Molina Healthcare's Provider Newsletter

Provider updates & resources from Molina Healthcare of South Carolina

March 2024

Resources

Molina Provider Websites

Preferred Drug List

Partners in Care Newsletters

Frequently Used Forms

Molina Fact Sheet

Provider Rep Map

Provider Portal

Molina's Provider Portal has a variety of tools to simplify your transactions, whether you need to check eligibility, check claim status, or submit disputes. For more information, contact Provider Services at

(855) 237-6178.

Provider Manuals

Manuals are typically updated every quarter or as needed. You can find our Provider Manuals here for each line of business:

Medicaid, MMP

Marketplace, Medicare

Molina Service Area by Line of Business (LOB)

Here’s where Molina is covered for each LOB:

Medicaid – every county,

MMP – every county,

Medicare – every county except Oconee,

Marketplace – every county except Oconee, Pickens, and Anderson.

Claim Updates

When you submit a corrected claim, the original claim number must be present in field 64 for a UB, and field 22 for a 1500. The claim will be rejected if this is not filled out correctly.

Molina currently has a 30 day readmission policy.

Optum Pre-Pay Information

Molina is performing additional pre-payment claim reviews. For more information on Optum Pre-pay, please click here.

Are you ADA Compliant?

Providers are required to inform Molina's South Carolina Network Administration by emailing us here if they are not ADA compliant or handicap accessible and provide what alternative accommodations are being offered to members.

Gap In Care Reports

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].

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 lookup can be found here for Medicaid, here for MMP, and on the provider web portal.

Welcome!

Thank you for reading Palmetto Partners, Molina's e-newsletter for providers, packed with information and valuable resources. Our newsletter covers what's going on with Molina Healthcare of South Carolina, important provider communications, and much more.

You are an essential part of quality care for our members. We value your partnership. As our partner, assisting you is one of our highest priorities. We welcome your feedback and look forward to supporting all your efforts to provide quality care.

Molina in the Community

Free Well Visits and Vaccination Clinics

Molina has started offering Molina members free well visits and vaccination clinics. These clinics are put on throughout each year and benefit our members. Watch above as one Molina family goes through their well visits and vaccinations at our signature event. Be on the lookout for more of these events coming to your community. Click on the picture above to play this video.

Community Easter Ham Drive-Thru Coming Up

Foothills Community Healthcare is partnering with Molina for the first time for our Community Easter Ham Drive-Thru Giveaway on March 30. We are bringing Easter to our members with 160 hams, 120 boxes of food, Food Lion gift cards, and more. Our community partners for this exciting event include Foothills Community Healthcare, Food Lion, Salem Missionary Baptist Church, Mill Village Farms, SC Thrive, and Foodshare.

SC Thrive will be at this event to support anyone needing assistance with their Medicaid renewal application. Attendees can pre-register for help with their renewal through this link here.

This event will occur on Saturday, March 30, from 9 a.m. to 11 a.m. at West Side Community Center in Anderson, SC.

Provider Highlights and Important Information

Provider Enhanced Fees

Molina will continue to offer eligible providers the following Medicaid immunization incentive opportunities for the 2024 calendar year:

HPV Vaccine Provider Enhanced Fee Incentive: $75 for administering each HPV dose before age 13 - Total $150
Childhood Influenza Vaccine Provider Enhanced Fee Incentive: $75 for administering each child influenza dose before age 2 - Total $150

Click here to review incentive eligibility requirements and billing criteria.

Redetermination

We can provide files to PCPs showing your member roster, gaps in care, and who is up for redetermination. Email your provider rep to set up a Quality meeting. Molina has partnered with Thrive SC to assist members with filling out redetermination packets.

Appeals Process

Please be sure to check your remits 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 Services representative for further research.

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.

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.

Measuring Member Satisfaction is Important

Member satisfaction is an important aspect of healthcare delivery. It refers to the measurement of members’ overall experience and satisfaction with the care they receive.

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey is used for the measurement of member satisfaction.

The CAHPS survey results are critical to the overall health plan ratings through NCQA.
The CAHPS Survey also provides insight to the patient satisfaction and experience. It includes all interactions with health care providers, health plans, drug plans, plan staff, and care received.

Click here to view some MHSC 2023 Medicaid CAHPS results.

A member can be satisfied with their health care but there still may be areas of improvement needed in the overall member experience. Join Molina in improving our member satisfaction and experience rates.

Changes to Hepatitis C Antiviral Therapy

Click here to see the full list of products affected and the summary of changes to the coverage policy.

Availity Portal Training

Contact [email protected] at any time to receive training on the Availity Portal.

Sepsis Information

Molina performs a pre-payment and post-payment review of all Sepsis-related claims across all product lines. We use Sepsis 3 Criteria and the Sequential Organ Failure Assessment (SOFA) scoring. If the clinical documentation reviewed does not support Sepsis definitions, the Sepsis diagnosis will be removed, and payment will be adjusted accordingly. If providers have standard reconsideration timelines via the Claims Reconsideration Process for Molina to review the additional documentation from providers, please ensure you clearly indicate you are appealing the Sepsis decision.

Medical Director Availability

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.

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.

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.

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.

Stay Connected

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:

[email protected]

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.

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

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.

Molina Healthcare of South Carolina

PO Box 40309

North Charleston, SC 29423-0309

Reach Out To Us

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.

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 [email protected].