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Provider updates & resources from Molina Healthcare of South Carolina, Inc.
December 2025
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Availity Provider Portal Important Prior Authorization Updates
Molina is committed to serving our Providers in the most efficient and transparent ways possible while also adhering to a regulatory landscape that is pushing us to faster, more streamlined UM processes. To achieve this, Molina will transition to a Digital-Only Prior Authorization Model via Availity and will no longer accept faxes after January 31, 2026. As of February 1, 2026, authorization requests will be required to be submitted through Availity. Please click here for the full article and more information.
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Update on DME Equipment
Starting April 1, 2026, Molina Healthcare has entered into a national provider agreements with Apria Healthcare and Byram Healthcare for DME equipment and supplies. Click here for more details.
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Headache to Relief: A Member Success Story
Not being able to leave the house is not just caused by anxiety; sometimes it is caused by pain. One Molina member felt that she couldn’t live a normal life or leave the house due to her immense pain from headaches. She needed a cranial surgery and a nerve stimulator placement. She needed support and reached out to Molina.
Community Connector Haley Schaefer answered the call and was able to set the member up with the support they needed. Now, the member will have the support she needs leading up to surgery and post-op. The member will now receive assistance with locating PAR pain management providers in her area to aid with nerve stimulator management, which should improve her overall quality of life and ability to leave her home. This support will help with a successful recovery and long-term management of her pain. Molina is here to help, and we care about every one of our members.
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Update on Medicaid Member Vision Care Benefits
Starting February 1, 2026, Molina will transition 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.
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Provider Manual Summary of Recent Changes
The Molina Provider Manuals have been updated for 2026. Click here to see the changes.
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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.
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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.
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Medicare-Medicaid Dual Demonstration Transition
The Centers for Medicare & Medicaid Services (CMS) has partnered with SCDHHS to provide a more coordinated, person-centered care experience for low-income seniors and people with disabilities who are Medicare-Medicaid enrollees, often referred to as dual eligibles, through the Dual Demonstration Program. In accordance with direction from CMS, HHSC will end the Dual Demonstration Project by December 31, 2025. Click here for the full article.
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2025 CAHPS Results for Medicare and Marketplace
The results of the 2025 Consumers Assessment of Healthcare Providers and Systems (CAHPS) survey for Molina Healthcare of South Carolina (MHSC) Medicare and Marketplace plans have been finalized. These results assess patient experiences across different healthcare services, reflecting MHSC’s dedication to quality care and patient satisfaction. The 2025 outcomes highlight both areas of exceptional performance and opportunities for further improvement. Click here for more information.
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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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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.
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Cite Auto Authorizations
Molina Clinical Services (MCS) Advanced Imaging (AI) prior authorization (PA) will need to be submitted through the portal and utilize MCG-Cite Auto-Auth (CAA) care guidelines.
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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.
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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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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.
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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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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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