFT/ERA is available at www.MolinaHealthcare.com or by contacting our Provider Services department.
Overpayments and Incorrect Payments Refund Requests
If, as a result of retroactive review of claim payment, 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.
A Provider shall pay a Claim for an Overpayment made by Molina which the Provider does not contest or dispute within the specified number of days on the refund request letter mailed to the Provider.
If a Provider does not repay or dispute the overpaid amount within the timeframe allowed Molina may offset the overpayment amount(s) against future payments made to the Provider.
Payment of a Claim for Overpayment is considered made on the date payment was received or electronically transferred or otherwise delivered to Molina, or the date that the Provider receives a payment from Molina that reduces or deducts the Overpayment.
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Claim Disputes/Reconsiderations
Providers disputing a Claim previously adjudicated must request such action within 120 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 Reconsideration Form 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: Providers should submit the following documentation: · Any documentation to support the adjustment and a copy of the Authorization form (if
applicable) must accompany the reconsideration 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 Texas, Inc. Attention: Claims Disputes / Adjustments PO Box 165089 Irving, TX 75016
Submitted via fax: (877) 319-6852
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 days of receipt of the Claims Dispute/Adjustment request.
Out-of-Network Provider Mediation/Arbitration Process
If an out-of-network provider disagrees with their payment amount, they can request mediation or arbitration. To learn more and submit a request, providers can go to www.tdi.texas.gov. After a provider submits a complete request, they must notify Molina Healthcare of Texas, Inc. at MolinaOONDisputeResolution@MolinaHealthcare.com.
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 Services is prohibited, other than for the Member's applicable copayment, amounts.
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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 Compliance section of this Provider Manual for more information.
Encounter Data
Each Provider, capitated Provider, or organization delegated for Claims processing is required to submit Encounter data to Molina for all adjudicated Claims. The data is used for many purposes, such as regulatory reporting, rate setting and risk adjustment, hospital rate setting, the Quality Improvement program and HEDIS® reporting.
Encounter data must be submitted at least once per month, and within30 days from the date of service in order to meet State and CMS encounter submission threshold and quality measures. Encounter data must be submitted via HIPAA compliant transactions, including the ANSI X12N 837I 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 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.
When Encounters are filed electronically Providers should receive two types of responses: · First, Molina will provide a 999 acknowledgement of the transmission.
· Second, Molina will provide a 277CA response file for each transaction.
Molina's Marketplace Payment Rate
Molina's Marketplace payment rate does not include any add on payments, adjustments or deductions that are only allowed for a Medicare Member, including but not limited to uncompensated disproportionate share hospital (DSH) payments, operating indirect medical education (IME) payments, direct graduate medical education expense payments, organ acquisition costs and deductions for sequestration.
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11. Complaints, Grievance and Appeals Process
Member Grievance and Appeal Procedure
Molina's Grievance and Appeal Procedure is overseen by our Grievance and Appeal Unit. Its purpose is to resolve issues and concerns from Members. We will provide Members a written copy of Molina's grievance and appeal process upon request. Molina will never retaliate against a Member in any way for filing a grievance or appeal. For the purpose of this section, any reference "Member" also refers to a representative or health care provider designated by the Member to act on the Member's behalf, unless otherwise noted.
Complaints
A complaint is any dissatisfaction that the Member has with Molina or any Participating Provider that is not related to the denial of health care services. For example, the Member may be dissatisfied with the hours of availability of their Provider. Issues relating to the denial of health care services are Appeals and should be filed with Molina or the Texas Department of Insurance in the manner described in the Internal Appeals section below.
Filing Complaints
If a Member has a problem with any Molina services, Molina wants to help fix it. Members can contact Molina for help in the following ways: · Call Molina toll-free at (888) 560-2025. Hours are Monday through Friday, 8:00 a.m.
5:00 p.m., local time. Deaf or hard of hearing Members may call 711. · Members may also send complaints in writing by mail or filing online at Molina's
website, www.MolinaHealthcare.com. Molina's mailing address is: Molina Healthcare of Texas, Inc. Attn: Member Complaints & Appeals P.O. Box 165089 Irving, TX 75016
Molina will provide oral language services that include answering questions in any applicable non-English language and provide assistance with filing claims and appeals (including external review) in any applicable non-English language. Members can request that any notice from Molina be provided in any applicable non-English language. With respect to any Texas county to which a notice is sent, a non-English language is an applicable non-English language if 10% or more of the population residing in the county is literate only in the same non-English language as determined by the Department of Health and Human Services (HHS).
Complaints Timeline
Molina will send the Member a letter acknowledging receipt of the grievance within five business days of receipt of the complaint. Grievances will be resolved within 30 calendar days from receipt of the complaint. A complaint or grievance concerning disagreement or
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dissatisfaction with an Adverse Benefit Determination constitutes an appeal of that Adverse Benefit Determination. Appeals of Adverse Benefit Determinations will be resolved as noted below.
Appealing Resolution of Complaints
If the Member is not satisfied with the resolution of the complaint, the Member may appeal that resolution in writing. The Member may request to appear in person before a complaint appeal panel or address a written appeal to the complaint appeal panel. If a Member appeals the resolution of a Complaint, Molina will send an acknowledgment letter to the member not later than the 5th business day after Molina receives the written request for appeal. Molina will complete the appeals process not later than the 30th calendar day after the date the written request for appeal is received.
If the Member appeals the complaint resolution, Molina will appoint members to a complaint appeal panel to advise us on the resolution of a disputed decision appealed. The complaint appeal panel will be composed of an equal number of Molina staff members, physicians or other providers, and enrollees. A member of a complaint appeal panel may not have been previously involved in the disputed decision. The physicians or other providers on a complaint appeal panel will have experience in the area of care that is in dispute and must be independent of any physician or provider who made any previous determination. If specialty care is in dispute, the complaint appeal panel will include a person who is a Specialist Physician in the field of care to which the appeal relates. The enrollee members of a complaint appeal panel will not be employees of Molina.
Adverse Benefit Determinations
An "Adverse Benefit Determination" means a determination by Molina that health care services provided or proposed to be provided to a Member are not Medically Necessary or are Experimental or Investigational. If Molina does not make an authorization decision within the expected time that is considered an adverse benefit determination. A rescission of coverage is also an Adverse Benefit Determination. A rescission does not include a termination of coverage for reasons related to non-payment of premium.
Providers are afforded a reasonable opportunity to discuss a case with a Molina Medical Director prior to medical necessity, investigational or experimental adverse benefit determination. For standard requests, providers are given one full day for a peer-to-peer discussion prior to adverse determination. Urgent requests must be completed within one day, therefore the time for peer-to-peer is abbreviated.
Molina shall provide notice of an adverse determination as follows: 1. With respect to a Member who is hospitalized at the time of the adverse
determination, within one working day by either telephone or electronic transmission to the Provider of record, followed by a letter within three working days notifying the Member and the Provider of record of the adverse determination;
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2. With respect to a Member who is not hospitalized at the time of the adverse determination, within three working days in writing to the Provider of record and the Member; or,
3. Within the time appropriate to the circumstances relating to the delivery of the services to the Member and to the Member's condition, provided that when denying post stabilization care subsequent to emergency treatment as requested by a treating physician Provider or other health care Provider, the agent shall provide the notice to the treating physician or other health care Provider not later than one hour after the time of the telephonic request.
The notice of an adverse determination will include: 1. The principal reasons for the adverse determination; 2. The clinical basis for the adverse determination; 3. A description of or the source of the screening criteria used as guidelines in making
the adverse determination; 4. The professional specialty of the physician, doctor, or other health care Provider
that made the adverse determination; 5. A description of the procedure for the URA's complaint system as required by
§19.1705 of this title (relating to General Standards of Utilization Review); 6. A description of the URA's appeal process, as required by §19.1711 of this title
(relating to Written Procedures for Appeal of Adverse Determination); 7. A copy of the request for an external review by Maximus is available at
https://externalappeal.cms.gov/ferpportal/#/forms /; 8. Notice of the external review process with instructions that:
· Request for a review by an external review form must be completed by the Member. If the member would like to have another person make an external review request on their behalf, the appointment of a representative form must be filled out and signed by the member and their authorized representative and returned to Maximus. Information about this process and the form are available at https://externalappeal.cms.gov/ferpportal/#/forms /;
· and A description of the Member's right to an immediate review by external review and of the procedures to obtain that review for a Member who has a lifethreatening condition.
In the case of an adverse determination resulting from a retrospective review, Molina will provide written notice to the Member, within 30 days after the claim is received.
Appeal Procedures for Adverse Benefit Determinations (including Expedited Clinical Appeals)
Expedited Clinical Appeals
If the Member's situation meets the definition of an expedited clinical appeal, the Member may be entitled to an appeal on an expedited basis.
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An "expedited clinical appeal" is an appeal of a clinically urgent nature related to health care services, including but not limited to, Prior Authorization for treatment, denial of emergency care or concurrent or continued hospitalization.
Before authorization of benefits for an ongoing course of treatment or concurrent or continued hospitalization is terminated or reduced, Molina will provide the Member with notice and an opportunity to appeal. For the ongoing course of treatment, coverage will continue during the appeal process. The procedure will include a review by a health care Provider who has not previously reviewed the case and is of the same specialty or a similar specialty as the health care Provider who would typically manage the condition under appeal. The provider is afforded an opportunity to discuss the appeal with the Molina Medical Director prior to an appeal adverse determination.
Upon receipt of an expedited Prior Authorization or concurrent clinical appeal, Molina will notify the party filing the appeal as soon as possible, but in no event later than twentyfour (24) hours after submission of the appeal, of all the information needed to review the appeal. Molina will render a decision on the appeal within 24 hours after it receives the requested information, but no later than 72 hours after the appeal has been received by Molina.
How to Appeal an Adverse Benefit Determination
An appeal of an Adverse Benefit Determination may be filed by the Member or a person authorized to act on the Member's behalf, or the Member's health care Provider. The Member's designation of a representative must be in writing as it is necessary to protect against disclosure of information about the Member except to authorized representative(s).
To obtain an Authorized Representative Form, the Member or the Member's representative may call Molina at (888) 560-2025.
Molina will review its decision in accordance with the following procedure: · Within 180 days after the Member receives notice of an Adverse Benefit
Determination, Member's may call or write to Molina to request an appeal. Molina will need to know the reasons why the Member does not agree with the Adverse Benefit Determination. Send the request to:
For MEMBER appeal requests for services: Molina Healthcare of Texas, Inc. Attn: Member Complaints & Appeals P.O. Box 165089 Irving, TX 75016
Or fax to 1-877-816-6416
Molina also will take telephone requests for an appeal.
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Within five business days from the date Molina receives the appeal, Molina will send the Member a letter acknowledging the date of receipt, the procedures to be followed in the appeal and a list of documents that must be submitted for review. When Molina receives an oral appeal, we will send the Member a short appeal form.
In support of the appeal, Members have the option of presenting evidence and testimony to Molina. The Member may ask to review the file and any relevant documents and may submit written issues, comments, and additional medical information within 180 days after receiving notice of an Adverse Benefit Determination or at any time during the appeal process. A physician will make the appeal decision.
Molina will provide the Member with any new or additional evidence or rationale and any other information and documents used in the review of the appeal without regard to whether such information was considered in the initial determination.
Molina will not rely on the initial Adverse Benefit Determination. The appeal determination will be made by a physician associated or contracted with Molina and/or by external advisors, but who were not involved in making the initial denial of the prior authorization. Before a Member may bring any action to recover benefits, the claimant must exhaust the appeal process and the appeal must be finally decided by Molina.
Timing of Appeal Determinations
Molina will make a determination of the appeal as soon as practical, but in no event more than 30 days after the appeal has been received by Molina.
Notice of Appeal Determination
Molina will notify the party filing the appeal, the Member, and, any health care Provider who recommended the services involved in the appeal, by a written notice of the determination.
The written notice will include: · The clinical basis for the determination; · A statement of the specific medical, or contractual reasons for the resolution; · A description of or the source of the screening criteria that were utilized in making the
determination; · Notice member can obtain a copy of criteria on which appeal decision was based; · Notice that member is entitled to receive reasonable access to and copies of all
documents related to the appeal free of charge, upon request; · Notice of the appealing party's right to seek review of the adverse determination by
an external review; · A reference to the benefit plan provisions on which the determination is based, or the
contractual, administrative or protocol basis for the determination; · The specialty of the physician or other health care provider making the determination;
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· In certain situations, a statement in non-English language(s) that written notice of claim denials and certain other benefit information may be available (upon request) in such non-English language(s) and how to access Molina's language services;
· If the decision is a denial, the title, qualification and specialty of the physician or other health care provider making the denial; and,
· An explanation of the Maximus external review process (and how to initiate an external review of the determination).
Your external review rights are described below.
Appeal to External Review Process
Members may request an external review of a denial of an internal appeal of an Adverse Benefit Determination made by Molina.
Method for Requesting an External Review with MAXIMUS
1. Submit Online Request at https://externalappeal.cms.gov/ferpportal/#/requestReview
2. Mail a request directly to MAXIMUS: MAXIMUS Federal Services State Appeals East 3750 Monroe Avenue, Suite 705 Pittsford, NY 14534
3. Fax a request to: 1-888-866-6190
This procedure is not part of the complaint process and pertains only to appeals of Adverse Benefit Determinations. In addition, in life-threatening or urgent care circumstances, Members are entitled to an immediate appeal for an external review and are not required to comply with Molina's internal appeal of an Adverse Determination process.
Any party whose appeal of an Adverse Determination is denied by Molina may seek review of the decision by an external review process through MAXIMUS. At the time the appeal is denied, Molina will provide the Member, the Member's designated representative, or Provider of record, information on how to appeal the denial, including any external review form, which must be completed.
In life-threatening or urgent care situations, the Member, Member's designated representative, or the Provider of record may contact MAXIMUS online or via fax 1-888866-6190 to request the review and provide the required information. For all other situations, the Member or Member's designated representative must submit a request to MAXIMUS to begin the external review process.
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· After the external review is initiated and MAXIMUS notifies the health plan, Molina will submit medical records, names of Providers and any documentation pertinent to the decision to MAXIMUS within three business days of receiving the request.
· Molina will comply with the external review decision by MAXIMUS. · Molina will pay MAXIMUS for the external review as indicated.
Upon request and free of charge, the Member may have reasonable access to, and copies of, all documents, records and other information relevant to the claim or appeal, including: · Information relied upon to make the decision; · Information submitted, considered or generated in the course of making the decision,
whether or not it was relied upon to make the decision; · Descriptions of the administrative process and safeguards used to make the decision; · Records of any independent reviews conducted by Molina; · Medical judgments, including whether a particular service is Experimental or
Investigational or not Medically Necessary or appropriate; and, · Expert advice and consultation obtained by Molina in connection with the denied
claim, whether or not the advice was relied upon to make the decision.
The appeal process does not prohibit Members from pursuing other appropriate
remedies, including: injunctive relief; a declaratory judgment or other relief available under
law, if the requirement to exhaust the process for appeal and review places the Member's
health in serious jeopardy. For more information about the external review process,
review
the
MAXIMUS
website
at
https://externalappeal.cms.gov/ferpportal/#/externalReviews.
Non-Discrimination Complaints
Molina complies with all Federal civil rights laws that relate to health care services. Molina offers health care services to all members without regard to race, color, national origin, age, disability, or sex. Molina does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. This includes gender identity, pregnancy and sex stereotyping.
To help you talk with our Members, Molina provides communication services free of charge: · Aids and services to people with disabilities.
o Skilled sign language interpreters. o Written material in other formats (large print, audio, accessible electronic formats,
Braille). · Language services to people who speak another language or have limited English
skills. o Skilled interpreters. o Written material translated in your language. o Material that is simply written in plain language.
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If you need these services, contact Molina Member Services at (866) 449-6849 TTY/TTD: (800) 346-4128.
If you think that Molina failed to provide these services or treated our Members differently based on their race, color, national origin, age, disability, or sex, you can help them file a complaint. Our Members can file a complaint in person, by mail, fax, or email. If they need help writing their complaint, we will help them. Call our Civil Rights Coordinator at (866) 606-3889, or TTY, 711.
Mail the complaint to: Molina Healthcare, Inc. Civil Rights Coordinator 200 Oceangate, Suite 100 Long Beach, CA 90802
Members can also email the complaint to civil.rights@MolinaHealthcare.com. Or, fax the complaint to (713) 623-0645.
Members can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. Complaint forms are available at: http://www.hhs.gov/ocr/office/file/index.html.
The complaint can be mailed to: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201
The complaint can also be sent to a website through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf.
If you need help, call (800)368-1019; TTY (800) 537-7697.
Provider Claims Reconsideration
The processing, payment or nonpayment of a Claim by MHT shall be classified as a Provider Dispute and shall be sent to the following address: Molina Healthcare of Texas, Inc. Attention: Provider Claims Disputes P.O. Box 165089 Irving, TX 75016
Appeal Process
Appeal means: the formal process by which a Provider requests a review of the MHT's Action.
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Action means: · The denial or limited authorization of a requested service, including the type or level
of service. · The reduction, suspension, or termination of a previously authorized service. · The denial in whole or in part of payment for services. · The failure to provide services in a timely manner. · The failure of an MHT to act within the timeframes set forth in the contract.
How to File an Appeal
An appeal must be submitted in writing to: Molina Healthcare of Texas, Inc. Attention: Appeals Department P.O. Box 165089 Irving, TX 75016
Appeal Timeframes
· The Provider is allowed 120 days from the date of the initial denial notification to submit a first level appeal.
· Provider or Practitioner appeal of a Utilization Management (UM) decision shall be adjudicated in a thorough, appropriate, and timely manner.
· A first level appeal for decisions made by Molina Utilization Management shall be reviewed by a Medical Director not involved in the initial denial decision.
Provider Complaints
A Provider has the right to file a complaint with Molina at any time. The Provider also has the right to file a complaint directly with Texas Department of Insurance (TDI).
How to File a Complaint
A complaint can be oral or written.
MOLINA Call: (855) 322-4080 Write to: Molina Healthcare of Texas, Inc. Attention: Complaints Department P.O. Box 165089 Irving, TX 75016
TDI Call: (800) 252-3439 Write to: TDI Consumer Protection P.O. Box 149091 Austin, TX 78714-0901
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Complaint Timeframes
· A Provider can file a complaint anytime. · Complaints will be investigated, addressed, and the provider will be notified of the
outcome, in writing, within 30 calendar days from the date the complaint is received by Molina.
Reporting
All Grievance/Appeal data, including Provider specific data, is reported quarterly to Member/Provider Satisfaction Committee by the Department Managers for review and recommendation. A Summary of the results is reported to the Executive Quality Improvement Committee (EQIC) quarterly. Annually, a quantitative/qualitative report will be compiled and presented to the Member/Provider Satisfaction Committee (MPSC) and EQIC by the chairman of MPSC to be included in the organization's Grand Analysis of customer satisfaction and assess opportunities for improvement.
Appeals and Grievances will be reported to the State quarterly. Grievance and Appeals reports will be reviewed monthly by the Credentialing Coordinator for inclusion in the trending of ongoing sanctions, complaints and quality issues.
Record Retention
MHT will maintain all grievance and related appeal documentation on file for a minimum of ten years. In addition to the information documented electronically via Call Tracking in QNXT or maintained in other electronic files, MHT will retain copies of any written documentation submitted by the Provider pertaining to the grievance/appeal process. Provider shall maintain records for a period not less than ten years from the termination of the Model Contract and retained further if the records are under review or audit until the review or audit is complete. (Provider shall request and obtain Health Plan's prior approval for the disposition of records if Agreement is continuous.)
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12. Credentialing and Recredentialing
The purpose of the Credentialing Program is to assure the 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. Additional information is available in the Credentialing Policy and Procedure which can be requested by contacting your Molina provider services representative.
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 Recredentialing
Molina does not make credentialing and recredentialing 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 & Recredentialed
Practitioners and groups of Practitioners with whom Molina contracts must be credentialed prior to the contract being implemented.
Practitioner types requiring credentialing include but are not limited to: · Acupuncturists · Addiction medicine specialists · Audiologists · Behavioral health care practitioners who are licensed, certified or registered by the
state to practice independently · Chiropractors · Clinical Social Workers · Dentists · Doctoral or master's-level psychologists · Licensed/Certified Midwives (Non-Nurse) · Massage Therapists · Master's-level clinical social workers · Master's-level clinical nurse specialists or psychiatric nurse practitioners · Medical Doctors (MD)
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· 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
TAHP CVO
All Medicaid MCOs must utilize the Texas Association of Health Plans' (TAHP's) contracted Credentialing Verification Organization (CVO) as part of its credentialing and recredentialing process regardless of membership in the TAHP. Molina utilizes this process for all lines of business.
The CVO is responsible for receiving completed applications, attestations and primary source verification documents. The MCO must complete the credentialing process for a new Provider and its claim systems must be able to recognize the Provider as a Network Provider no later than ninety (90) Days after receipt of a complete application.
Credentialing Application
The Texas Department of Insurance Standardized Credentialing Application is required for all Practitioners being credentialed and recredentialed with Molina for participation in the network. http://www.tdi.texas.gov/hmo/crform.html
If an application does not include required information, Provider is given written notice of all missing information no later than five (5) business days after receipt.
Expedited Credentialing
(TIC 1452 subchapter C) - Practitioners (MD, DO, DPM and therapeutic OD) joining a medical group currently contracted by Molina and meet the following requirements will be eligible for thirty (30) day expedited credentialing: · Current Texas licensed in good standing with the Texas Medical Board; · Submits all documentation and other information required as necessary to enable
Molina to begin the credentialing process; and, · Agrees to comply with the terms of Molina's Participating Provider contract currently
in force with the established medical group.
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Expedited Credentialing applies to the following practitioners: · Physicians · Podiatrists · Therapeutic Optometrists · Dentists · Dental Specialists · Licensed Clinical Social Workers · Licensed Professional Counselors · Licensed Marriage and Family Therapists · Psychologists
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. These criteria have been designed to assess a Practitioner's ability to deliver care. This policy defines the criteria that are applied to applicants for initial participation, recredentialing and ongoing participation in the Molina network. To remain eligible for participation Practitioners 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 Practitioner 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 Practitioner fails to 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 ProView 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 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.
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· 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.
· Specialty Provider must only be credentialed in the specialty in which they have adequate education and training. Provider must confine their practice to their credentialed area of practice when providing services to Molina Members.
· Education Provider must have graduated from an accredited school with a degree in their designated specialty.
· Residency Training Providers must have satisfactorily completed residency programs from accredited training programs in the specialty in which they are practicing. Molina only recognizes residency training programs that have been accredited by the Accreditation Council of Graduate Medical Education (ACGME) 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.
· Fellowship Training If the Provider is not board certified in the specialty in which they practice and has not completed a residency program in the specialty in which 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 is 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 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 American Board of Addiction Medicine (ABAM) o College of Family Physicians of Canada (CFPC) o Royal College of Physicians and Surgeons of Canada (RCPSC) o Behavioral Analyst Certification Board (BACB)
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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 (5) 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 (5) 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.
· Work History Provider must supply most recent five (5)-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 (6) months, the Practitioner must clarify the gap verbally or in writing. The organization will document a verbal clarification in the Practitioner's credentialing file. If the gap in employment exceeds one (1) year, the Practitioner must clarify the gap in writing.
· Malpractice History Provider 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 body3.
3 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,
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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 nonprocurement 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. · 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. · 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. · 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. · 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 Practitioner's 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. · Inability to Perform Practitioner 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. · Lack of Present Illegal Drug Use Practitioners must disclose if they are currently using any illegal drugs/substances. · 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. · 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
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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detailed response is required from the Practitioner. At recredentialing, 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 & Medicaid Services (CMS).
Notification of Discrepancies in Credentialing Information & Provider'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 file. 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's response must be sent to Molina Healthcare, Inc., Attention:
Credentialing Director, 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
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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.
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.
The Practitioner can 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
A letter is sent to every practitioner with notification of the Professional Review Committee or Medical Director decision regarding their acceptance or non-acceptance, in writing for participation in the Molina network. This notification is sent within ninety (90) calendar days from the receipt of an application for participation by the practitioner as per TAC 28: 11.1402. Copies of the letters are filed in the practitioner's credentials files.
Recredentialing
Molina recredentials 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
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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. · 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 recredentialing 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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13. Delegation
Delegation is a process that gives another entity the ability 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/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.
Delegation Reporting Requirements
Delegated entities contracted with Molina must submit monthly and quarterly reports. Such reports will be determined by the function(s) delegated to the identified Molina Delegation Oversight Staff within the timeline indicated by Molina.
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.
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14. 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 www.MolinaHealthcare.com or calling Molina at (855) 322-4080.
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 www.MolinaHealthcare.com.
Information on procedures to obtain these medications is described within this document and also available on the Molina website at www.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
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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.
Step Therapy
Plan restrictions for certain Formulary drugs may require that other drugs be tried first. The Formulary 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 Texas Standard Prior Authorization Request (PA) 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 Formulary 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 (6) 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 Molina Marketplace are excluded from coverage. For example, drugs used in the treatment of fertility or those used for cosmetic purposes are not part of the benefit. For a complete list of drugs excluded from the plan benefit please refer to the member's Evidence of Coverage.
Submitting a Prior Authorization Request
Molina will only process completed PA 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
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· 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 PA 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 review. To avoid delays in decisions, be sure to complete the Texas Standardized Prior Authorization Request form in its entirety, including medical justification and/or supporting clinical notes.
Fax a completed Texas Standard Prior Authorization Request form to Molina at (888) 487-9251. A blank Texas Standard Prior Authorization Request Form may be obtained by accessing www.MolinaHealthcare.com or by calling (855) 322-4080.
Providers and office staff can review Molina Clinical Criteria and Clinical Policies online to ensure all required information is submitted for review.
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 (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 nonformulary policies and other non-formulary utilization criteria until a coverage decision is
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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 Opioidsafety and Substance Use Disorder resources at www.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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15. 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. · Identify 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 (e.g. diabetic patient needs an eye exam or multiple
comorbid conditions) 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 face-to-face 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 that the diagnosis data submitted by Molina is appropriate 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
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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.
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