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Provider updates & resources from Molina Healthcare of South Carolina
September 2024
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Provider Highlights and Important Information | |
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Managing Claims Infographic
Molina Healthcare and Availity Essentials™ are offering providers new features for managing claims
to help facilitate the timely processing of your claims. There are three categories for managing
claims described below — corrected claims, claims reconsideration and claims appeal. Corrections
and reconsiderations are a quick and efficient way to get a response for your finalized claim. Click here for the full article.
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Upcoming Provider Town Halls
Molina will be hosting virtual Town Halls. We want to keep open and ongoing communication with you, and one of the best ways for us to do this is through our town halls.
Wednesday, November 6, 10 a.m. & 2 p.m.
Where to register: Click on the session you will be attending above to register.
What we need: Practice name and the following for all attendees: name, phone, title and email address
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Upcoming Provider Orientations
We also have virtual provider orientations available. Check the schedule below and click on any date to register.
Monday, October 7, 2 p.m.
Monday, November 4, 2 p.m.
Monday, December 2, 2 p.m.
Where to register: Click on the session you will be attending above to register.
What we need: Practice name and the following for all attendees: name, phone, title and email address
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2024 Medicaid CAHPS Results Are In!
Molina conducted an annual Consumer Assessment of Health Care Providers and Systems (CAHPS) survey of Medicaid members, asking how they rate their doctor, their overall health, and their health plan. The survey results indicate where to focus improvement efforts. The 2024 data shows a decline in the CAHPS scores, indicating there are areas where MHSC can improve.
To address the declines, the following areas of focus have been identified:
- Rating of Personal Doctor
- Rating of Health Care
- Getting Needed Care
- Getting Care Quickly
- How Well Doctors Communicate
Click here to view MHSC’s 2024 survey strengths and opportunities. For additional CAHPS information, visit the Molina Healthcare Provider website or contact your Provider Relations Representative.
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Provider Manual Summary of Recent Changes
Updates have been made to our 2024 Provider Manual for Medicaid. Click here to find these changes outlined. You may view these changes at MolinaHealthcare.com.
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Single PDL
The South Carolina Department of Health and Human Services (SCDHHS) moved to a Single Preferred Drug List (SPDL) for all Healthy Connections Medicaid members that started on July 1, 2024. Molina has created a drug list called the “Comprehensive Drug List,” which includes drugs on the SPDL along with additional covered products to provide visibility to a more extensive drug benefit listing.
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Evolent
Molina has entered a collaboration with Evolent Health, which manages the Oncology and Cardiology Quality Management programs and handles specific code reviews on Molina's behalf. The managed codes will be available through the Prior Authorization Code Lookup Tool here. Searches will show a note that Evolent provides services for these codes on behalf of Molina.
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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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Well Visit Incentive Clarification
For ages 3-21, The diagnosis pointer (ICD-10) for G9153 must point to a DX from the well visit column and an applicable DX from the BMI column for those 3 and older. Please reach out to your Provider Relations Representative for the latest flyer with detailed criteria.
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PCMH
Per SCDHHS, only NCQA-recognized PCMH facilities will be paid the pass-through.
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Model of Care
Our Medicare Model of Care training must be completed and attested before 12/31/2024. It can be found on our Medicare landing page, which is towards the middle of the page. Your Provider Relations Representative can send you the training and attestation if needed.
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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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Model of Care
Our Medicare Model of Care training must be completed and attested before 12/31/2024. It can be found on our Medicare home page towards the middle of the page. Your Provider Relations Representative can send you the training and attestation if needed.
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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 Services Agreement. Please mail the documentation with a copy of the claim to the appropriate address per the Provider Manual.
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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 rep or our website to ensure you use the latest credentialing forms.
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Medical Record Review and Supplemental Data Feed
It is HEDIS season. Please be on the lookout for Medicare records requests from Molina. We also offer remote EMR, where we will pull the records for you if you want to explore this option. Supplemental data may be the answer if your Quality Scores are not where they need to be.
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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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Molina Help Finder
Do you know any members who need help finding basic needs such as housing, food, clothing and job training? Molina Help Finder can help members get connected with the resources they need to help them. Send them to MolinaHelpFinder.com for more information. | |
Access To Care Standards
Molina is committed to providing timely access to care for all members in a safe and healthy environment. Molina will ensure providers offer hours of operation no less than offered to commercial members. Access standards have been developed to ensure that all health care services are provided in a timely manner.
The PCP or designee must be available 24 hours a day, seven days a week, to members for emergency services. This access may be by telephone. Appointment and waiting time standards are shown below. Any member assigned to a PCP is considered his or her patient. Molina may also assist with scheduling preventative health care appointments for our members. All specialty referrals should be coordinated by the primary care provider. To view the latest appointment standards, refer to the Quality section in Molina's Medicaid Provider Manual.
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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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