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Provider updates & resources from Molina Healthcare of South Carolina, Inc.
March 2025
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Provider Highlights and Important Information | |
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Member Success Story: I Can See Clearly Now
Sometimes, things can be a little blurry for members when navigating the healthcare system. One member was missing her appointments due to her inability to drive, and she wasn’t sure how to schedule appointments. She also didn’t know how to update her information with the state. The member had glasses held together with super glue and tape and also had fragmented teeth that were causing additional health problems. She reached out to Molina, and Community Connector Haley Schaefer came to her aid.
Haley quickly acted and set the member up with the correct information for SCDHHS, located a dentist, a vision provider, and information for transportation to all her appointments. The member received a brand-new pair of glasses, has an appointment with an oral surgeon, and now has her information updated by the state. She can freely schedule appointments and transportation on her own and is so grateful for the fast service and help that Molina provided her. She said that Molina has made all of the difference in improving her health and happiness.
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Notification of Moral and Religious Objections to Specific Services
As per our South Carolina Department of Health and Human Services Medicaid Contract, we are required to identify providers who decline to offer certain services due to moral or religious objections, including family planning services. If you have any objections, please complete this form and return it via email at SCProvider.Services@MolinaHealthcare.com.
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Attention BH Providers
In following with the state we have changed our counts to match the Respective Manual. IE Psychotherapy is no longer 24 visits of any combo before you need a PA and follows the procedure code section of your SC DHHS manual. Notably, Individual and Family are split when it comes to counting visits needed before PA. Please check the PA Lookup Tool to see the specifics of the code you want to use. Please request a PA two weeks before you run out of services. ** School-based providers, please indicate the school name along with yours; please indicate POS 3 and put the Modifiers with the requested service.**
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PA Update
The referring provider can no longer be a facility. To complete the request, we need the name of the referring/ordering provider; otherwise, it will be returned to you. If you are not using our PA request form, please access it here.
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Attention Pharmacy Providers
As of March 1, our PBM will be denying claims for Pharmacies that are not enrolled with SCDHHS.
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Expectations for Utilization Management Decisions
Our organization wants to make it clear to all of our members, practitioners and providers, as well as employees who make utilization management decisions, that Molina Healthcare of South Carolina adheres to the following:
- Utilization management decision-making is based only on appropriateness of care and service and existence of coverage.
- The organization does not specifically reward practitioners or other individuals for issuing denials of coverage.
- Financial incentives for utilization management decision-makers do not encourage decisions that result in under-utilization.
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Case Management and Care Coordination
Molina Healthcare’s Case Management Program involves collaborative processes aimed at meeting an individual’s health needs, promoting quality of life, and obtaining best possible care outcomes to meet the member’s needs so they receive the right care, at the right time, and in the right setting. Click here for the full article.
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2025 Member Healthy Rewards
Molina’s 2025 Annual Member Healthy Rewards are here! These incentives reward our members for completing their recommended screenings by the end of the year. Check out the complete list of Member Healthy Rewards by clicking here. Medicaid members have been notified by mail of their recommended screenings and eligible rewards.
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Measuring Member Satisfaction is Important
Member satisfaction is an important aspect of healthcare delivery. It refers to the measurement of members' overall experience and satisfaction with the care they receive. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey is used for the measurement of member satisfaction.
- The CAHPS survey results are critical to the overall health plan ratings through NCQA.
- The CAHPS survey also provides insight into patient satisfaction and experience. It includes all interactions with healthcare providers, health plans, drug plans, plan staff, and care received.
Click here to view the MHSC 2024 CAHPS results. A member can be satisfied with their healthcare, but there still may be areas of improvement needed in the overall member experience. Join Molina in improving our member satisfaction and experience rates.
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Provider Manual Summary of Recent Changes
The Molina Provider Manuals have been updated for 2025. Click here to see the changes.
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Contracting
Please remember that contracting and credentialing are separate processes. If you change your current TIN or start a New Entity, your contract will need to be updated. Contact your Provider Relations Representative for more information.
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Credentialing Updates
Please note that we will no longer accept a SCDHHS Medicaid ID reference number to begin credentialing. A provider must receive a full South Carolina Medicaid ID to proceed with a credentialing application. Check with your Provider Relations representative or our website to ensure you use the latest credentialing forms.
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Lab Redirection
Our preferred lab is Quest Diagnostics. We have identified some providers who are referring members to out-of-network labs. We will be doing outreach to understand why and help providers understand the importance of referring to Quest or another in-network lab.
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Appeals Process
Please be sure to check your remits and Availity for denial reasons. If a corrected claim is not needed, then file a formal appeal. Instructions can be found in the corresponding product manual. If you still do not agree with the outcome, you may escalate to your Provider Relations Representative for further research. Please note that a Reconsideration and Appeal are different on Availity. A reconsideration is an informal review. These have a turnaround time of 15 days. Formal appeals are still held to their turnaround time per the respective manual.
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Claims Denials
Claims denied for missing or additional documentation requirements such as consent forms, invoices, Explanation of Benefits from the primary carrier, or itemized bills are not considered claim disputes. To process your claim appropriately and promptly, these documents, along with a copy of the claim, must be received within federal and state timely filing requirements and/or your Provider Agreement with Molina. Please mail the documentation with a copy of the claim to the appropriate address per the Provider Manual.
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Medical Director Availability
Our Molina Medical Director can speak with a provider about any utilization management decision from 8 a.m. to 5 p.m., Monday through Friday, by calling our Provider Relations team at (855) 237-6178. First, select your requested line of business and follow the prompts for “Authorization” to reach the Utilization Management department.
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Continuity and Coordination of Provider Communication
Molina stresses the importance of timely communication between providers involved in a member's care. This is especially critical between specialists, 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.
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General Billing Requirements Reminder
Prior authorized codes/services that are manually priced on the Medicaid Fee Schedule will be reimbursed at 35% of billed charges for covered benefits.
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Join Our Email List
Sign up for Molina's provider email list here. Be the first to receive our provider newsletters, news, and updates about Molina services, delivered automatically to your inbox. We will not spam your inbox but just send important information and updates.
For other questions or inquiries regarding this newsletter, please email us at:
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Verify Your Fax Number
Molina sends out other important communications to providers by fax. We'd like to ensure we have your most up-to-date fax numbers and information.
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The Molina Communications team produced this e-newsletter, which is designed for South Carolina health care providers. We welcome your feedback, news and ideas for content.
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PO Box 40309
North Charleston, SC 29423-0309
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CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
All summaries of the measures contained herein are reproduced with permission from HEDIS Volume 2: Technical Specifications for Health Plans by the National Committee for Quality Assurance (NCQA).
The information presented herein is for informational and illustrative purposes only. It is not intended, nor is it to be used, to define a standard of care or otherwise substitute for informed medical evaluation, diagnosis and treatment which can be performed by a qualified medical professional. Molina Healthcare, Inc. does not warrant or represent that the information contained herein is accurate or free from defects.
COPYRIGHT NOTICE AND DISCLAIMER
The HEDIS® measures and specifications were developed by and are owned by NCQA. The HEDIS measures and specifications are not clinical guidelines and do not establish a standard of medical care. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures and specifications. NCQA holds a copyright in these materials and can rescind or alter these materials at any time. These materials may not be modified by anyone other than NCQA. Use of the Rules for Allowable Adjustments of HEDIS to make permitted adjustments of the materials does not constitute a modification. Any commercial use and/or internal or external reproduction, distribution and publication must be approved by NCQA and are subject to a license at the discretion of NCQA. Any use of the materials to identify records or calculate measure results, for example, requires a custom license and may necessitate certification pursuant to NCQA’s Measure Certification Program. Reprinted with permission by NCQA. © [current year] NCQA, all rights reserved.
Limited proprietary coding is contained in the measure specifications for convenience. NCQA disclaims all liability for use or accuracy of any third-party code values contained in the specifications.
The American Medical Association holds a copyright to the CPT® codes contained in the measure specifications.
The American Hospital Association holds a copyright to the Uniform Billing Codes (“UB”) contained in the measure specifications. The UB Codes in the HEDIS specifications are included with the permission of the AHA. The UB Codes contained in the HEDIS specifications may be used by health plans and other health care delivery organizations for the purpose of calculating and reporting HEDIS measure results or using HEDIS measure results for their internal quality improvement purposes. All other uses of the UB Codes require a license from the AHA. Anyone desiring to use the UB Codes in a commercial product to generate HEDIS results, or for any other commercial use, must obtain a commercial use license directly from the AHA. To inquire about licensing, contact ub04@aha.org.
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