Providers are responsible for verifying eligibility and obtaining approval for services that require prior authorization. Providers agree that under no circumstance will a Member be liable to the Provider for any sums that are the legal obligation of Molina to the Provider. Balance billing a Member for Covered Services is prohibited, except for the Member's applicable copayment, coinsurance, and deductible amounts.

The Level of Care Determination Form 185 is required when submitting a request for Nursing Facility admissions.

Provider Manual Summary of Recent Changes

Updates have been made to our 2023 Provider Manuals for Medicaid, Marketplace, Medicare and MMP. Click here to find these changes outlined. You may view these changes at MolinaHealthcare.com.  

Molina Healthcare of South Carolina has a program in place to identify therapeutic duplications at the point-of-sale based on over- lapping fills of separate products to minimize duplicate therapy and associated risks. The targeted medication classes (listed below) are at high-risk of concurrent use and overutilization that may result in adverse effects and health outcomes. Prescriptions of the same class are permitted to have a 15 percent overlap within a 90-day look-back period. Click here for the full article.

Molina partnered with ProgenyHealth, a company specializing in Neonatal Care Management Services, to improve services to our members and promote healthy outcomes for premature and medically complex newborns. Please notify ProgenyHealth directly of admissions via fax at (888) 250-8468, and their clinical staff will contact your designated staff to perform utilization management and discharge planning throughout the inpatient stay. To learn more about ProgenyHealth’s programs and services, call (888) 832-2006 or visit progenyhealth.com.

As children and adolescents return to school this Fall, healthcare providers are in a key position to help increase rates of vaccinations and annual health screenings. Every visit, from sports physicals to medication management check-ups, should be used as an opportunity to get young patients back on track.

Please see below for links to the HEDIS Immunizations for Adolescents (IMA), Childhood Immunization Status (CIS), and Child and Adolescent Well-Care Visits (WCV) provider tip sheets. These resources contain helpful information about the measures, including best practices for measure improvement:

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 2023 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 Specialist

• Coordination of Care

• Getting Care Quickly

• Getting Needed Care

• Customer Service

Click here to view MHSC’s 2023 survey strengths and opportunities. By focusing on these identified areas, the declining rates can be reversed, and patient experience/satisfaction improved. Commitment to delivering exceptional care and prioritizing patient satisfaction is crucial in achieving these goals. For additional CAHPS information, visit the Molina Healthcare Provider Website here or contact your Provider Services Representative.

An Expedited/Urgent service request, including appeal requests, should only be used if the treatment is required to prevent serious deterioration in the member’s health or could jeopardize the member’s ability to regain maximum function. Requests outside of this definition should be submitted as routine/non-urgent requests (pursuant to Medicare 42 CFR § 422). If the request meets the criteria for Expedited/Urgent, please indicate the reason at the time of the submission to avoid delays and follow all CMS guidelines. As a reminder, request services in a timely manner and provide necessary information for review so appropriate and timely decisions can be made. 

Our Molina Medical Director can to speak with a provider about any utilization management decision from 8 am to 5 pm, Monday through Friday, by calling our Provider Services team at (855) 237-6178. First, select your requested line of business and follow the prompts for “Authorization” to reach the Utilization Management department.

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.

Prior authorized codes/services that are manually priced on the Medicaid Fee Schedule will be reimbursed at 35% of billed charges for covered benefits.

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.

Molina offers an electronic authorization code look-up tool for both our Medicaid and MMP lines of business. The authorization code lookup can be found here for Medicaid, here for MMP, and on the provider web portal. It can also be found on our main provider main page here.

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 [email protected].

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:

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.

Please email us at [email protected] to verify or update your information.

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.

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 [email protected].