Provider Orientation 2018 - STAR, STAR+PLUS, CHIP and ... · Provider Orientation 2018 - STAR,...

Provider Orientation2018 - STAR, STAR+PLUS, CHIP and Molina Dual Options STAR+PLUS MMP

1MHTPS_Orientation_2018

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Agenda

• Molina Story• Programs

– Texas Programs– Service Areas– Program Overviews

• Members– Enrollment– Who Must Enroll– Eligibility– Program ID Cards– Benefits– Cost Sharing– Medical Transportation– Value Added Services– Rights & Responsibilities

• Providers– Contract Requirements– Provider Access & Availability– Cultural Competency– Provider Web Portal– Roles & Responsibilities– Electronic Visit Verification– Support

• Claims & Billing– Claims Submission– Claims Submission Requirements– Billing Maternity Claims– Newborn Claims Submission– Claims Submission Tips– Claims Payment– Electronic Fund Transfers

• Health Services– Referrals and Prior Authorizations– Requesting Prior Authorizations– Prior Authorization Requirements– LTSS Services

– LTSS Prior Authorization Requirements– Management/ Model of Care– Interdisciplinary Care Team– Care Management Design– Long-Term Services and Supports– Mental Health/Behavioral Health Services– Medicare Comprehensive Health Evaluation

– Service Coordination

• Lab Services• Pharmacy Services• Behavioral Health Services• Complaints & Appeals• Quality Improvement Program• Immunizations• Texas Health Steps (THSteps)• Questions

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Our Story & Who We Are

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In 1980, the late Dr. C. David Molina, founded Molina Healthcare with a single clinic and a commitment to provide quality healthcare to those most in need and least able to afford it. This commitment to providing access to quality care continues to be our mission today, just as it has been for the last 30 years.

Our Mission

Our mission is to provide quality health services to people receiving

government assistance.

Our Vision

We envision a future where everyone receives quality health care.

We strive to be an exemplary organization.

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Molina’s Core Values• Caring: We care about those we serve and advocate on their behalf. We

assume the best about people and listen so that we can learn.

• Enthusiastic: We enthusiastically address problems and seek creative solutions.

• Respectful: We respect each other and value ethical business practices.

• Focused: We focus on our mission.

• Thrifty: We are careful with scarce resources. Little things matter and the nickels add up.

• Accountable: We are personally accountable for our actions and collaborate to get results.

• Feedback: We strive to improve the organization and achieve meaningful change through feedback and coaching. Feedback is a gift.

• One Molina: We are one organization. We are a team.

This is the Molina way.4

Our Story & Who We Are

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Recognized for Quality, Innovation and Success

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Molina Healthcare, Inc.

Molina Healthcare plans have been ranked among America’s top Medicaid plans by U.S. News & World Report and NCQA.

FORTUNE 500 Company by Fortune Magazine

Business Ethics magazine 100 Best Corporate Citizens

Alfred P. Sloan Award for Business Excellence in

Workplace Flexibility in 2011

Ranked as the 2nd largest Hispanic owned company by

Hispanic Business magazine in 2009

Recognized for innovation in multi-cultural health

care by The Robert Wood Johnson Foundation

http://www.cio.com/archive/120106/index.html

http://www.cio.com/archive/120106/index.html

http://money.cnn.com/magazines/fortune/global500/2006/full_list/

http://money.cnn.com/magazines/fortune/global500/2006/full_list/

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Programs

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Texas Programs

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Service Areas STAR STAR+PLUS CHIP MMP

BexarAtascosa, Bandera, Bexar, Comal, Guadalupe, Kendall, Medina, Wilson

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DallasCollin, Dallas, Ellis, Hunt, Kaufman, Navarro, Rockwall

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El PasoEl Paso, Hudspeth

X X X

HarrisAustin, Brazoria, Fort Bend, Galveston, Harris, Matagorda, Montgomery, Waller, Wharton

X X X X

HidalgoCameron, Duval, Hidalgo, Jim Hogg, Maverick, McMullen, Starr, Webb, Willacy, Zapata

X X X X

JeffersonChambers, Harden, Jasper, Liberty, Newton, Orange, Polk, San Jacinto, Tyler, Walker

X X X

Rural174 counties

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Service Areas

8Active Molina Service Areas.

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Program Overview

• STAR – State of Texas Access ReformThe STAR program offers Medicaid services to members through a managed care system.

• STAR+PLUS is a Texas Medicaid managed care program designed to provide health care, acute and long-term services and support through a managed care system.

• CHIPProvides low-cost insurance for children under the age of 19 whose families earn too much to qualify for Medicaid, but cannot afford private insurance.

• CHIP PerinateIs a state and federally funded CHIP program for Non-Medicaid eligible pregnant women and their Medicaid/Non-Medicaid eligible newborns.

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Program Overview

• Medicare Medicaid Program (MMP)• Texas Health and Human Services Commission in partnership with Centers for Medicare & Medicaid

Services is launching a demonstration to promote coordinated high quality health care delivery to seniors and people with disabilities or individuals who are dually eligible for both Medicare and Medicaid and help them stay in their homes for as long as possible

• Services under the demonstration include, but are not limited to:• All Medicare Services• All Medicaid Services• Long term support services, including in home supportive services• Custodial care in nursing facilities, and• Mental health and substance abuse programs

• Enrollment began March 2015

• The Texas MMP removes fragmentation in care and promotes care coordination, improved beneficiary health and is cost effective. Members will receive high quality care and enhanced benefits from one health plan, like Molina Healthcare of Texas, that will be responsible for coordinating medical, behavioral and social and supportive service needs. Among other benefits, members will have access to our nurse advice line and member services via telephone for assistance, 24 hours a day, 7 days a week, 365 days a year.

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Members

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Enrollment

HHSC• Eligibility Process

Maximus

• Enrollment Broker

• Assist with Health Plan Enrollment & Changes

Molina

• Health Plan

• Receives a monthly file of assigned Members from Enrollment Broker

• Assist Member with PCP changes and administers health care services.

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Who Qualifies?

• STAR – State of Texas Access Reform• TANF/TANF-related recipients• Pregnant Women• Children receiving Medicaid assistance only

• STAR+PLUS • Mandatory

• Supplemental Security Income (SSI) consumers age 21 or older

• Medicaid Buy-In (MBI)

• Community Based Alternatives (CBA) waiver consumers

• Consumers eligible because they are in a Social Security exclusion program such as:

-Disabled Adult Children Program, and

-Widow/Widower Program.

• Voluntary

• SSI-eligible children (under age 21)

• SSI children that do not volunteer, will be in traditional Medicaid.

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Who Qualifies? Continued

• CHIP • Eligibility is determined by the state administrative services

contractor and members are enrolled in CHIP for a continuous 12-month enrollment period. During the 10th month, the member must initiate the renewal process to ensure continued enrollment. Members are encouraged to ensure that the application is successfully processed.

• CHIP Perinate• The unborn children of uninsured pregnant women who are Texas

residents and• Have a household income greater than 185% FPL, and at or

below 200% FPL• Have a household income at or below 200% FPL, but do not

qualify for Medicaid because of immigration status.

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Who Qualifies? Continued

• MMP• Age 21 or older• Get Medicare Part A, B, and D, and are receiving full Medicaid

benefits• Eligible for or enrolled in the Medicaid STAR+PLUS program,

which serves members who have disabilities and those who meet a nursing facility level of care and get STAR+PLUS home and community-based waiver services

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Eligibility

• Providers should verify eligibility before each service• Ways to verify eligibility

• Molina Provider Web Portal • Molina’s Interactive Voice Response System (IVR)

1-855-322-4080• Monthly PCP Roster• AIS line/TXMedConnect• Calling Customer Service at:

• 1-866-449-6849 • 1-877-319-6826 (CHIP Rural Service Area)

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STAR Member ID Card

• STAR Members receive two ID Cards : State issues Medicaid ID Card and Molina issues Member ID Card

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STAR+PLUS Member ID Card

• STAR+PLUS Members receive two ID Cards: State issues Medicaid ID Card and Molina issues Member ID Card

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CHIP Member ID Card

• CHIP Members only receive one ID Card from Molina Healthcare

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CHIP Perinate Member ID Card

• CHIP Perinate Members only receive one ID Card from Molina Healthcare

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MMP Member ID Card

• MMP Members only receive one ID Card from Molina Healthcare

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Covered Services

For a full detail of covered services, please see the appropriate Provider Manual found on our website at www.molinahealthcare.com or a hard copy can be provided upon request.

Medicaid providers can also refer to the Texas Medicaid Provider Procedures Manual, located at www.tmhp.com, for the most updated list of Medicaid Covered Benefits for STAR and STAR+PLUS, including limitations and exclusions.

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http://www.molinahealthcare.com/

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CHIP Cost Sharing

• Co-pay amounts vary from $0 to $100 based on Federal Poverty Levels (FPL) and type of service

• Co-pay amounts can be found:

– On Member’s ID Card

– By contacting Customer Service

• Upon meeting cost-sharing limits the Member must contact Maximus to report they have reached their maximum out of pocket

• Maximus will notify Molina Healthcare of cost-sharing limit being met.

– Molina Healthcare will re-issue the Member a new Member ID Card, indicating no co-pay amount ($0)

• Federal law prohibits charging premiums, deductibles, coinsurance, copayments, or any other cost-sharing to Native American or Alaskan Natives Members.

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Medical Transportation

Molina Healthcare of Texas provides non-emergent medical transportation for our members. Transportation can be scheduled on a reoccurring basis ahead of time.

If one of your patients is in need of this service, please have them contact one of our Transportation Vendors or our Member Services Department to see if they qualify.

Note: It is important to have your patient(s) call three (3) days in advance of the appointment to schedule the transportation.

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Logisticare 855-687-3255

TTD/TTY 866-288-3133

Medical Transportation Management 855-687-4786

Medical Transportation Program 877-633-8747

Logisticare 866-475-5423

TTD/TTY 866-288-3133

Member Services-Medicaid 866-449-6849

Member Services-Medicare 866-856-8699

Member Services

Medicaid

Dallas

Houston

El Paso, Laredo, McAllen, San Antonio

Medicare

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Value Added Services

Molina cares about the health of our members and the quality of the care and support they receive. That is why we offer Value Added Services at no cost to help our members stay healthy.

Value Added Services are updated every September.

A list of Value Added Services available to Molina members can be found on our website, MolinaHealthcare.com

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Member Rights and Responsibilities

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Member Rights

Member Rights vary by Line of Business. Below is a sample of our member’s rights.

For complete lists of Member Rights, visit MolinaHealthcare.com

• Members have the right to get accurate, easy-to-understand information to help

them make good choices about their/their child’s health plan, doctors, hospitals,

and other providers.

• Members have the right to know the health plan decides whether a service is

covered or medically necessary, regardless of cost or benefit coverage. Members

have the right to know about the people in the health plan who decide those

things.

• Members have the right to emergency services if they reasonably believe

their/their child’s life is in danger or that they/their child would be seriously hurt

without getting treated right away. Coverage of emergencies is available without

first checking with the health plan.

• Members have the right to be treated fairly by the health plan, doctors, hospitals,

and other providers.

• Members have the right and responsibility to take part in all the choices about

their/their child’s health care.

• Members have the right to get a second opinion from another doctor in the health

plan about what kind of treatment they/their child needs.

• Members have the right to know that doctors, hospitals, and others who care for

them/their child can advise them about their/their child’s health status, medical

care and treatment. The health plan cannot prevent them from giving members

this information, even if the care or treatment is not a covered service.

Member Responsibilities

Member Responsibilities vary by Line of Business. Below are examples of members’ responsibilities. A full list can be found on MolinaHealthcare.com

• Members must become involved in the decisions about their/their child’s treatments.

• Members must learn about what their health plan does and does not cover.

• Members must get to their appointments on time. If they cannot keep an appointment, they should be sure to call and cancel it.

• Members must talk to their providers about the medications that are prescribed.

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Contract Requirements –Behavioral Health

• To the extent Provider is a primary care physician:

– Provider shall have screening and evaluation procedures for detection and treatment of, or referral for, any known or suspected behavioral health problems and disorders. (UMCC Att. B-1, §8.1.15.4.)

– To the extent Provider provides inpatient psychiatric services: Provider shall schedule Members for outpatient follow-up and/or continuing treatment prior to discharge. The outpatient treatment must occur within seven days from the date of discharge. Behavioral health providers must contact Members who have missed appointments within twenty-four (24) hours to reschedule appointments. (UMCC Att. B-1,§8.1.15.5.)

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Contract Requirements –Early Childhood Intervention (ECI)

• Providers must cooperate and coordinate with local Early Childhood Intervention (ECI) programs to comply with federal and state requirements relating to the development, review and evaluation of Individual Family Service Plans (IFSP).

• Provider understands and agrees that any Medically Necessary health and behavioral health services contained in an IFSP must be provided to the Member in the amount, duration, scope and setting established in the IFSP. (UMCC Att. B-1, §8.1.9.)

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Contract Requirements –Family Planning

• If a Member requests contraceptive services or family planning services, Provider must also provide the Member counseling and education about family planning and available family planning services.

• Provider shall not require parental consent for Members who are minors to receive family planning services.

• Provider shall comply with state and federal laws and regulations governing Member confidentiality (including minors) when providing information on family planning services to Members. (UMCC Att. B-1, §8.2.2.2.)

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Contract Requirements –Liability

• In the event Health Plan becomes insolvent or ceases operations, Provider understands and agrees that its sole recourse against Health Plan will be through the Health Plan’s bankruptcy, conservatorship, or receivership estate. (UMCC Att. A, §4.05(f).)

• Provider understands and agrees that the Health Plan’s Members may not be held liable for the Health Plan’s debts in the event of the entity’s insolvency. (UMCM, Ch 8.1, 37)

• Provider understands and agrees that HHSC does not assume liability for the actions of, or judgments rendered against, Health Plan, its employees, agents or subcontractors. Further, Provider understands and agrees that there is no right of subrogation, contribution, or indemnification against HHSC for any duty owed to Provider by the Health Plan or any judgment rendered against the Health Plan. HHSC’s liability to Provider, if any, will be governed by the Texas Tort Claims Act, as amended or modified (Tex. Civ. Pract. & Rem. Code §101.001 et seq.).

(UMCC Att. A, §4.05(f).)

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Contract Requirements –Marketing

• Provider agrees to comply with HHSC’s marketing policies and procedures, as set forth in the UMCC (which includes UMCM). (UMCC Att. B-1, §8.1.6, UMCM, Ch. 4.)

– Provider is prohibited from engaging in direct marketing to enrollees that is designed to increase enrollment in a particular health plan. The prohibition should not constrain Providers from engaging in permissible marketing activities consistent with broad outreach objectives and application assistance. (UMCC Att. B-1, §8.1.6, UMCM Ch. 4.)

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Contract Requirements –Medicaid Provider Agreement

• Acute care providers serving Medicaid Members must enter into and maintain a Medicaid provider agreement with HHSC or its agent to participate in the Medicaid Program, and must have a Texas Provider Identification Number (TPIN).

• All Providers, both CHIP and Medicaid, must have a National Provider Identifier (NPI) in accordance with the timelines established in 45 C.F.R. Part 162, Subpart D (for most Providers, the NPI must be in place by May 23, 2007.) (UMCC Att. B-1, §8.1.4.)

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Contract Requirements –Member Communications

• Health Plan is prohibited from imposing restrictions upon Provider’s free communication with a Member about the Member’s medical conditions, treatment options, Health Plan referral policies, and other Health Plan policies, including financial incentives or arrangements and all managed care plans with whom Provider contracts. (UMCC Att. A, §7.02, and BBA §438.102.)

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Contract Requirements –Primary Care Physicians(PCPs)

• To the extent Provider is a primary care physician:– Provider shall be accessible to Members 24 hours per day, 7 days per

week. (UMCC Att. B-1, §8.1.4.)– Provider shall provide preventative care

• to children under age 21 in accordance with AAP recommendations for CHIP Members and the THSteps periodicity schedule published in the THSteps Manual for Medicaid Members; and

• (ii) to adults in accordance with the U.S. Preventative Task Force requirements. (UMCC Att. B-1, §8.1.4.2.)

– Provider shall assess the medical needs and behavioral health needs of Members for referral to specialty care providers and provide referrals as needed. PCPs must coordinate Members’ care with specialty care providers after referral. (UMCC Att. B-1, §8.1.4.2.)

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Contract Requirements –Texas Health Steps (THSteps)

• Provider shall send all THSteps newborn screens to the Texas Department of State Health Services (DSHS), formerly the Texas Department of Health, Bureau of Laboratories or a DSHS-certified laboratory.

• Provider shall include detailed identifying information for all screened newborn Members and each Member’s mother to allow HHSC to link the screens performed at the hospital with screens performed at the two-week follow-up. (UMCC Att. B-1, §8.2.2.3.)

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Contract Requirements –Tuberculosis

• Provider shall coordinate with the local tuberculosis (TB) control program to ensure that all Members with confirmed or suspected TB have a contact investigation and receive Directly Observed Therapy (DOT).

• Provider shall report to the Texas Department of State Health Services (DSHS) or the local TB control program any Member who is non-compliant, drug resistant, or who is or may be posing a public health threat. (UMCC Att. B-1, §8.2.2.6.)

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Contract Requirements –Women, Infants and Children (WIC) Services

• Provider shall coordinate with the WIC Special Supplemental Nutrition Program to provide medical information necessary for WIC eligibility determinations, such as height, weight, hematocrit or hemoglobin. (UMCC Att. B-1, §8.1.10.)

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Provider Access and Availability

• Appointment availability is imperative to keep our members healthy. The following schedule should be followed regarding appointment availability:

• Routine exams should be provided within 14 days of request• Preventive health services for children within 60 days• Preventive health services for adults within 90 days• Urgent care should be received within 24 hours of the request• Emergency care should be received immediately

• A contracted PCP must ensure that he/she will be available or accessible or arrange coverage by another qualified healthcare professional 24 hours a day, seven days a week.

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Cultural Competency

• Cultural competency begins with understanding culture

• Culture is learned beliefs, values and traditions that affect how individuals of a particular group perceive, think, interact, behave, and make judgments about their world

• Components to interact effectively with people of different cultures:– Awareness of one’s own culture

– Attitude towards other cultures

– Knowledge of differences in cultures

• It is important to recognize that people of different cultures have different ways of communicating, behaving and problem-solving

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Cultural Competency

• Stereotypes may lead to racial and ethnic disparities in healthcare

• Most people are unaware of their biases and how the behavior displays or exposes a perception of stereotypes and biases

• Stereotyping can lead to discrimination. Patients are less likely to utilize care due to lack of trust, fear, or perceived discrimination.

• Cultural sensitivity can start with open communication

• Open communication by:– Ask open-ended questions and seek clarification

– Show respect for cultural beliefs

– Listen without interrupting

– Don’t appear rushed, even if you are 41

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Cultural Competency Tips

• Spend some time learning about various cultures

• Be aware of how culture affects perceptions and pay attention to challenges presented

• Wait until it is clear that the person has finished speaking before you respond

• Withhold judgment until comprehension of the message is complete.

• Restate or paraphrase your understanding of the message and reflect it back for verification

• Your viewpoint may be different but consider the other’s position and perspective

• Look for feelings or intent beyond the words

• Before you hang up the phone, ask if there is anything

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Provider Online Resources

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Provider Manuals

Provider Online Directories

Web Portal

Preventative & Clinical Care Guidelines

Prior Authorization Information

Advanced Directives

Model of Care Training

Claims Information

Pharmacy Information

HIPAA

Fraud Waste and Abuse Information

Frequently Used Forms

Communications & Newsletters

Member Rights & Responsibilities

Contact Information

www.MolinaHealthcare.com

www.MolinaMedicare.com

www.MolinaHealthcare.com (DUALS WEBSITE)


http://www.molinamedicare.com/

https://www.molinahealthcare.com/providers/tx/duals/Pages/duals.aspx

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Provider Manual and Highlights

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MHT’s Provider Manual is written specifically to address the requirements of delivering healthcare services to our members, including your responsibilities as a participating provider. Providers may request printed copies of the Provider Manual by contacting your Provider Services Representative or view the manual on our provider website, at:

Medicaid Program Provider Manual MMP Provider Manual Medicare Provider Manual MarketPlace Provider Manual

All can be found at www.molinahealthcare.com

Provider Manual Highlights

Benefits and Covered Services Overview Long Term Supports and Services

Claims, Encounter Data and Compensation (including no member billing requirements)

Member Grievances and Appeals

Compliance and Fraud, Waste, and Abuse Program Member’s Rights and Responsibilities

Important Phone Numbers Model of Care

Credentialing and Re-credentialing Pharmacy

Delegation Oversight Preventive Health Guidelines

Eligibility, Enrollment, and Disenrollment Provider Responsibilities

Healthcare Services Quality Improvement

Health Insurance Portability and Accountability Act (HIPAA) Transportation Services

Interpreter Services Utilization Management, Referral and Authorization

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Provider Online Directory

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MHT providers may request a copy of our

Provider Directory from your Provider

Services Representative(s), or providers

may also use the Provider On-line

Directory (POD) on our website.

To find a Medicaid provider, visit us at

www.molinahealthcare.com, and click

Find a Provider or Find a Hospital or Find

a Pharmacy.

To find a Medicare provider, visit us at

www.molinahealthcare.com

To request a copy of our printed Provider

Directory, call (866) 449-6849 or contact

your Provider Services representative.

https://eportal.molinahealthcare.com/Provider/ProviderSearch?RedirectFrom=MolinaStaticWeb

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Web Portal

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MHT participating providers may register for access to our Web Portal for self service member eligibility, claims status, provider searches, to submit requests for authorization and to submit claims. The Web Portal is a secure website that allows our providers to perform many self-service functions 24 hours a day, 7 days a week. Some of the services available on the Web Portal include:

Web Portal Highlights

Member eligibility verification and history Claims status inquiry

View Coordination of Benefits (COB)

information

View Nurse Advice Line call reports for

members

Update provider profile View HEDIS® missed service alerts for

members

View PCP Member Roster Status check of authorization requests

Submit online service/prior authorization

requests

Submit claims online

Self Service registration instructions and a complete training guide for the Web Portal are included in your Welcome Kit.

Register online at https://provider.molinahealthcare.com/provider/login.

https://provider.molinahealthcare.com/provider/login

Web Portal

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Verifying Member

Eligibility

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MHT offers various tools to verify member eligibility. Providers may use our online self-

service Web Portal, integrated voice response (IVR) system, eligibility rosters or speak

with a Customer Service Representative.

Please note - At no time should a member be denied services because his/her name

does not appear on the eligibility roster. If a member does not appear on the eligibility

roster please contact the Plan for further verification.

Web Portal: https://provider.molinahealthcare.com/provider/login

Medicaid Customer Service/IVR Automated System: (866) 449-6849

MMP/Texas Customer Service/IVR Automated System: (866) 856-8699

https://provider.molinahealthcare.com/provider/login

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Role of Primary Care Providers (PCPs)

• Accessible to Members 24 hours a day, 7 days a week

• Responsible for providing, arranging, and coordinating all aspects of the Member’s health

• Providing medically necessary routine, urgent and emergent services within the health care professional’s scope of practice

• Providing screening and evaluation for detection and treatment of, or referral for, any known or suspected behavioral health problems and disorders with the scope of his/her practice.

• Providing preventative health services

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PCP Assignment and Changes

PCP Assignment – Members have the right to choose their PCP. If the Member or

his/her designated representative does not choose a PCP, one will be assigned using

the following considerations:

Proximity of the provider must be within 10 miles or 30 minutes of member’s

residence

Member’s last PCP, if known

Member’s age, gender and PCP needs

Member’s language preference

Member’s covered family members, in an effort to keep family together and

maintain establish relationships

PCP Changes – Members may change their PCP at any time. All changes completed

by the 25th of the month will be in effect on the first day of the following calendar

month. Any changes on or after the 26th of the month will be in effect on the first day

of the second calendar month

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PCP/Plan Initiated Disenrollment and Dismissals

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PCP Dismissals - A PCP may find it necessary to dismiss a Member from his/her practice due to member non-compliance with recommended health care, or unruly and disorderly behavior.

• If the dismissal is inevitable, PCPs must immediately notify MHT’s Member Services Department, attn: Member Services Director.

• These requests must include a detailed description of the circumstances prompting the Provider/Practitioner to initiate the request, including statement of the specific issue, dates of occurrence, and frequency of occurrence.

• Upon receipt of such request, the Member Services Director or designee will first make an effort to resolve the problem with the member through avenues such as PCP reassignment, education or referral services, and involvement of a Medical Case Manager RN to attempt to coordinate care.

• The member will be notified in writing of the intent to disenroll and given an opportunity to appeal. • At no time should the Provider/Practitioner contact the member without approval of the Member

Services Director or designee.

Plan Initiated Disenrollment (PID) - A Provider/Practitioner may request that a PID be processed for any of its members. However, MHT is responsible to initiate the process with HFS. Disenrollment can occur based on member:

• Permanently moving outside Molina’s service area• Committing Fraud and/or abusing membership card• Losing Medicaid eligibility and/or entitlement to Medicare benefits

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Specialty Providers Responsibilities

• Responsible for providing consulting expertise, specialty diagnostic, surgical and other medical care.

• On-call coverage 7 days a week, twenty-four (24) hours a day, either personally or by a reasonable call coverage arrangement with other appropriate individuals.

• Responsible for submitting a report of the Member’s treatment to the Member’s PCP.

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Hospital Responsibilities

• Providing services to the Members admitted by participating providers in accordance with the Physician’s orders.

• Hospital will admit Members upon orders of a participating provider, and with prior authorization, excluding emergency services.

• Notifying Molina of all admissions of Members during regular working hours, but in no event later than twenty-four (24) hours or the next working day following the admission of a Member.

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Electronic Visit Verification

• Effective April 1, 2016, Providers of attendant care services, and any other services identified by HHSC, must use an Electronic Visit Verification system to verify all care provided to members.

• Providers will be required to submit transactions for all care provided and conduct Visit Maintenance on any transaction (clock in/out) that does not match the services rendered prior to billing Molina. This Visit Maintenance period is 60 days from the date of service

• Molina will receive transaction files daily from each vendor.

• These files will be compared to claims to locate a “match.”

• Claims with a matching transaction will proceed through the claims system.

• Claims without a “match” will be denied; however, Molina will continue to compare that denied claim with the incoming transaction files on a weekly basis. If during the 60 day visit maintenance period, a match is located, the claim will be processed.

• There is no change to Molina’s requirements for prior authorization. If the visit verification and claim match, but there is not a valid authorization on file or the number of authorized units are exhausted, the claim will be denied. In the event additional services are required, providers must work with Molina’s Health Care Services department to ensure additional authorizations are in place prior to providing the services.

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Electronic Visit Verification

If a provider agency fails to meet a Provider Compliance Plan Score (preferred vs non preferred reason codes) of at least 90% for a review period, the provider agency may be subject to corrective action plans, liquidated damages, or contract actions.

Score cards will be distributed to providers every month.

• The score card will serve as a compliance reminder to all Molina Providers

• The score cards will give a monthly compliance score of the provider; showing the verified preferred visits, auto-verified visits, and verified non-preferred visits.

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Provider Support

You are important!• External Provider Service Representatives

– Representatives throughout Texas

– 4 Provider Service Managers

• Dallas/El Paso

• Harris/Jefferson

– Provider Service Representatives can assist with:• Claims Statuses

• Complaint & Appeal Statuses

• Member Eligibility & Benefit Verification

• Immediate Customer Service Monday – Friday 8am – 5pm

– 1-855-322-4080

– Email: [email protected]

• Provider Website

– https://www.molinahealthcare.com/members/tx/en-US/health-care-professionals/Pages/home.aspx

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• Bexar

• Hidalgo

• Utilization Management

• Quality Improvement Initiatives

• Prior Authorization & Referrals Requests

https://www.molinahealthcare.com/members/tx/en-US/health-care-professionals/Pages/home.aspx

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Claims & Billing

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Claims Submission

• Timely filing of claims is 95 days from the date of service

• Methods for submitting claims:

– Electronic Submission

• Approved vendors:

– EMDEON

• Payor ID for all - 20554

– Molina Provider Web Portal

– Paper

– TMHP Single Source Portal

• A request for correction or adjustment must be submitted within 120 days from denial date shown on original Explanation of Payment (EOP) or Remittance Advise (RA)

• Members may not be balance billed for any Covered Services

– May collect any Member Co-pays, or

– Payment for non-covered services, only with Member

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Claims Address

Medicaid Claims Submission Address “Fee-For-Service Claims”Molina Healthcare of TexasP.O. Box 22719Long Beach, CA 90801

Medicare Claims Submission Address Molina MedicareP.O. Box 22719Long Beach, CA 90801

EDI Claims Submission – Medicaid & MedicareEdmeon Payor ID# 20554Emdeon Telephone (877) 469-3263

Note: Online submission is

also available through Web

Portal Services at:

www.molinahealthcare.com

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Claims

Claims Processing Standards: On a monthly basis, 98% of Medicaid claims received by Molina from

our health plans network providers are processed within 30 calendar days, 100% of claims are processed

within 45 working days. These standards have to be met in order for Molina to remain compliant with

State requirements and ensure providers are paid timely.

Claims Submission Options

1. Submit claims directly to Molina Healthcare of Texas

2. Clearinghouse (Emdeon)

⁻ Emdeon is an outside vendor that is used by Molina Healthcare of Texas

⁻ When submitting EDI Claims (via a clearinghouse) to Molina Healthcare of Texas, please

utilize the following payer ID # 20554.

⁻ EDI or Electronic Claims get processed faster than paper claims

⁻ Providers can use any clearinghouse of their choosing. Check with your clearinghouse to

determine if any fees would apply.

EDI Claim Submission Issues

⁻ Please call the EDI customer service line at (866) 409-2935 and/or submit an email to

[email protected]

⁻ Contact your provider services representative

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mailto:[email protected]

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Claims Submission Requirements

• Use standard, nationally recognized codes:

– CPT Codes

– HCPCS

– Revenue Code

– Modifiers when appropriate

– ICD-10

– NDC as required by TMHP http://www.tmhp.com/Pages/Topics/NDC.aspx

– POA as required by TMHP http://www.tmhp.com/Pages/Medicaid/Hospital_POA.aspx

• Covered Services and codes are outlined in the Texas Medicaid Provider Manual

• Claims must contain following provider identification numbers:

– National Provider Identification (NPI) attested on the TMHP Master Provider File

– EPSDT Texas Provider Identification (TPI) when billing THStep services

– LTSS provider may have an API

– Both billing provider NPI and rendering provider’s NPI

are required on claims and must be attested.

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http://www.tmhp.com/Pages/Topics/NDC.aspx

http://www.tmhp.com/Pages/Medicaid/Hospital_POA.aspx

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Billing Maternity Claims

• Delivery charges should be billed with the appropriate CPT codes:– 59409 & 59410 = Vaginal Delivery

– 59514 & 59515 = C-Section

• Delivery Codes must be billed with one of the following modifiers (59409, 59410, 59514, 59515, 59612,59614, 59620, or 59622):

• U1 – Medically necessary delivery prior to 39 weeks of gestation

• U2 – Delivery at 39 weeks of gestation or later

• U3 – Non-medically necessary delivery prior to 39 weeks of gestation

– 59430-TH = Postpartum Care after discharge

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Newborn Claims Submission

• Routine Newborn Care - STAR: – Initial care should be billed under the Mother’s Medicaid Number (PCN),

or identification number, for the first 90 calendar days

• Routine Newborn Care - CHIP: – Newborns are not automatically eligible

– Mother must apply for baby’s coverage

• Routine Newborn Care - CHIP Perinate: – Newborns are automatically eligible

– Issued their own Medicaid identification number

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After Hours & Weekend Visit (99050)

• This applies to services provided:– After 5p.m., or

– Before 8 a.m., or

– On weekends, or

– On days when the office is normally closed (e.g. holidays, Saturdays or Sundays)

• After-hours services will be reimbursed only when CPT code 99050 is billed. Reimbursement will be based on 100% of prevailing Medicaid Fee Schedule.

• CPT 99050 will be reimbursed to the primary services provided.

• PCPs can see any Molina member after hours without an authorization – this benefit is not limited to their own assigned members.

• Services rendered can be emergent or non-emergent

(Well Child).

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Claims Submission Tips

• Report services performed correctly– Reporting the most comprehensive CPT code that describes the services performed – do

not unbundle and do not fragment a procedure into component parts.

– Use appropriate modifiers and condition indicators

– Use age and gender appropriate codes.

– Report units correctly

– Avoid down coding or up coding

• Make sure you are billing with the correct NPI/Tax ID/TPI combination that is attested to with Medicaid/TMHP.

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Claims Payment

• Claims Payment Timeline:

– Molina has up to 30 days to pay all clean claims

• Claim must be submitted in the correct format and contain all of the elements required to adjudicate the claim.

– On average claims submitted electronically are paid in 9 days

– On average paper claims are paid in 14 days

• Payment Methods

– Paper or Live Check

– Electronic Fund Transfers (EFT)

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Claims Concerns

• All reconsideration and appeals forms can be found on our website at: www.molinahealthcare.com under “I am a Healthcare Provider” and forms

• Providers may also file appeals using our web portal, found at www.molinahealthcare.com

• You may also call the Molina Contact Center at 1-(855)-322-4080 for assistance with your claims concerns.

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Electronic Funds Transfer & Remittance Advice (EFT & ERA)

Molina Healthcare has partnered with our payment vendor, FIS ProviderNet, for Electronic Funds Transfer andElectronic Remittance Advice. Access to the ProviderNet portal is FREE to our participating providers and weencourage you to register after receiving your first check from Molina Healthcare.

New ProviderNet User Registration:1. Go to https://providernet.adminisource.com2. Click “Register” 3. Accept the Terms 4. Verify your information

a. Select Molina Healthcare from Payers list b. Enter your primary NPI c. Enter your primary Tax ID d. Enter recent claim and/or check number

associated with this Tax ID and Molina Healthcare5. Enter your User Account Information

a. Use your email address as user name b. Strong passwords are enforced (8 or more

characters consisting of letters/numbers) 6. Verify: contact information; bank account

information; payment address a. Note: any changes to payment address may

interrupt the EFT processb. Add any additional payment addresses, accounts,

and Tax IDs once you have logged in.

If you are associated with a Clearinghouse:1. Go to “Connectivity” and click the “Clearinghouses” tab2. Select the Tax ID for which this clearinghouse applies3. Select a Clearinghouse (if applicable, enter your Trading Partner ID)4. Select the File Types you would like to send to this clearinghouse and click “Save”

If you are a registered ProviderNet user:1. Log in to ProviderNet and click “Provider Info”2. Click “Add Payer” and select Molina Healthcare from the Payers list 3. Enter recent check number associated with your primary Tax ID and Molina Healthcare

If you have questions regarding the actual registration process, please contactProviderNet at: (877) 389-1160 or email: [email protected]

BENEFITS Administrative rights to sign-up/manage your own EFT Account Ability to associate new providers within your organization to receive EFT/835s View/print/save PDF versions of your Explanation of Payment (EOP) Historical EOP search by various methods (i.e. Claim Number, Member Name) Ability to route files to your ftp and/or associated Clearinghouse

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• Item 1• Item 2• Item 3 Health Services

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Referrals and Prior Authorization

Referrals are made when medically necessary services are beyond the scope of the PCPs practice.Most referrals to in-network specialists do not require an authorization from MHT. Out-of-networkreferrals will require prior authorization. Information should be exchanged between the PCP andSpecialist to coordinate care of the patient.

Prior Authorization is a request for prospective review. It is designed to:

Assist in benefit determination Prevent unanticipated denials of coverage Create a collaborative approach to determining the appropriate level of care for Members receiving

services Identify Case Management and Disease Management opportunities Improve coordination of care

Requests for services on the Molina Healthcare Prior Authorization Guide are evaluated by licensednurses and trained staff that have authority to approve services.

A list of services and procedures that require prior authorization is included in your Welcome Kit, in ourProvider Manual and also on our website at:


www.MolinaMedicare.com

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Request for Authorization

Authorization for elective services should be requested with supporting clinical documentation at least 5 business days

prior to the date of the requested service. Authorization for emergent services should be requested within one business

day. Information generally required to support decision making includes:

⁻ Current (up to 6 months), adequate patient history related to the requested services

⁻ Physical examination that addresses the problem

⁻ Lab or radiology results to support the request (Including previous MRI, CT, Lab or X-ray report/results)

⁻ PCP or Specialist progress notes or consultations

⁻ Any other information or data specific to the request

MHT will process all “non-urgent” requests in no more than 14 business days of the initial request. “Urgent” requests will

be processed within 72 hours of the initial request. If we require additional information we will pend the case and provide

written communication to you and the Member on what we need. All referrals from Nursing Facilities and Hospitals will be

managed as expedited requests.

Providers who request prior authorization approval for patient services and/or procedures can request to review the

criteria used to make the final decision. Providers may request to speak to the Medical Director who made the

determination to approve or deny the service request.

Upon receipt of prior authorization, MHT will provide you with a Molina unique authorization number. This authorization

number must be used on all claims related to the service authorized.

Our goal is to ensure our members are receiving the Right Services at the Right Time AND in the Right Place. You can

help us meet this goal by sending all appropriate information that supports the member’s need for Services when you

send us your authorization request. Please contact us for any questions/concerns.

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Prior Authorization Request Form

Providers should send requests for prior authorizations to the Utilization Management Department using the Molina Healthcare Service Request Form, which is included in your Welcome Kit and available on our website, at:

Medicaid: www.MolinaHealthcare.com

Medicare: www.MolinaMedicare.com

Service Request Forms may be faxed to the Utilization Management Department to the numbers listed below, or submitted via our Provider Web Portal.

Web Portal : https://provider.molinahealthcare.com/provider/login

Medicaid: Phone (866) 449-6849Fax (866) 420-3639

Medicare: Phone (866) 440-0012Fax (866) 420-3639

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Breast Pump Requirements

Molina does not require Prior Authorization for Breast Pumps. Below listed codes Molina will pay for:

• E0602- Breast pump, manual, any type- for purchase only

• E0603- Breast pump, electric (AC and/or DC), any type for purchase only

• E0604- Breast pump, hospital grade, electric (AC and/or DC), any type rental only

Per TMHP:

A manual or non-hospital-grade electric breast pump may be considered for purchase only with the

appropriate documentation supporting medical necessity. The purchase of a breast pump is limited to

one every three years. Providers must use procedure code E0602 or E0603 when billing for the purchase

of a manual or non-hospital-grade electric breast pump. A hospital-grade breast pump (procedure code

E0604) may be considered for rental, not purchase. Rental of a hospital-grade breast pump is not time limited. If more than one type of breast pump is billed on the same day by the same provider, only one will be reimbursed. The following procedure codes for replacement parts are benefits of Texas Medicaid: A4281, A4282,A4283, A4284, A4285, and A4286. Breast pumps are also available through the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

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LTSS Services

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LTSS Prior Authorizations Requirements

• Services are “unbundled” in STAR+PLUS.

• Example: Medical supplies & DME equipment will not be provided by the home care agency, such services will be provided by contracted DME provider.

• Assisted Living Facility:

• When requesting authorization please identify the type of facility the member resides in.

• Personal Assistant Services (PAS) –

• Providers can submit referrals to Molina Healthcare for members to be assessed for PAS services (new services or an increase in existing services) via fax.

• Once fax is received with referral for PAS services, the member will be contacted to verify request. After request is confirmed, the member’s information will be assigned to Service Coordinator by zip code for an initial or increase PAS assessment.

• The most efficient way to request an assessment for a member is to have the member contact the Service Coordination dept at 1-866-409-0039 to request an initial or increase assessment.

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LTSS Prior AuthorizationsRequirements Continued

• Adult Day Care Centers (ADC)• All new prior authorizations should be faxed with a completed 3050

• Molina will issue prior authorization effective on the date the request and completed 3050 is received

• Molina will take up to 5 days to review the prior authorization request

• All Adult Day Care services rendered during this review period will be authorized and paid

• Upon completing the review Molina will contact the requesting Adult Day Care to communicate the results of our review.

• For renewal or transfer of existing member, fax the prior authorization request and Molina will authorize on the receipt date of the referral request.

• DME Referrals • Providers can submit referrals to Molina Healthcare for members to be assessed for DME

supplies via fax.

• Once fax is received with referral for DME supplies, a Service Coordinator will review and determine if the supplies meet criteria.

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Care Management Program/Model of Care

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To ensure that members receive high quality care, Molina uses an integrated system of care that provides

comprehensive services to all members across the continuum of Medicare and Medicaid benefits. Molina

strives for full integration of physical health, behavioral health, long term care services and support and social

support services to eliminate fragmentation of care and provide a single, individualized plan of care for

members. Molina’s Care Management program consists of four programmatic levels. This approach

emphasizes high-touch, member-centric care environment and focuses on activities that supports better health

outcomes and reduces the need for institutional care.

As a network provider, you play a critical role in providing quality services to our members. This includes

identifying members in need of services, making appropriate/timely referrals, collaborating with Molina case

managers on the Individualized Care Plan (ICP) and Interdisciplinary Care Team meetings (ICT; if needed),

reviewing/responding to patient–specific communication, maintaining appropriate documentation in member’s

medical record, participating in ICT/ Model of Care provider training and ensuring that our members receive

the right care in the right setting at the right time.

Please call our Care Management Department at (866) 409-0039 when you identify a

Member who needs/might benefit from such services.

For additional Model of Care information, please visit our website at


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Interdisciplinary Care Team (ICT)

Molina’s ICT may include:

Registered Nurse (RN)

Social Worker

Case Manager

Utilization Management Staff

Molina Medical Director

Pharmacy

Member’s Primary Care Provider

Member and/or Designee

Care Transition Coach

Service Providers

Community Health Worker

Other entity that member selects

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Note: Molina’s ICT is built around the member’s preferences and decisions are made

collaboratively and with respect to member’s right to self-direct care. Members have the

right to limit and/or may decline to participate in:

Case management

Participate in ICT and/or approve all ICT participants

ICT meetings; brief telephonic communications

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Care Management Design

Level 1 – Health Management

Health Management is focused on disease prevention and

health promotion. It is provided for members whose lower

acuity chronic conditions; behavior (e.g., smoking or missing

preventive services) or unmet needs (e.g., transportation

assistance or home services) put them at increased risk for

future health problems and compromise independent living.

The goal of Health Management is to achieve member

wellness and autonomy through advocacy, communication,

education, identification of service resources and service

facilitation throughout the continuum of care.

At this level, members receive educational materials via mail

about how to improve lifestyle factors that increase the risk of

disease onset or exacerbation. Topics covered include smoking

cessation, weight loss, nutrition, exercise, hypertension,

hyperlipidemia, and cancer screenings, among others.

Members are given the option, if they so choose, to engage in

telephone-based health coaching with Health Management

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All members will have initial and annual health risk assessments and integrated care plans based on identified needs.

Members are placed in the appropriate level of care management based on the assessment, their utilization history

and current medical and psycho-social-functional needs. Molina’s Care Management program consists of four

programmatic levels as follows:

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Level 2 – Case Management

Case Management is provided for members who have

medium-risk chronic illness requiring ongoing

intervention. These services are designed to improve the

member’s health status and reduce the burden of disease

through education and assistance with the coordination of

care including LTSS. The goal of Case Management is to

collaboratively assess the member’s unique health needs,

create individualized care plans with prioritized goals, and

facilitate services that minimize barriers to care for

optimal health outcomes.

Case Managers have direct telephonic access with

members. In addition to the member, Care Management

teams also include pharmacists, social workers and

behavioral health professionals who are consulted

regarding patient care plans. In addition to telephonic

outreach to the member, the Care Manager may enlist the

help of a Community Health Worker or Community

Connector to meet with the member in the community for

education, access or information exchange.

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Level 3 – Complex Case Management

Complex Case Management is provided for members who

have experienced a critical event or diagnosis that requires

the extensive use of resources and who need help navigating

the health care system to facilitate the appropriate delivery of

care and services.

The goal of Complex Case Management is to help members

improve functional capacity and regain optimum health in an

efficient and cost-effective manner. Comprehensive

assessments of member conditions include the development

of a case management plan with performance goals and

identification of available benefits and resources. Case

Managers monitor, follow-up and evaluate the effectiveness of

the services provided on an ongoing basis. Complex Case

Management employs both telephonic and face-to-face

interventions.

Community Connector program will also be available for

members receiving Level 3 & 4 – Complex Case

Management. Community Connectors or “Promotoras”

support Molina’s most vulnerable members within their home

and community with social services access and coordination.

Community Health Workers serve as patient navigators and

promote health within their own communities by providing

education, advocacy and social support.


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Level 4 – Imminent Risk

Level 4 focuses on members at imminent risk of an emergency

department visit, an inpatient admission, or institutionalization,

and offers additional high intensity, highly specialized

services. Level 4 also includes those members who are currently

institutionalized but qualify to transfer to a home or community

setting. Populations most often served in Level 4 are the Dual-

Eligibles (Medicare/Medicaid), those with severe and persistent

mental illness (SPMI), those with Dementia, and the

Developmentally Delayed. These services are designed to

improve the member’s health status and reduce the burden of

disease through education as described in level 1.

These criteria include meeting an intensive skilled nursing (ISN)

level of care, facing an imminent loss of current living

arrangement, deterioration of mental or physical condition, having

fragile or insufficient informal caregiver arrangements, having a

terminal illness, and having multiple other high risk factors.

Comprehensive assessments of Level 4 conditions include

assessing the member’s unique health needs utilizing the

comprehensive assessment tools, identify potential transition from

facility and need for LTSS referral coordination, participate in ICT

meetings, create individualized care plans with prioritized goals,

and facilitate services that minimize barriers to care for optimal

health outcomes.


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Based on the level of Care Management needed, outreach is made to the member to determine the best plan to

achieve short and long-term goals. Each level of the program has its own specific health assessment used to determine

interventions that support member achievement of short- and long-term goals. At the higher levels, this includes

building an individualized care plan with the member and/or representative. These assessments include the following

elements based on NCQA, state and federal guidelines:

- Health status and diagnoses - Clinical history, Medications prescribed

- Cultural and linguistic needs - Visual and hearing needs

- Caregiver resources - Available benefits and community resources

- Body Mass Index, Smoking - Confidence

- Communication barriers with providers - Treatment and medication adherence

- Emergency Department and inpatient use - Primary Care Physician visits

- Psychosocial needs (e.g., food, clothing, employment) - Durable medical equipment needs

- Health goals - Mental health

- Chemical dependency

- Readiness to change and Member’s desire / interest in self-directing their care

- Life-planning activities (e.g., healthcare power of attorney, advance directives)

- Activities of daily living, functional status, need for or use of LTSS

The resulting care plan is approved by the member, maybe reviewed by the ICT and maintained and updated by the

Case Manager as the member’s condition changes. The Case Manager also addresses barriers with the member

and/or caregiver, and collaborates with providers to ensure the member is receiving the right care, in the right setting,

with the right provider.


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Long Term Services and Supports (LTSS)

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Qualifying Molina members have access to a variety of Long Term Services and Supports (LTSS) to help them meet daily needs for assistance and improve quality of life. LTSS benefits are provided over an extended period, mainly in member homes and communities, but also in facility-based settings such as nursing facilities as specified in his/her Individualized Care Plan. Overall, Molina’s care team model promotes improved utilization of home and community-based services to avoid hospitalization and nursing facility care.

LTSS includes the following:

Community Based Services

In Home Supportive Services

Skilled nursing facility services and

Sub-acute care services

Personal Assistant Service (PAS)

Day Activity Health Service (DAHS)

Providers can submit referrals to Molina Healthcare for members to

be assessed for PAS & DAHS services (new services or an increase

in existing services) via fax (866) 420-3639.

The most effective way to request an assessment for a

member is to have the member contact the Service

Coordination department at (866) 409-0039 to request

an initial or increase assessment.

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Mental Health/Behavioral Health Services

Mental and emotional well-being is essential to overall health. Sound mental health allows people to realize their full potential, live more

independent lives, and make meaningful contributions to their communities. Reducing the stigma associated with behavioral health diagnoses

is important to utilization of effective behavioral health treatment. Identifying and integrating behavioral health needs into care coordination,

traditional health care, social services, person-focused care and community resources, is particularly important.

The following benefits are available to Molina members and are a responsibility of the Health Plan:

For Molina MMP members, rehabilitative mental health services, including crisis intervention, stabilization and residential, Molina works with

and refers to county-administered behavioral health services to coordinate care for Molina members.

How to refer Molina members in need of Mental Health/Behavioral Health services?

Refer to Molina Prior Authorization requirements: MolinaHealthcare.com.

Behavioral health participating providers should fax the Molina Healthcare Inpatient/PHP/IOP/Outpatient Behavioral Health Treatment

Request form to Molina for outpatient treatment, to (866) 617-4967

For both participating and non-participating providers, if the request is for inpatient behavioral health, Partial Hospitalization or an

Intensive Outpatient Program for psychiatric and substance use disorders, the Molina Healthcare Inpatient/PHP/IOP/Outpatient

Behavioral Health Treatment Request form should be faxed as soon as possible to the same number at (866) 617-4967

If the admission to inpatient behavioral health is an emergency, prior authorization is not needed but the form should be faxed as soon

as possible to (866) 617-4967

The Molina Care Manager may call the behavioral health provider for additional clinical information, particularly if the Molina

Healthcare Inpatient/PHP/IOP/Outpatient Behavioral Health Treatment Request form is not completely filled out.

Interqual® medical necessity criteria is used to review the provided clinical information. The Molina psychiatrist may also contact the

behavioral health provider for a peer-to-peer discussion of the member behavioral health needs.

Crisis Prevention and Behavioral Health Emergencies

Please contact our Nurse Advice Line available 24 hours a day, 7 days a week at (888) 275-8750 /

TTY: (866) 735-2929

Mental health hospitalization

Mental health outpatient services

Psychotropic Drugs

Mental health services within the scope of primary care physician

Counseling Services

Medication Management


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Medicare Comprehensive Health Evaluation/Annual Assessment

All Molina Medicare and Medicare/Medicaid (Dual)

members should receive a Comprehensive Annual

Assessment from their PCP, at least once every year. As

part of our Initial Health Risk Summary Program, Molina

collects specific information about our members’ health

conditions from these assessments in order to improve

coordination of care.

PCPs should ensure that all Molina Medicare members are

assessed at least annually, and submit a completed Molina

Medicare Health Evaluation Form to MHT and/or fax

directly to (866) 420-3639. Please note the following:

All chronic conditions should be adequately assessed

and documented on your progress note (documentation

such as monitoring, evaluation, assessment, and plan);

Conditions for diagnosis codes submitted must be

documented in your progress note; and

Documentation and coding should be to the highest

specificity possible.

We recognize that documenting this assessment creates

additional work for PCPs and their staff, so we have

developed a method of reimbursement to compensate

providers for this service. For additional information contact

your Provider Services Representative.

For risk adjustment, coding questions, and inquiries,

please send an email to: [email protected]

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Service Coordination

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Service Coordination

• Service Coordinators

• Members are assigned to Service Coordinators by status (waiver or non waiver) and zip code.

• Service Coordinators are remote staff; therefore, providers should contact the Service Coordination department at 1-866-409-0039 and speak with a Care Specialist. All Care Specialists can assist with basic inquiries.

• If additional follow up is needed, the assigned Service Coordinator will contact the provider or member within 24 hours.

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Communication with Service Coordination

• Providers can communicate with the Service Coordination department via phone or fax.

• Phone number – 1-866-409-0039

• Fax number – 1-866-420-3639

• Providers can fax in member case information on 2067 forms. See example below.

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Lab Services

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Laboratory Services

Quest Laboratories is the provider of laboratory services for Molina Healthcare of Texas members.Your patients will benefit from Quest Diagnostics comprehensive access, convenience, and choice with abroad array of services available locations throughout Texas.

Quest Laboratories offers:

An extensive testing menu with access to more than 3,400 diagnostic tests so you have theright tool for even your most complicated clinical cases

Approximately 900 PhDs and MDs are available for consultation at any time

Results within 24 hours for more than 97% of the most commonly ordered tests

24/7 access to electronic lab orders, results, ePrescribing and Electronic Health Records

Trained IT Specialists provide 24/7/365 support for all Quest Diagnostics IT solutions in youroffice, minimizing downtime and providing the answers you need quickly

Less wait time at Patient Service Center locations with Appointment Scheduling by phone oronline

Email reminders either in English or Spanish about upcoming tests or exams

If you do not currently use Quest Diagnostics for outpatient laboratory services or have questions aboutQuest Diagnostics services, test menus, and patient locations, please call 866-MY-QUEST to request aconsultation with a Quest Diagnostics Sales Representative.

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Pharmacy Services

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Pharmacy/Drug Formulary

The Molina Drug Formulary was created to help manage the quality of our Members’ pharmacy benefit. The Formulary is the cornerstone for a progressive program of managed care pharmacotherapy. Prescription drug therapy is an integral component of your patient's comprehensive treatment program. The Formulary was created to ensure that Molina Healthcare of Texas members receive high quality, cost-effective, rational drug therapy. Molina Healthcare of Texas Drug Formularies are available on our website, at:

Medicaid Formulary: click here Medicare Formulary: click here

Prescriptions for medications requiring prior approval, most injectable medications or for medications not included on the Molina Drug Formulary may be approved when medically necessary and when Formulary alternatives have demonstrated ineffectiveness. When these exceptional needs arise, providers may fax a completed Prior Authorization/Medication Exception Request.

Medicaid Phone: (855) 322-4080 Medicare Phone: (855) 322-4080Prior Authorization Fax: (888) 487-9251 Prior Authorization Fax: (888) 487-9251

The Prior Authorization/Medication Exception Request is included in your Welcome Kit and available on our website

Medicaid: click here Medicare: click here

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http://www.molinahealthcare.com/medicaid/providers/ca/drug/Pages/formulary.aspx

https://www.molinahealthcare.com/members/common/en-US/PDF/Medicare/formulary-2019-tx.pdf

http://www.molinahealthcare.com/medicaid/providers/ca/forms/pages/fuf.aspx

https://www.molinahealthcare.com/providers/common/medicare/Pages/medicare.aspx

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Pharmacy Services

• Pharmacy services are covered by Molina Healthcare instead of the Texas Vendor Drug Program (VDP).

– Effective March 1, 2012

– The Vendor Drug Program (VDP) Drug Formulary and Preferred Drug List (PDL) is used.

– The VDP Drug Formulary can be found at: http://www.txvendordrug.com/

• HHSC offers a free subscription service for accessing the Drug Formulary and PDL through the internet and hand-held devices. This service is called Epocrates and can be found at: https://www.txvendordrug.com/formulary/epocrates

• Pharmacy Basics– Members will need to get prescription drugs and medical supplies at pharmacies and suppliers that

accept Molina Healthcare.

– The drugs that are eligible for coverage are determined by the State’s Vendor Drug Program.

– Within the VDP Drug Formulary there is also a Preferred Drug List (PDL) that must be used prior to drugs that are not preferred on the PDL. (STAR and STAR+PLUS only)

– All medications must have a written prescription for member to receive services at the network pharmacy.

– Molina Healthcare will handle all pharmacy inquiries from our members and providers. Examples of inquires include:

• Members’ questions about pharmacy or prescription coverage

• Providers’ claims questions and PA requests; (855) 322-4080, prompt #1.

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http://www.txvendordrug.com/

https://www.txvendordrug.com/formulary/epocrates

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Pharmacy Benefit Manager (PBM)

• CVS/Caremark is Molina Healthcare’s Pharmacy Benefit Manager (PBM).

• CVS/Caremark processes Molina Healthcare’s pharmacy claims.

• CVS/Caremark maintains the pharmacy network for Molina.

• The pharmacies bill CVS/Caremark electronically for the claims at the point of sale.

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Pharmacy Prior Authorization

• Non-Preferred drugs and specialty drugs require a Prior Authorization.

• Prior Authorization requests can be faxed to Molina Healthcare of Texas at 1-888-487-9251

• If a prescribed drug is not found on the Formulary then it is not eligible for coverage. Prior authorization can not be obtained.

• 72 Hour Override Policy • A 72-hour emergency supply of prescribed medication may be dispensed any time a prior

authorization is not available and a prescription must be filled without delay for a medical condition.

• Pharmacies are able to enter an override code (instructions are on the reject messaging and also on the VDP website) if it follows outlined parameters.

• Drugs not on the formulary will NOT be eligible for 72 hour supply or be allowed for prior authorization.

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https://www.molinahealthcare.com/providers/tx/medicaid/drug/Pages/priorauthorizationforms.aspx

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Participating Pharmacies

Molina Healthcare will only pay for prescriptions filled at network pharmacies.• Most in-state pharmacies accept Molina Healthcare.

• HHSC requires that all pharmacies be participants in the Texas VDP network before being allowed entry into Molina’s network.

• Molina Healthcare will not reimburse members for prescriptions filled at non-participating pharmacies – services rendered at these pharmacies are considered not covered.

• It is recommended that if members plan to travel out-of-state, they should fill their prescription drugs before traveling out-of-state.

• To find a network pharmacy please visit :https://providersearch.molinahealthcare.com/Provider

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Behavioral Health

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Behavioral Health Services

• Molina Healthcare of Texas manages all Behavioral Health Services for all Products and Services areas.– Prior Authorization Phone Number –1-866-449-6849

– Prior Authorization Fax Number – 1-866-617-4967

• For questions about Behavioral Health Services, call (855) 322-4080.

• If a member is in a crisis situation, they can call Molina’s 24-hour Behavioral Health Crisis Line at (800) 818-5837.

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Prior Authorizations

• Services rendered by contracted providers that require prior authorization are furnished on the

• CHIP/Medicaid/Medicare Prior Authorization Guide

• Marketplace Prior Authorization Guide– Available at http://www.molinahealthcare.com

• All services rendered by a non-contracted provider, except emergency care and family planning; require prior authorization

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http://www.molinahealthcare.com/providers/tx/medicaid/forms/PDF/pa-pre-service-review-guide.pdf

http://www.molinahealthcare.com/providers/tx/marketplace/forms/PDF/pa-pre-service-review-guide.pdf


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Requesting Prior Authorizations

• Authorizations may be requested via:– Provider Web Portal

– Fax: 1-866-617-4967

– Phone: 1-866-449-6849

• Prior Authorization requests will be processed within regulatory timeframes

• Member name and Member Identification Number

• Diagnosis with the correct ICD code

• Procedure with the CPT, HCPCS code

• Facility name (if applicable) and NPI number

• Specialist or name of attending physician & NPI number

• Clinical information supporting the request

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Behavioral Health Requirements

• Behavioral Health Service Providers are required to refer Members with known or suspected and untreated physical health problems or disorders to their PCP for examination and treatment, with the Member’s or the Member’s legal guardian’s consent

• Behavioral Health Providers must refer members with known or suspected and untreated physical health problems or disorders to their PCP for examination and treatment, with the Member’s or the Member’s legal guardian’s consent. Behavioral Health Providers may only provide physical health care services if they are licensed to do so.

• Behavioral Health Providers must send initial and quarterly (or more frequently if clinically indicated) summary reports of a Members’ behavioral health status to the PCP, with the Member’s or the Member’s legal guardian’s consent

• Providers must ensure that all Members receiving inpatient psychiatric services are scheduled for outpatient follow-up and/or continuing treatment prior to discharge

• The outpatient treatment must occur within seven days from the date of discharge

• Providers must contact Members who have missed

appointments within 24 hours to reschedule appointments

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Complaints & Appeals

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Provider Complaints

• Complaint:A complaint is defined as a verbal or written expression by a provider which indicates dissatisfaction or dispute with Molina’s policies, procedures, claims, or any other aspect of Molina’s functions.

– Complaints are processed for resolution within 30 calendar days of receipt.

– Providers will receive written notice detailing the decision.

– Providers not satisfied with a complaint decision may file an appeal.

• All Complaints must include:

– Provider’s name

– Date of the incident

– Description of the incident

• Timeframes

– An acknowledgement letter is sent within five business days of receipt of the complaint

– A resolution letter is sent within 30 calendar days of receipt of the complaint

• Submit a Provider Complaint to:

– Molina Healthcare of Texas

Attention: Provider Dispute Resolution Department

P.O. Box 165089 • Irving, TX 75016105

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Provider Appeals

• An appeal is the mechanism which allows the right to appeal actions of Molina to a provider who:– Has a claim for reimbursement or a request for authorization of service

delivery denied or not acted upon with reasonable promptness; or

– Is aggrieved by any rules, policies, procedures, or decisions by Molina.

– The provider must file an appeal within 120 days from the date of the complaint resolution letter received from Molina.

• Submit a Provider Appeal to:– Fax 1-877-319-6852

– Molina Healthcare of Texas

Attention: Provider Dispute Resolution Department

P.O. Box 165089

Irving, TX 75016

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• Item 1• Item 2• Item 3 Quality Improvement

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Quality Improvement Philosophy

• Molina Healthcare maintains the following values, assumptions, and operating principles for the Quality Improvement Program (QIP):

– The QIP provides a structure for promoting and achieving excellence in all areas through continuous improvement.

– The QIP aims to define and address the health care and health outcome needs of members that experience a higher burden of multiple chronic illnesses (medical and behavioral), aspects of care and coordination for frail/disabled populations, culturally diverse, and those undergoing multiple care transitions with complex or unresolved needs.

– Improvements are based on industry “best practice” or on standards set by regulators or accrediting organizations.

– The QIP is applicable to all disciplines comprising the health plan, at all levels of the organization.

– Teams and teamwork are essential to the improvement of care and services.

– Data collection and analysis is critical to problem-solving and process improvement.

– Each employee is highly valued as a contributor to quality processes and outcomes.

– Compliance with CMS Standards and the State of Texas regulations demonstrates Molina Healthcare's commitment to quality improvement.

– Information about the QIP is available for members and providers upon request.

– Integration of feedback into Molina’s programs and processes to enhance

QIP success.

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Quality Improvement Program Goals

• Molina Healthcare has defined the following goals for the QI Program:

– Design and maintain programs that improve the care and service outcomes within identified member populations, ensuring the relevancy through understanding of the health plan’s demographics and epidemiological data.

– Define, demonstrate, and communicate the organization-wide commitment to and involvement in achieving improvement in the quality of care, member safety and service.

– Improve the quality, safety, appropriateness, availability, accessibility, coordination and continuity of the health care and service provided to members. Through ongoing and systematic monitoring, interventions and evaluation improve Molina Healthcare structure, process, and outcomes.

– Develop processes to continually measure and improve member and provider satisfaction with Molina Healthcare's services, including medical and behavioral health.

– Use a multidisciplinary committee structure to facilitate the achievement of quality improvement goals.

– Encourage and support a collaborative relationship among members, providers and regulators to promote health management/promotion and wellness education.

– Foster a shared, organization-wide approach to protecting the privacy and security of confidential member and provider information in accordance with State and Federal requirements and accreditation standards.

– Facilitate organizational efforts to achieve CMS, Federal, and Texas regulatory

compliance.

– Facilitate organizational efforts to achieve regulatory compliance 109

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Quality Performance

• Quality Improvement strives to ensure participating providers share Molina’s focus on appropriate care at the right time and that any bonus programs for measuring performance of patient outcomes are:

– Predicted on HEDIS, CAHPS or State-mandated quality bonus metrics;

– Easy to understand and administer; and

– Are administered frequently so providers know where they stand in terms of outcome measurement.

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Provider Assistance with Quality Improvement

• Contracted Providers are responsible for:

– Ensuring Member have timely access to quality healthcare services.

– Assisting and cooperating with medical record reviews.

– Assisting and cooperating with HEDIS data collection.

– Participating in:• Appointment availability surveys

• Provider satisfaction surveys

• Provider orientation and other training activities

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Immunizations

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Immunizations – Medicaid & CHIP

• Providers who administer immunizations must comply with the:

– Immunization Standard Requirements set forth in Chapter 161, Health and Safety Code;

– Advisory Committee on Immunization Practices (ACIP) Immunization Schedule standards;

– AAP Periodicity Schedule for CHIP members; and

– Texas Health Steps Periodicity Schedule for Medicaid members

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• Texas Vaccines for Children (TVFC) Program

– Provides Medicaid and CHIP children who are younger than age 19 with vaccines that are routinely recommended according to the Recommended Childhood Immunization Schedule.

– Medicaid and CHIP providers can enroll, as applicable, as TVFC Providers

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• Medicaid members under age 20 must be immunized during the Texas Health Steps checkup according to the ACIP routine immunization schedule.

– The screening provider is responsible for administration of the immunizations and should not refer children to local health departments to receive immunizations

– An administration fee is paid for each immunization given during a THSteps check up as part of a follow-up claim, except for services performed in a FQHC or RHC setting.

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• DSHS requires children not previously immunized to be given immunizations unless medically contraindicated or excluded from immunizations for reasons of conscience, including religious beliefs.

• It is important for all immunizations to be properly documented in the member’s medical record.

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• ImmTrac

– ImmTrac is a central repository of a child’s immunization record.

• It is a free service offered to medical providers, parents, public health authorities, schools and licensed childcare facilities.

– Texas law requires that medical providers report to ImmTracany vaccines administered to children under age 18 whose parents have consented in writing to participate in the registry.

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Texas Health Steps (THSteps)

– A federally mandated health care program focusing on prevention, diagnosis and treatment.

– Known in Texas as Texas Health Steps (THSteps).

– Known nationally as Early and Periodic Screening, Diagnosis, and Treatment (EPSDT).

– Jointly funded by state and federal funds

– Administered by HHSC/DSHS

– Serves children from birth through age 20.

• Self-referral– Molina Members may self-refer to any participating THSteps provider.

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THSteps Program Goals

• Detect and treat medical and dental concerns for eligible Medicaid clients.

• Provide continuing preventive health care to infants, toddlers, children, adolescents, and young adults.

• Provide appropriate case management.

• Link clients with PCP to establish a Medical Home.

• Link clients with providers for preventive and on-going care.

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THSteps Medical Checkups

• Based on the American Academy of Pediatrics (modified to meet Federal and State requirements)

• AAP Comprehensive assessment

• Purpose– Early detection of health problems

– Offer guidance on a child’s growth and development

– Comprehensive assessment of the infant, child or adolescent

– To detect problems and address before medical/dental problems become more complex

– Make appropriate referrals

– To provide anticipatory guidance to family to encourage healthy behaviors and enhance parenting knowledge of family

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THSteps Medical CheckupComponents

• Federally Mandated Components– Comprehensive Health and Developmental History

– Comprehensive Unclothed Physical Examination

– Immunizations

– Laboratory Screening

– Health Education/Anticipatory Guidance

• State Requirements– Dental referral every 6 months until a dental home is established

• A THSteps medical checkup is only complete if it includes all required components or documentation of why a particular component could not be completed.

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THSteps Timeliness

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Molina actively encourages members to receive timely THSteps checkups.• Criteria for timely THSteps Checkups:

New Members: Newborns within 14 days of enrollment No later than 90 days of enrollment for other eligible children Allowances made to 90-day requirement if documentation of child previously

receiving THSteps checkup through a different provider and the next checkup is not due.

• Existing Members:• For children under 36 months of age, a checkup is defined as timely if

received within 60 days beyond the periodic due date based on their birth date

• For children 36 months or older, a checkup is defined as timely if it occurs within 364 days after the child’ birthday.

• Checkups received before the periodic due date are notreportable as timely medical checkups.

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THStepsPeriodicity Schedule

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Age Range Allowed Number of Checkups

Birth through 11 months(Does not include the newborn or 12 months)

6

12 months through 4 years of age 7

5 though 11 years of age 7

12 through 17 years of age 6

18 through 20 years of age 3

• Children less than 12 months of age: Checkups in this age group occur within two weeks of the due date

based on the child’s date of birth.

• Children 12 months of age or older: Should have a yearly checkup as soon as they become due.

Checkups may be completed anytime after their birthday (timely).

Checkups will not be considered late unless the child does

not have their checkup prior to their next birthday.

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THStepsPeriodicity Schedule

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How does this affect providers?

• More flexibility in scheduling a member’s yearly THSteps

medical checkup.

• Families with more than one child will be able to more

easily schedule checkups at the same time.

• Can more easily avoid scheduling a checkup during flu

season.

• Migrant workers can schedule a checkup prior to or after

returning to their home communities.

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THSteps Checkups -Documentation & Billing

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• To be reimbursed for THSteps checkups, all components

and their individual elements must be documented in the

medical record: Comprehensive health and developmental history which includes nutrition

screening, developmental and mental health screening and TB screening;

Comprehensive unclothes physical examination which includes

measurements; height or length, weight, fronto-occipital circumference, BMI,

blood pressure, and vision and hearing screening;

Appropriate immunizations, as established by the Advisory Committee on

Immunization Practices, according to age and health history, including

influenza, pneumococcal, and HPV;

Appropriate laboratory tests which include newborn screening, blood lead

level assessment appropriate for age (12 and 24 months) and risk factors, and

anemia;

Health education (including anticipatory guidance) and;

Dental referral every six months until a dental home is

established

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THSteps Checkups -Documentation & Billing

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• To be reimbursed for THSteps checkups, all components

and their individual elements must be documented in the

medical record (continued): Quality review activities include:

Random chart review

Focused studies of THSteps medical checkup completeness

• Correct CPT codes are required Codes are available in the Texas Medicaid Provider Procedure

Manual (TMPPM)

• Additional Requirements THSteps Benefit Code: EP1

Codes identifying provider type after completing the physical

Condition Indicators

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THSteps Checkups -Billing & Documentation

• How to bill THSteps: THSteps Medical Checkups:

99381, 99382, 99383, 99384, 99385, 99391, 99392, 99393, 99394, 99395

THSteps Follow-up Visits: 99211

Oral Evaluation and Fluoride Varnish: 99429 with U5 (Note: Must be certified by the State to perform)

Must include diagnosis code V202

Must include benefit code EP1

Must include 2‐digit modifier to indicate practitioner (AM, SA, TD,U7)

FQHC provider must submit using modifier EP for all THSteps medical checkups

RHC providers should file using POS 72

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• Exception to Periodicity

THSteps medical exception-to-periodicity services must be billed with the same procedure codes, provider type, modifier, and condition indicators (NU, ST, S2) as a medical checkup.

Providers must use the following modifiers to indicate the exception:

SC: Medically necessary (developmental delay or suspected abuse) or Environmental high-risk (sibling of child with elevated blood lead)

32: To meet state or federal exam requirements for Head Start, daycare, foster care, or pre-adoption

23: Dental services provided under general anesthesia

Claims for periodic THSteps medical checkups exceeding periodicity that do not include one of these modifiers will be denied as exceeding periodicity.

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THSteps Checkups -Billing & Documentation

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Immunization Administration

• Administration procedure codes 90460, 90461, 90471, 90472, 90473, or 90474 must be submitted on claims.

• Administration procedure codes 90460 and 90461 are benefits for the administration of vaccines and toxoids that require counseling for clients who are birth through 18 years of age.

• Each vaccine or toxoid and its administration must be submitted on the claim in the following order:

– Vaccine or toxoid procedure code

– Administration procedure code(s)

All of the administration procedure codes that correspond to a single vaccine or toxoid procedure code must be submitted on the same claim as the vaccine or toxoid procedure code.

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THSteps Checkups –Children of Migrant Farm Workers

• HHSC Definition of Migrant: “A migratory agriculture worker whose principal employment is in

agriculture on a seasonal basis, who has been so employed within the last twenty four months, and who establishes for the purpose of such employment a temporary abode.”

• Texas Migrant Population* An estimated 200,000 – 300,000 migrant farmworkers reside in Texas

100,000 are children 0-19 years of age

Texas migrant children face higher proportions of dental, nutritional and chronic health problems than non-migrant children

Assessing the health care needs of Texas migrants is difficult due to outdated data sources.

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According to the Migrant Clinicians Network:

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“Migrant” includes: “Migrant” is not:

• Families/dependents of migrant farmworkers

• Persons employed in non-migrant work who have been migrant farmworkers in the past 24 months

• Persons who meet the definition regardless of visa or immigration status

• Persons who may not return the next season but who meet the definition and would otherwise be in Health Disparities Collaboratives

• Necessarily an immigrant• Defined the same way by Migrant

Education or other non-HRSA (Health Resources and Service Administration) agencies

• A non-agricultural worker• A worker with animal farms or

production (eg., dairies, poultry, hogs, canneries, etc.)

• A migratory worker associated with fisheries

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• Barriers to Healthcare Access Language differences

Unreliable transportation

Unfamiliarity with local resources

Legal status/Fear of ramifications

Limited formal education

Lack of funds

No health insurance

No disability or worker’s compensation\

Limited access to Medicaid

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Mobility should not be a barrier for health care access and continuity of care.

• Children, of a migrant farm workers (MFW) who are due for THSteps medical checkup may receive their checkup, on an

accelerated basis, before leaving the area.– A checkup performed under this circumstance is an accelerate

service, but should be billed as a checkup

• Providers should allow children of MFW to obtain THStepsservices expeditiously.

• Performing a make-up exam for a late THStep medical checkup previously missed under the periodicity schedule is considered a late checkup.

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THSteps Checkups –Quick Reference Guide

THSteps medical checkup must include the following:

• Procedure Codes– THSteps Medical Checkups: 99381, 99382, 99383, 99384, 99385, 99391,

99392, 99393, 99394, 99395

– THSteps Follow-up Visit: 99211

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• Performing Provider Modifiers

– AM: Physician

– SA: Nurse Practitioner

– TD: Registered Nurse

– U7: Physician Assistant

• Condition Indicators– NU: Not used (no referral)

– ST: New services requested

– S2: Under treatment

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THSteps Checkups –Quick Reference Guide

Additional components which may be reimbursed on the same day as a medical checkup:

• Oral Evaluation & Fluoride Varnish: 99429 with U5 modifier

• Developmental Screening: 96110

• Autism Screening: 96110 with U6 modifier

• TB Skin Test: 86580

• Point-of-Care Lead Testing: 86580 with QW modifier

Additional THSteps Quick Reference Guide information can be found online at www.TMHP.com.

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THSteps Help

• Help Links:http://www.dshs.state.tx.us/thsteps/links.shtm

• Helpful Information:

http://www.dshs.state.tx.us/thsteps/providers.shtm

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http://www.dshs.state.tx.us/thsteps/links.shtm

http://www.dshs.state.tx.us/thsteps/providers.shtm

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• Item 1• Item 2• Item 3 Questions

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