Take a Dive into Molina's Care Management Program
Molina Healthcare offers Care Management to our members and providers. Care Managers based in each of our service areas work directly with members and providers to assess medical, behavioral and psychosocial needs, coordinate care, and develop member-centric care plans. Molina Healthcare staff outreaches upon enrollment to conduct health information screener, comprehensive risk assessment as well as develop and update individualized care plans.
For Medicaid the state of Mississippi requires that Primary Care Providers (PCPs) and Molina Healthcare provide Comprehensive Medical, Behavioral Health and Substance Use Care Management to each Medicaid member. There are two main categories of Care Management:
Basic Care Management
services are provided by the primary care provider in collaboration with Molina Healthcare and include:
- Identification of appropriate providers and facilities to meet member care needs (such as medical, behavioral health, substance use, rehabilitation, and support services)
- Direct communication between the provider and member/family
- Member and family education, including healthy lifestyle changes when warranted
- Coordination of services and referral to appropriate community resources and other agencies
Complex Care Management
services are provided by the primary care provider, in collaboration with Molina Healthcare, and include:
- Basic Care Management Services
- Management of acute or chronic illness, including emotional, substance use and social support issues by a multidisciplinary care management team
- Intense coordination of resources to ensure member regains optimal health or improved functionality
- With Member and PCP input, development of care plans specific to individual needs, and updating of these plans at least annually
- Coordination of Care during Planned and Unplanned Transitions, such as when a Molina member is discharged from a hospital.
On a continuous basis, Molina Healthcare identifies members who may benefit from Care Management services, using utilization data, clinical data, and any other available data, as well as physician referrals and member self-referrals. Members appropriate for Care Management are those who have complex service needs and may include your patients with multiple medical conditions, high level of dependence, conditions that require care from multiple specialties and/or have additional social, psychosocial, psychological, substance abuse and emotional issues that exacerbate the condition, treatment regime and/or discharge plan.
Molina Healthcare Care Management staff support your efforts in the above requirements with the following activities on identified members:
- Conduct a needs assessment of the patient, patient’s family, and/or caregiver
- Provide intervention and care coordination services within the benefit structure across the continuum of care
- Educate and empower our members to optimize their health and level of functioning
- Facilitate access to preventative and medically necessary services and ensure that they are provided at the appropriate level of care in a timely manner
- Provide a comprehensive, interdisciplinary and on-going care plan in coordination with you, your staff, your patient, and the patient’s family
If you would like to learn more about this program, speak with a Case Manager and/or refer a patient to this program, please call toll-free
(844) 826-4335
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Care Management
Health Management
Behavioral Health
Quality Improvement
Utilization Management
Network Management
Stay Connected
Billing Tips & Updates
Pharmacy News
Caring for Members
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Improving Member Health
Molina Healthcare offers focused Health Management Programs that can significantly influence the health of our members and provide a variety of helpful services for those with chronic conditions such as asthma, depression and diabetes.
Molina Healthcare offers the following Health Management Programs to our members:
- Asthma management
- Depression management
All Health Management Program interventions are targeted to the specific needs of each member. Members are automatically enrolled based on medical and pharmacy claims. Program materials include condition specific pamphlets and brochures, workbooks, patient logs, action plans, newsletters and other tools that educate the patient...
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Weight Watchers Referrals
Molina Healthcare of Mississippi offers qualifying MSCAN members a no-cost 3 month Weight Watchers membership. Providers are encouraged to refer Molina members to Weight Watchers who are 18 years of age or older and have a BMI of or greater than 27. Molina members between the ages of 15-17 who are in or above the 95
th
percentile of weight may also participate in the Weight Watchers program with a provider referral.
During enrollment in Weight Watchers, your patient will be assigned to a Molina Care Manager or Community Connector. Molina’s Care Management will assist your patient with coordinating their medical care, health education, and finding additional community resources.
Molina Healthcare of Mississippi Care Managers will work in collaboration with you and the member or caregiver to develop an individualized care plan that addresses chronic conditions such as obesity, diabetes, hypertension, heart disease and other conditions that are directly impacted by diet.
To refer a Molina member to the no cost Weight Watcher program, providers may complete the referral form on our website or contact Care Management directly at
(844) 826-4335
Monday – Friday from 8:00 am to 5:00 pm.
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One of the goals of Molina Healthcare’s Utilization Management (UM) department is to render appropriate UM decisions that are consistent with objective clinical evidence. To achieve that goal, Molina Healthcare maintains the following guidelines..
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Clinical Practice Guidelines
Clinical practice guidelines are based on scientific evidence, review of the medical literature, or appropriately established authority, as cited. All recommendations are based on published consensus guidelines and do not favor any particular treatment based solely on cost considerations. The recommendations..
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Preventative Health Guidelines
Preventive Health Guidelines can be beneficial to the provider and his/her patients. Guidelines are based on scientific evidence, review of the medical literature, or appropriately established authority, as cited. All recommendations are based on published consensus guidelines and do not favor any particular...
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Standards for Medical Record Documentation
Providing quality care to our members is important; therefore, Molina Healthcare has established standards for medical record documentation to help assure the highest quality of care. Medical record standards promote quality care though communication, coordination and continuity...
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Primary Care Providers provide outpatient behavioral health services, within the scope of their practice, and are responsible for coordinating members’ physical and behavioral health care, including making referrals to Behavioral Health providers when necessary. A member can also self-refer directly to a Behavioral Health provider without a referral from the primary care physician. If you need assistance with the referral process for Behavioral Health services, please contact the Utilization Management Department at
(844) 826-4335
.
Providers may send requests and inquiries for Provider Field Services directly to
[email protected]
. A representative will respond to your correspondence within 24-48 hours.
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The Molina Healthcare Quality Improvement Program (QIP) provides the structure and key processes that enable the health plan to carry out our commitment to ongoing improvement in members’ health care and service. The Quality Improvement Committee (QIC) assists the organization to achieve these goals. It is an evolving program that is responsive to the changing needs of the health plan’s customers and the standards established by the medical community, regulatory and accrediting bodies.
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Provider Field Services Department
Our Provider Field Services Department provides education and training to the provider community. This team also handles telephone and written inquiries from network providers for inquiries such as demographic changes, claims, credentialing assistance, and web portal assistance.
This department has Provider Services Representatives who serve all providers in Molina Healthcare of Mississippi’s provider network. Providers may view the Provider Representative Map at the bottom of this publication to locate the Provider Services Representative that serves your local area.
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Prior Authorizations
The PA Code list, PA Guide and Request Form is located on our website under the "Forms" tab. Molina updates the PA Code list quarterly and as needed. Always use the list available on our website. Please do not print the list.
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Provider Engagement Program
Molina Healthcare’s Provider Engagement Program partners with select provider groups to promote the importance of preventive health care and encourage our members and your patients to lead healthier lifestyles and be more active participants in their ongoing health care.
Provider Advantages and Benefits:
- Opportunities for improvement to increase quality scores
- Proper coding
- Increased revenue by maximizing needed services
- Staff and patient educational materials and tips (multiple languages available)
- Alignment with other incentive programs
- Processes to identify barriers to care and avoid missed opportunities
- Coordinated member outreach events
- Specialized interventions and incentives
- Increased patient satisfaction
- Timely Provider Web Portal and training updates
- And more!
If you have any questions or concerns, please contact Provider Engagement at
(844) 826-4335
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Provider Contact Center
We are here to help you
–
we offer self-service options for the following services and more:
- Calling about an authorization
- Verifying Eligibility
- Verify Member Benefits
- Network Status
- Claim Status
Enhancing your experience
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the Provider Services Contact Center is always happy to help you.
Having the following information available will save you time and help us give you the right information in a convenient and efficient way:
- Tax ID or NPI
- Name associated to either of these numbers
- CPT codes or HCPCS
- Member ID number
- County where your facility is located
- Request Care Management Services
Call us at
(844) 826-4335
Monday through Friday from 7:30 am to 5:30 pm.CST.
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Confirm your Demographics
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It is important to Molina Healthcare and your patients that your provider directory demographics are accurate. Please visit our Provider Online Directory at:
providersearch.molinahealthcare.com
to validate your information and notify us if there are any updates.
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Updating your Demographics
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It is important for Molina Healthcare of Mississippi
(Molina Healthcare)
to keep our provider network information up to date. Up to date provider information allows Molina Healthcare to accurately generate provider directories, process claims and communicate with our network of providers. Providers must notify Molina Healthcare in writing at least 30 days in advance when possible of changes, such as:
- Change in practice ownership or Federal Tax ID number
- Practice name change
- A change in practice address, phone or fax numbers
- Change in practice office hours
- New office site location
- Primary Care Providers Only: If your practice is open or closed to new patients
- When a provider joins or leaves the practice
Changes should be submitted on the Provider Information Update Form located on the Molina Healthcare website at
MolinaHealthcare.com/provider
under the Frequently Used Forms section.
Contact your Provider Services Representative if you have questions.
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Update Demographics on Provider Portal
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Molina Healthcare has implemented a new feature that allows providers to report updates and correction to demographics.
To submit demographic updates, select “Account Tools” on the Provider Portal at
https://Provider.MolinaHealthcare.com
and under “View/Update Profile” click “Report data change in the Provider Directory: Submit Here.”
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We are now collaborating with DirectAssure to help maintain a more accurate and timely provider directory. Working in concert with CAQH ProView®, which is accessed by 1.4 million providers to self-report and regularly attest to their professional and practice information, DirectAssure enables providers to update their directory information once and share it with all participating health plans they authorized to receive that data.
We encourage all providers to sign up for CAQH ProView® in order to utilize DirectAssure as a tool to easily update and distribute provider directory data to Molina Healthcare. DirectAssure reduces the burden on healthcare providers and health plans alike, eliminating redundant outreach and increasing directory accuracy.
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Molina Healthcare has a duty to protect its members by assuring the care they receive is of the highest quality. One protection is assurance that our providers have been credentialed according to the strict standards established by the state regulators and accrediting organizations. Your responsibility, as a Molina Healthcare provider, includes full disclosure of all issues and timely submission of all credentialing and re-credentialing information.
Molina Healthcare also has a responsibility to its providers to assure the credentialing information it reviews is complete and accurate. As a Molina Healthcare provider, you have the right to:
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Appeals Quick Reference
Molina Healthcare Member Resolution Team (MRT) and Provider Resolution Team (PRT) are working together to re-route any misdirected requests. However, participating providers sending disputes/appeal requests to the wrong department could delay response times.
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For providers seeking to appeal a denied Prior Authorization (PA) on behalf of a member only, fax Member Appeals at
(844) 808-2407
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For providers seeking to appeal a denied claim only, fax Provider Claim Disputes/Appeals at
(844) 808-2409
.
If a provider rendered services without getting an approved PA first, providers must submit the claim and wait for a decision on the claim first before submitting a dispute/appeal to Molina.
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Duplicate claim/service submission
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If a claim is in process, resubmitting duplicate claim will not speed up claim processing for payment
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No prior authorization on file
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For services that require authorization, provider should obtain authorization prior to submitting claim and/or rendering services
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Procedure code inconsistent with modifier
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To ensure that claims are as accurate as possible, cross-check with medical coding resources to ensure the correct code and modifier combination is being used
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Missing/incomplete/invalid replacement claim information
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Corrected Claim can be submitted via EDI or E-Portal
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Procedure not covered when performed for reported diagnosis code
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To ensure that claims are as accurate as possible, cross-check with medical coding resources to ensure the correct code and modifier combination is being used
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EDI Top Denials & Rejections
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Baby claim submitted with mother’s ID number
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Claims must be submitted with member’s own unique ID number
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Claim for inpatient hospital care with POS 21 missing Date of Admission
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For services that require authorization, provider should obtain authorization prior to submitting claim and/or rendering services
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Patient Relationship to Insured not checked off as Self
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Provider should validate all required fields are checked off and filled out correctly prior to submitting claim
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Invalid/missing member ID
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Member ID can be submitted with or without leading zero’s. When leading zero’s are added, it must only contain 5 leading zeros
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CMS 1500 Box 33 - Billing Provider Info
Box 33 is used to indicate the name and address of the Billing Provider that is requesting to be paid for the services rendered. Enter the name, address, city, state, and ZIP code. Enter the information in the following format:
- Name
- Address
- City, State, and ZIP Code
This information should match the information provided during the contracting process and the practice’s W-9 on file. This is essentially the name and mailing address for the billing provider’s NPI in box 33a. For more information, please contact our Provider Contact Center at
844-826-4335
or your Provider Services Representative.
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NICU Authorization Fax Transition Effective August 1, 2019
After examining our NICU Model of Care for ways to better assist our members and providers, Molina Healthcare of Mississippi NICU Authorization fax will transition from central to local. Effective August 1, Providers should fax all NICU Authorization request to
(844) 207-1622
.
The Benefits of sending the NICU cases to the Health Plan’s general inpatient fax number will allow the Health Plan to assign and delegate a local UM Nurse to the case based on the providers location, prioritize and adjust the number of reviewers as needed or based on the number of PAs received, and help foster a better working relationship while promoting two way communication to provide a better overall experience for both members and providers.
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Provider Website Available to you 24/7!
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- Clinical Practice and Preventive Health Guidelines
- Health Management Programs for Asthma, Diabetes, Hypertension, CAD, CHF & Pregnancy
- Quality Improvement Programs
- Member Rights & Responsibilities
- Privacy Notices
- Provider News
- Provider Training
- Claims/Denials Decision Information
- Provider Manual
- Current Preferred Drug List & Updates
- Pharmaceutical Management Procedures
- UM Affirmative Statement (re: non-incentive for under-utilization)
- How to Obtain Copies of UM Criteria
- How to Contact UM Staff & Medical Reviewer
- New Technology
- How to access language services
If you would like to receive any of the information posted on our website in hard copy, please call
(844) 826-4335
.
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Electronic
Remittance Advice
Please be advised we have added an enhanced feature to our portal you will definitely love. Now, you are able to retrieve remittance advice via the Molina of MS secure portal. If you have any questions regarding this process, please feel free to contact your designated Provider Services Representative.
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Primary Care Provider (PCP) Member Roster
As a Primary Care Provider (PCP) for Molina Healthcare of Mississippi, you have access to your Member Roster which is available on our secure provider portal. It is the sole responsibility of the provider to review your Member Roster frequently to identify new and current members. To register for the secure provider portal or to view your Member Roster, please follow the provided instructions below.
The Member Roster application enables the registered user to view and navigate through a list of Members assigned to a PCP.
You will be able to:
- Customize Member search with built-in filters and sorting functions.
- View various statuses (e.g. needed services, inpatient, new Members, etc.) for Members.
- Check Member eligibility.
- Easily access other functions to view Member details, submit claims and request service authorizations.
If you need additional assistance, please contact your Provider Services Representative.
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Submitting Prior Authorizations/Service Request
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The Service Requests/Authorizations page has 4 functionalities:
- Service Requests/Authorizations Status Inquiry
- Create Service Requests/Authorizations
- Open Incomplete Service Requests/Authorizations
- Create Service Request/Authorization Templates
Service Requests/Authorizations
Inquiry
To search for a Service Request/Authorization, you must use one of the following criteria:
- Molina Healthcare Member ID
- Member Name
- Service Request Number
- Refer to Provider
- Refer from Provider/Facility
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Preferred
Drug List and Pharmaceutical Procedures
At Molina Healthcare, the Preferred Drug List (PDL) is maintained by the Mississippi Division of Medicaid. The P&T Committee is an advisory panel who conducts in-depth clinical evaluations and recommends appropriate drugs for preferred status on DOM’s Preferred Drug List (PDL) and/or drugs for prior authorization. The P&T committee meets on a quarterly basis and is composed of your peers – practicing physicians (both primary care physicians and specialists) , nurse practitioners and practicing pharmacists who are active MS Medicaid Providers and in good standing with their representative organizations.
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Hours of Operations
Molina Healthcare requires that providers offer Medicaid members hours of operation no less than hours offered to commercial members
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Patient Safety
Safe Clinical Practice
The Molina Healthcare Patient Safety activities address the following:
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Care for Older Adults
Many adults over the age of 65 have co-morbidities that often affect their quality of life. As this population ages, it’s not uncommon to see decreased physical function and cognitive...
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Translation Services
We can provide information in our members’ primary language. We can arrange for an interpreter to help you speak with our members in almost any language. We also provide written materials in different languages and formats...
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Nondiscrimination
As a Molina Healthcare provider, you have a responsibility to not differentiate or discriminate in providing covered services to members because of sex, race, color, religion, ancestry, national origin, ethnic group identification,...
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Advance Directives
Helping your patients prepare Advance Directives may not be as hard as you think. Any person 18 years or older can create an Advance Directive. Advance Directives include a living will document and a durable power of attorney document.
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Member Rights and Responsibilities
Molina Healthcare wants to inform its providers about some of the rights and responsibilities of Molina Healthcare members.
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Share Molina Matters
Thank you for reading Molina Matters. Our goal is to reach everyone in your organization, and you can help by sharing and recommending this newsletter to your colleagues and partners. Any provider who receives a forwarded copy of this newsletter can subscribe to receive future editions directly by
clicking here
. Or providers can contact their Provider Services Representative or email
[email protected]
with a first and last name, email, plus your organization name. The newsletters are archived on our Provider Website. It is a pleasure to partner with you and we encourage you to stay connected with us.
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Provider Representatives
Please
click here
to locate your Provider Services Representative
Provider Services Contact Center
Phone: (844) 826-4335
Hours of Operations: M-F 7:30 am - 6:00 pm CST
Provider Field Services
Member Services
Phone: (844) 809-8438
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