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Provider updates & resources from Molina Healthcare of South Carolina, Inc.
June 2025
| | Provider Highlights and Important Information | | |
Medicare-Medicaid Dual Demonstration Transition
Since 2014, the Centers for Medicare & Medicaid Services (CMS) has partnered with the South Carolina Department of Health and Human Services and Molina Healthcare to provide a more coordinated, person-centered care experience for low-income seniors and people with disabilities who are Medicare-Medicaid members, often referred to as dual eligibles, through the Dual Demonstration Program. In accordance with direction from CMS, Molina Healthcare of South Carolina will end the Dual Demonstration Project by December 31, 2025. Click here for the full article.
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Member Success Story
A Molina member with Lupus, vision issues, COPD, and other health issues was not able to get to her appointments. She reached out to Molina for help. Care Manager Haley Schaefer answered her call and helped set up her appointments, set her up with transportation from Modivcare, provided resources for food and clothes, and helped contact her pharmacy to update her medications. The member now has a better understanding of her conditions and a treatment plan because of Haley’s help and the resources provided to her.
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Legacy Prior Authorization Tool Retiring
Starting August 25, 2025, the legacy prior authorization (PA) application in Availity Payer Spaces will be removed. You will need to use the multi-payer Availity authorization tool to continue submitting digital authorization requests. We encourage you to start using the tool now to ensure a smooth transition. Please click here for the full report.
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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, July 7, 2pm; Monday, Aug. 4, 2pm; Monday, Sept. 8, 2pm; Monday, Oct. 6, 2pm; Monday, Nov. 3, 2pm; Monday, Dec. 1, 2pm.
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NCQA Credentialing Requirements Update
Effective July 1, NCQA will require Health Plans to have processes to monitor licenses upon expiration. Historically, NCQA has only required that licenses be verified as active/current at initial credentialing and recredentialing decisions, but not between decisions. Beginning July 1, the Credentialing team will send out immediate termination notifications for practitioners who do not renew their license prior to or on the expiration date. In alignment with NCQA standards, if the practitioner renews their license within 30 days after the expiration date and notifies us of that renewal, we can lift that contract termination without needing new credentialing. However, initial credentialing will be required if they do not renew until 31 days or more after contract termination. Credentialing will not monitor expired licenses to see who has renewed them and put them back into the network. Practitioners must notify the Network team that they have renewed their license. They need to notify us if they have a lapse, but not if they auto-renew and have no lapse. Our Salesforce system will continuously monitor license expiration dates and alert us to any license renewals. Please make sure they renew their license on time.
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New Pharmacy DUR Edit: DPP-4 Inhibitor and GLP-1 Receptor Agonist
Prior to August 1, patients taking combination ingredient DPP-4 inhibitor drugs will need a new prescription for the other drug ingredients in the combination. Evaluate whether patients should be counseled to stop taking a prescribed DPP-4 inhibitor after starting a prescribed GLP-1 receptor agonist. Click here for more information and the full article.
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Medicaid Food Security Network Initiative
Molina attended the Medicaid Food Security Network National Summit in May. SC Thrive invited Molina to participate in Share Our Strength's Medicaid Food Security Network Initiative at this event. This project is focused on mobilizing Medicaid systems to become a key partner in food and nutrition security. Molina shared the Managed Care perspective of food and nutrition at this conference.
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Town Halls
Molina will be hosting virtual Town Halls. Register by clicking on the links below.
Wednesday, Aug. 13, 10am & 2pm
Wednesday, Oct. 22, 10am & 2pm
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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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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.
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