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Provider updates & resources from Molina Healthcare of South Carolina, Inc.
December 2024
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Provider Highlights and Important Information | |
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Member Success Story: Mental Health Matters
"We all have dealt with mental health symptoms at some point in our lives. Sometimes, we just need someone with a little more hope and a lot more resources to help get us on our feet," said Jen Herrman, Molina Case Manager. Resources and help were just what was needed when the parent of a 9-year-old Molina member reached out. The parents cited their son had suicidal thoughts and ADHD and had threatened violence to himself, his family, and their property. The family was also living in shelters without a place to live. The father was overwhelmed, unsure of where he was in the process with providers, and in desperate need of help.
Jen Herrman reached out to the family and took immediate action. She connected the member with the Department of Disabilities and Special Needs to get his son tested and therapy. She also secured temporary housing for the family until more permanent housing was available. Jen and her team engaged and scheduled appointments with specialists, arranged for transportation to appointments for the member, and reached out to the member's church for additional resources of food, utilities, and emotional support.
As a result of all of the hard work from Jen and her team, the member is much more stable and at peace and can focus on his mental and physical health. No hospitalizations have been identified since CM's engagement, and the member has documented no further outbursts of anger.
"It's one thing to give our members’ the tools, but another to see them use them and succeed. I'm happy to be able to teach members to move within the systems to better their lives," said Herrman.
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NEW SCDHHS Director
Governor Henry McMaster announced his appointment of Eunice Medina as the next director of the South Carolina Department of Health and Human Services (SCDHHS). Medina, who currently serves as the chief of staff and deputy director of programs for SCDHHS, will succeed former Director Robert Kerr, who retired on November 1, 2024. Click here for the full story.
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2025 Summary of Benefits for DSNP
Please click here to see the summary of benefits for DSNP.
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NEW H.E.A.R. for Moms
MUSC is conducting a research project for mothers. They are currently looking for volunteers. Please refer members to HEAR4Mamas@MUSC.edu if they are interested. Click here for the flyer and more information.
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2024 Medicare & Marketplace CAHPS Results
The 2024 Molina Healthcare of South Carolina (MHSC) Medicare and Marketplace Consumers Assessment of Healthcare Providers and Systems (CAHPS) survey results are complete. The rates evaluate patient experiences across various healthcare settings and highlight MHSC’s commitment to quality care and patient satisfaction. MHSC’s 2024 results below showcase areas where the plan excels and identifies opportunities for improvement. Click here for the full article.
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Provider Manual Summary of Recent Changes
The Molina Provider Manuals will be updated for 2025. Click here to find out about the upcoming changes in January.
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Respiratory Recommendations
Molina looks forward to partnering with our providers to ensure our patients are vaccinated against respiratory illnesses like Influenza, COVID-19 and RSV. Optimally, vaccination should occur before peak onset of respiratory virus activity in the community. Click here for the full article.
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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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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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PCMH
Per SCDHHS, only NCQA-recognized PCMH facilities will be paid the pass-through.
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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 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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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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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. | |
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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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