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Provider updates & resources from Molina Healthcare of South Carolina, Inc.
September 2025
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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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Availity Enhancements
At Molina, we’re committed to making it easier for providers to do business with us. That’s why we’re excited to share several important enhancements to Availity Essentials that will streamline processes, improve communication and support more efficient care delivery. Click here for more information on the enhancements. In addition, the Reports Tile currently located in Payer Spaces will soon be replaced by the Reports (New) Tile. Click here for more information.
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Value Added Benefits for Medicaid Molina Members
Molina cares about our members and their health. Did you know about our value-added benefits? To learn about the extra FREE benefits that we offer our Medicaid members, go to MolinaHealthcare.com/SC-Rewards.
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NCQA Survey Results
We are thrilled to share that Molina received the final results from NCQA for our May 6th, 2025, survey submission across multiple Medicaid and Marketplace markets. The outcome is exceptional. We achieved a 100% score on all requirements, a perfect result that reflects our unwavering commitment to quality.
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Specialty Drug List
If your patients received a notice about an upcoming change to the Molina Healthcare of South Carolina specialty drug list, please take the proper steps to ensure you submit specialty prescriptions to an in-network specialty pharmacy. Click here for more information.
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Quality Updates
Per NCQA, when certain immunizations are administered after specific timeframes, the member will not be considered compliant for the Childhood Immunization Status (CIS-E) and Immunizations for Adolescents (IMA-E) HEDIS measures. Take advantage of the Boo to the Flu and HPVIP campaigns to help get your members in and compliant. To learn more, please email SCProvider.Services@MolinaHealthcare.com.
As a reminder:
- Molina offers providers a $75 enhanced fee opportunity for completing a comprehensive well visit for members aged 1-21 years.
- Molina offers up to $200 for Medicaid-enrolled newborns who complete six well visits with recommended immunizations ($150) AND both Influenza doses ($50) by age two.
- Molina offers up to $50 for Medicaid-enrolled adolescents who complete both HPV doses before age 13.
Members can claim Molina Healthy Rewards by logging into their Molina Member Portal at MyMolina.com.
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Got Value-Based Contracts?
Now is the time to sign up for calendar year 2026 Value-Based Contracts with Molina.
- Per the new CMS guidelines (eCFR: 42 CFR 438.3), any reimbursement outside of fee-for-service must be tied to specific, measurable, and documented clinical or quality improvement standards, also referred to as a Value-Based Contract (VBC).
- The PMPM (Per Member Per Measure) Component of your provider agreement will be discontinued effective October 1, 2025.
Don’t let this additional reimbursement for your practice pass you by!
To learn more, please reach out to SCProviderContract@MolinaHealthcare.com.
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Progeny Health for NICU
The Clinical Operations Team, in partnership with the Molina Marketplace Utilization Management and Care Management teams, is excited to announce the start of a vendor partnership with Progeny Health for managing NICU babies. Starting 8/4, Progeny Health began managing both established NICU babies with Molina Marketplace and any NICU babies with admissions received on 8/4 or thereafter.
Progeny will utilize its own health management system, BabyTrax, to manage Molina members. Progeny will be delegated for Case Management and will provide telephonic CM services to NICU babies up to 60 days post-initial NICU discharge or up to 1 year of life (whichever comes first). Progeny will be delegated for Inpatient Utilization Management approvals and medical necessity denials.
- Member and Provider notifications, including denials.
- Providers will be directed to send NICU authorizations requests and clinicals to Progeny directly.
- All inpatient NICU UM functions, including initial admissions, continued stay requests, discharge planning, and all admissions up to 60 days post-discharge of initial NICU discharge will be managed by ProgenyHealth.
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Prior Authorizations
Molina will begin requiring additional documentation—including clinical records—for all prior authorization submissions. The clinical records submitted should be for the prior authorization being requested. Attachments will function as required fields. Without them, the system will block the submission. Click here for more information.
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Reminder to Marketplace Providers
In accordance with CMS guidance, as outlined in Chapter 2, Section 3.ii.b of the 2023 Final Letter
to Issuers in the Federally facilitated Exchanges, all Qualified Health Plan (QHP) issuers are required to maintain timely access to care by meeting specific appointment wait time standards. These standards are designed to ensure that members have consistent and equitable access to essential health services within reasonable time frames. Click here to see the required wait time standards.
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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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Digital Correspondence Hub in Availity
The Digital Correspondence Hub is a brand-new tool, crafted to streamline communication,
allowing providers to receive, manage, and track digital communications from Molina within the
Availity Essentials workflow. This will reduce inefficiencies tied to traditional correspondence
methods. Experience the future of communication with our digital letters (initially rolling out with Prior Authorization letters) along with paper letters! Digital PA letters will be sent in real-time and
tracked seamlessly. Click here for more information.
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Provider Orientations
We offer online Provider Orientations monthly. Click on the times below to register for the session you are interested in attending.
Monday, Oct. 6, 2pm; Monday, Nov. 3, 2pm; Monday, Dec. 1, 2pm.
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Town Halls
Molina will be hosting virtual Town Halls. Register by clicking on the links below.
Wednesday, Oct. 22, 10am & 2pm
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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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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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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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