Member Success Story: From Squalor to Hope

As one Molina member stumbled across his camper, he almost fell through the holes in the floor just to open another bottle of alcohol. He had no clean clothes, no running hot water, and no hope left if he continued down this empty path of addiction. Thankfully, he was referred to Molina, and that’s when Virginia Mack, Jamie Hudson, Lynette Nelson, and Ashley Clark all stepped in from Molina to help. They worked as a team to get this member from the path of resistance to the path of peace. The member fought the idea of change along the way, but they were able to convince him that if he doesn’t accept help that disease and addiction could end his life.

Through dedicated persistence, teamwork, and coordinated planning, they were able to get the member into a residential living facility where he is getting assistance with medication management, transportation to appointments, food, clothing, assistance with his ADLS, and a roof over his head. Since getting the help he needed, he hasn’t been to the ER or hospital this year. He is seeing his provider regularly, taking his medications, and not drinking alcohol. Molina helped turn his living from squalor to hope. 

DME Navigator program for Durable Medical Equipment (DME) products

Effective June 1, 2026, Molina Healthcare of South Carolina, Inc. (Molina) will implement a new DME Navigator® program for our members in all lines of business. DME Navigator is an end-to-end solution operated by Optum® and CareCentrix® leveraging CareCentrix’s DME provider network. Through a digital DME Navigator Point-of-Care (POC) Platform powered by Parachute Health, it streamlines provider workflows and reimagines how members access their DME products and services. Click here for the full article.

Pregnancy & Postpartum Transportation

Molina offers a value‑added transportation benefit for Medicaid members who are pregnant or up to six months postpartum. Members can get up to ten one‑way non‑emergency rides each year to reach food resources, WIC or SNAP, or other community programs that support them during and after pregnancy. Rides can go up to 50 miles, with longer trips reviewed case by case. Members can schedule a ride by calling MTM at (888) 889‑0308, Monday through Friday, 8 a.m. to 8 p.m.

Non‑emergency medical transportation is still provided through the Healthy Connections transportation broker, ModivCare. For more information, visit MyModivcare.com/members/sc.

Ordering, Referring and Prescribing (ORP) Providers

An ORP provider orders or refers patients for Medicaid services, prescribes prescription drugs to Medicaid members, and/or serves as the attending practitioner in institutional settings for Medicaid members. ORP providers may be identified as the ordering, referring, prescribing, or attending provider on professional, pharmacy, or institutional claims. Federal law, Title 42, Code of Federal Regulations, Section 455.410(b), requires all ordering or referring physicians or other professionals providing services to Medicaid members to enroll as participating providers with the state Medicaid agency. Claim will deny if the ORP provider is not listed on the claim.

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.

The Molina case managers are licensed professionals and are educated, trained and experienced in the care coordination process to empower the member to understand and access quality, efficient and cost effective health care. Please click here for the full article.

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.

Help your patients share their voice

Soon, some of your patients who are Molina members will get the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Survey in the mail. This survey asks about their care, including visits with you and your staff. Creating positive experiences helps patients stay engaged in their care and achieve healthier results. You can help by:

• Reminding patients to complete the CAHPS® Survey if they get it

• Listening to and addressing patient concerns and questions

• Making sure patients understand their care plans

• Offering timely appointments when possible

The CAHPS Survey helps us all work together to make care better. Thank you for the care you give to our members every day.

Molina's mission to reduce mental health stigma

Join Molina in addressing behavioral health stigma. We've compiled some resources that outline the impact of stigma, provide insights, and suggest strategies to build support and promote open conversations. Let's work together to break down barriers and change people's perceptions. Click here to watch a quick video on what we can do to help Molina members experiencing mental health symptoms. To access more videos from PsychHub on stigma, create an account by clicking here and then search for 'stigma' after logging in.

Update on Medicaid Member Vision Care Benefits

On February 1, 2026, Molina transitioned from March Vision to VSP Vision for Medicaid member vision benefits. Members will continue to enjoy the same great benefits, now with VSP. Please note the contact number for VSP: (844) 859-5870, available daily from 8 a.m. to 8 p.m.

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.

Important Information for Healthcare Providers: Requesting Medical Necessity Procedures

As part of your role in caring for our members, it’s essential to understand that you can request information regarding Molina's procedures for Medical Necessity determinations. According to our agreement, Molina must provide written procedures outlining the information required when making these important decisions. This ensures that you have the clarity needed to support members effectively. To request these procedures, please reach out to Provider Services at (855) 237-6178. We encourage you to take advantage of this resource to better serve Molina members. 

Availity Provider Portal Important Prior Authorization Updates

Effective 2/1/26, fax submissions for medical benefit PAs have been discontinued and must be submitted through Availity Essentials. Pharmacy benefit PA requests continue to follow existing pharmacy submission processes and are not submitted through Availity.

Provider Manual Summary of Recent Changes

The Molina Provider Manuals have been updated for 2026. Click here to see the changes.  

You Matter To Molina

Our ‘You Matter to Molina’ program is built around supporting you. We understand that providing high-quality, efficient healthcare for Molina members starts with strong, collaborative relationships within our entire network of providers.

Our dedicated Provider Relations Team is here to serve as your direct connection to the health plan by listening, responding, and resolving your questions and concerns quickly. We actively seek your input on how we can strengthen our technology, tools, and processes to reduce administrative burdens and allow you to focus on caring for your patients. Your feedback is always valuable and prompts action. By collaborating, we can improve efficiency, enhance experience, and ultimately achieve better outcomes for our members. Click here for the full You Matter website.

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.

PA Request

The preferred method of PA submission is through Availity. Availity offers a more streamlined provider experience compared to faxing. Contact Training@availity.com for training. Using an older version of the PA request form may cause delays in processing.

Authorization Code Look-Up Tool

Molina offers an electronic authorization code look-up tool for both our Medicaid and MMP lines of business. The authorization code look-up can be found here for Medicaid, here for MMP, and on the provider web portal.

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. 

Gap in Care Reports

Let us help you close gaps in care! Request your gaps in care report to identify who needs a well visit, immunizations, screenings, and tests. Call the Provider Engagement team manager for your latest report or email SCProvider.Services@MolinaHealthcare.com.

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.

Are you ADA Compliant?

As a provider, you must inform Molina's South Carolina Network Administration by emailing us here if your facility is not ADA compliant or handicap accessible. Please outline the alternative accommodations being provided to members.

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. © 2026 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.