Thank you for joining the Molina Healthcare of Wisconsin 2018 … · 2019-01-12 · Thank you for...
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Thank you for joining the Molina Healthcare of Wisconsin 2018 Provider Orientation. Please hold as we wait for additional participants to join. We will begin shortly. As a courtesy to others please ensure you mute your phone. 1
Transcript of Thank you for joining the Molina Healthcare of Wisconsin 2018 … · 2019-01-12 · Thank you for...
Thank you for joining the Molina Healthcare of Wisconsin 2018 Provider Orientation.
Please hold as we wait for additional participants to join.
We will begin shortly.
As a courtesy to others please ensure you mute your phone.
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Molina Healthcare Provider Responsibilities Contracting/Credentialing Provider Resources Provider Web Portal Member Information Prior Authorization Claims Timely Filing Limits ERA/EFT Additional Resources
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Orientation Overview
Molina Healthcare
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A leader in health care!Molina Healthcare, a FORTUNE 500, multi-state health care organization, arranges for the delivery of health care services and offers health information management solutions to nearly five million individuals and families who receive their care through Medicaid, Medicare and other government-funded programs in fifteen states.
Molina Healthcare
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Providers contracted with Molina cannot bill the Member for any covered benefits. The Provider is responsible for verifying eligibility and obtaining approval for those services that require prior authorization.
Providers agree that under no circumstance shall a Member be liable to the Provider for any sums owed by Molina to the Provider
Provider agrees to accept payment from Molina as payment in full, or bill the appropriate responsible party
Provider may not bill a Molina Member for any unpaid portion of the bill or for a claim that is not paid with the following exceptions:
• The Member has been advised by the Provider that the service is not a covered benefit and the Provider has documentation.
• The Member has been advised by the Provider that he/she is not contracted with Molina and has documentation.
• The Member agrees in writing to have the service provided with full knowledge that they are financially responsible for payment.
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Provider Responsibilities
Access to Care Standards:Molina appreciates the care that you provide to our members.
• Access standards have been developed to ensure that all health care services are provided in a timely manner. The PCP or designee must be available twenty-four (24) hours a day, seven (7) days a week to Members for Emergency Care services.
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Provider Responsibilities Continued…
Fraud, Waste, and Abuse:
Molina Healthcare of Wisconsin ("Molina") supports the highest ethical standards for providing healthcare benefits and services to its members. Molina supports the work of federal and state authorities to prevent fraud, waste and abuse by providers. This includes those who help with providing healthcare services.
Definitions:• “Abuse” means acts that do not meet sound fiscal, business or medical practices. These acts result in needless cost
to the Medicaid or Medicare programs. They may result in payment for services that are not medically needed. They may also fail to meet the bet standards for health care. It also includes acts by members that cause needless cost to the Medicaid or Medicare programs.
• "Fraud" means a planned deception or false account of information. It is fraud when a person knows that the deception could result in illegal benefit. The illegal benefit might be for himself or another person. It includes any act that is defined as fraud under Federal or State law.
• "Waste" is health care spending that can be stopped without reducing the quality of care.
Health care fraud includes, but is not limited to, making intentional false statements. False statements include false accounts or purposely leaving out material facts from records used for billing. Records include any record, bill, claim or any other form to obtain payment for health care services.
Failure to report instances of suspected Fraud and Abuse is a violation of the Law and subject to the penalties provided by Law
Report Fraud, Waste and Abuse to Molina Healthcare:• (866) 606-3889• https://molinahealthcare.AlertLine.com
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Provider Responsibilities Continued…
Contracted providers are an essential part of delivering quality care to our members. Molina Healthcare of Wisconsin values our provider partnerships and supports the doctor-patient relationship our members share with you.
If you are not currently a Molina Healthcare provider, but are interested in contracting with us, please submit a:
• Non-Par Provider Contract Request Form
• W-9 Form
Send completed forms to:
• Provider Contracting: [email protected]
• Fax: (877) 556-5863
Contracting takes up to 60 days, once completed you will receive a welcome packet with an executed contract.
If you have questions or concerns, please call Molina Healthcare Provider Services at (888) 999-2404
***Forms are located on the Molina Healthcare website
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Provider Contracting
The purpose of the Molina Healthcare of Wisconsin (MWI) credentialing program is to ensurethat the MWI provider network consists of quality health care practitioners who meet definedcriteria and standards. It is the objective of MWI to provide superior health care to thecommunity.
The credentialing program has been developed in accordance with standards of the NationalCommittee for Quality Assurance (NCQA).
The decision to accept or deny an applicant is based on the recommendation of the MWI MedicalDirector and MWI Professional Review Committee. The information gathered is confidential anddisclosure of information is limited to the parties providing application processing and peerreview functions.
Once a Provider or facility is approved for participation in Molina Healthcare’s network, re-credentialing will be performed every three years.
If a practitioner meets any one of the following criteria, Molina does not require them to becredentialed:
– Practitioners who practice exclusively within the inpatient setting and who providecare for Molina members only as a result of members being directed to the hospital orother inpatient setting
– Practitioners who practice exclusively within freestanding facilities and who providecare for Molina members only as a result of members being directed to the facility, won't have clinical contact with members, or doesn't have an independent relationship w/ Molina.
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Provider Credentialing
Providers required to credential:
Molina requires credentialing for the following specialties:
• Advanced Registered Nurse Practitioners (ARNP)- Nurse Practitioners• Agencies (Home Health, Hospice and PCW)• Audiologists• Behavioral Health Care Practitioners (Master’s Level)• Certified Nurse Midwife• Chiropractors (DC)• Dentists• Occupational Therapists (OT) (Practicing independent of a hospital)• Optometrists (OD) • Oral Surgeons (DDS)• Physical Therapists (PT) (Practicing independent of a hospital) • Physicians (MD, DO)• Podiatrists (DPM) • Psychologists (Ph.D., Psy.D.) • Social Workers (Clinical/ Licensed) • Speech Language Pathologists• Physicians that work at Urgent Care Facilities
***This list may not be all inclusive, contact Provider Services for any questions
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Provider Credentialing Continued…
A new practitioner, even though the office is participating with Molina, should not see Molina members until theyare credentialed and receive a notification letter stating the credentialing process is complete.
• Individual Practitioner Credentialing:– If you have a CAQH number
• Complete the Molina Healthcare of WI CAQH Credentialing Checklist– If you do not have a CAQH number
• Complete the Molina Healthcare of WI Practitioner Application
• Facility Credentialing:– If you are a Hospital, Ambulatory Surgical Center, Home Health Agency, Personal Care Worker Agency,
DME Supplier, SNFs, or Urgent Care Center• Complete the Molina Healthcare of WI Health Delivery Organization (HDO) Application
Forms are located on the Molina Healthcare website under forms – frequently used forms – Credentialing:http://www.molinahealthcare.com/providers/wi/medicaid/forms/Pages/fuf.aspx
Failure to provide/return requested information within the specified time will result in automatic suspension and/or termination from the Molina Healthcare network as a non-compliant Provider.
Send completed applications to:Molina Healthcare of Wisconsin
Attn: Credentialing 11200 West Parkland Ave.
Milwaukee, WI 53224-3127Fax: 414-214-2481
Email: [email protected]
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Provider Credentialing Continued…
Headline Goes HereProvider Resources
• Provider Manual• Provider Online Directories• Provider Portal• Frequently Used Forms• Preventive & Clinical Care Guidelines• Prior Authorization Information• EDI/EFT/ERA Information• Advanced Directives• Model of Care Training• Pharmacy Information• HIPAA• Fraud, Waste & Abuse Information• Communications & Newsletters• Member Rights & Responsibilities• Training• Contact Information
https://Molinahealthcare.com
Molina’s Provider Web Portal is an easy-to-use online tool designed to meet all your needs!
• Easily search for Member details, eligibility status , covered benefits , missed services information
• Create, submit, correct and void claims, submit attachments and receive notifications of status changes
• Submit Claim Appeals
• Inquire on current claim status and print your claims
• You can also quickly download claims reports and create claim templates with commonly used fields pre-populated Create
• Submit and print Service Requests/Authorizations with notification of status changes
• View Service Request approval status
• PCP Rosters
• Track required HEDIS® services for Members and compare your HEDIS® scores with national benchmarks
• View Member Personal Health Record
• Send secure email messages to the Member's Care Management team
• available for MMP/Dual Members only
• Access account information, manage and add users and update your profile
To sign up, go to: https://Provider.MolinaHealthcare.com
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Provider Web Portal
Registration is easy as 1, 2, 3!
Go to https://Provider.MolinaHealthcare.com Click on the “Register now” link under the Provider Web Portal Login box. Under Admin User Responsibility, select “To continue with registration, click here” and you will be
taken to the registration page
1. Select your Line of Business
2. Select your Provider Type• Facility/Group can be used by any Provider, including solo practitioners
• This registration type allows users to submit claims and service request/authorizations• Provider is registered only as a Facility/Group, they will be limited to information for
that registered group only• Individual Physician is recommended for use when a Provider does not need to submit new or
corrected claims • Providers who participate with multiple provider groups and want to see information
pertaining to each group should register with the Individual Physician type
3. Tax ID Number & Molina Provider ID • If you do not know your Provider ID contact: [email protected]
***Refer to the Web Portal Quick Reference Guide for step by step instructions
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Provider Web Portal Registration
Molina Healthcare Members are issued one membership card, identified as a ForwardHealth card. The card is not dated, nor is it returned when a Member becomes ineligible.
– Providers can see any member regardless of PCP assignment
***Possession of a Member identification card does not guarantee that the Member is eligible for benefits
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Member ID Card
Providers are strongly encouraged to check Member eligibility frequently as member eligibility changes occur frequently.
To facilitate reimbursement for services, providers are strongly advised to verify a Member's eligibility upon admission to treatment and on each subsequent date of service.
How to verify member eligibility:
• Provider Contact Center: (855)326-5059
• Interactive Voice Response (IVR) System: (888)999-2404
• Via the Provider Web Portal
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Member Information
A list of services/procedures requiring prior authorization is located on the Molina website under forms - frequently used forms – Prior Authorization - 2018 Prior Authorization/Pre-Service Review Guide
• The list updated quarterly and should be checked for updates
Molina Healthcare does not require Referrals, however, the member must use an in-network provider
• All non par providers, facilities, and labs require prior authorization on all services
Request for New Authorization:• Submit via the provider portal
• The Service Requests/Authorizations page has 4 functionalities: 1. Service Requests/Authorizations Status Inquiry2. Create Service Requests/Authorizations 3. Open Incomplete Service Requests/Authorizations 4. Create Service Request/Authorization Templates
OR• Complete the Prior Auth/Pre-Service Review Form
• Located on the Molina website under forms - frequently used forms – Prior Authorization
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Prior Authorization
Approval Process:The Urgent/Expedited service request designation should only be used if the treatment is required to prevent serious deterioration in the member’s health or could jeopardize the enrollee’s ability to regain maximum function.
• Molina Healthcare will process any non-urgent requests within 14 business days of receipt of request. Urgent requests will be processed within 72 business hours
• Urgent behavioral health authorizations will be processed within 24 business hours. Routine BH requests will be handled within 14 business days with a goal of handling them within 5 business days. Processing time includes weekends
• Pharmacy prior authorization requests will be processed with 14 business days for routine requests and within 24 business hours for urgent requests
Emergency Services:Emergency service are covered on a 24-hour basis without the need for prior authorization for all members experiencing an emergency medical situation
For members within our service area, Molina Healthcare contracts with vendors that provide 24-hour emergency services for ambulance and hospitals
In the event that our member is outside of the service area, we are prepared to authorize emergency treatment and services to ensure that the patient is stabilized
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Prior Authorization
Molina supports our Providers, and as such would like to highlight the many benefits of electronic claims submission that will have direct impact on your time! EDI will help:
• Efficient information delivery• Reduce operational costs associated with paper claims (printing, correlating, and postage)• Increase accuracy of data• Ensure HIPAA compliance
Molina offers the following electronic Claims submission options at no cost:
1. Online Submission via the Provider Portal: https://Provider.MolinaHealthcare.com• Reach out to [email protected] if you do NOT have your
Provider ID 2. Clearing House (Change Healthcare):
• Change Healthcare is an outside vendor that is used by Molina Healthcare• When submitting claims (via a clearinghouse) to Molina Healthcare, please utilize the
following payer ID ABRI1.
Molina Healthcare of Wisconsin requires month to month billing with appropriate rev code, HCPCS codes and billing for each single service line per date of service
***Molina Healthcare will adjudicate each clean claim no later than forty five (45) working days after receipt.
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Claims Molina is Green!
Molina Healthcare has a claims pre-payment auditing process that identifies frequent billing errors such as but not limited to:
• Bundling and unbundling coding errors
• Duplicate claims
• Services included in global care
• Incorrect coding of services rendered
All denials related to coding edits must be appealed.
• Submit the appeal & accompanying documentation via:
• Fax: 844-254-1446
• Provider Portal: MolinaHealthcare.com
• Email: [email protected]
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Claims Editing Process
Molina’s Provider Portal includes functionality to submit Institutional and Professional claims:
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Claims Continued…
Corrected Claims must be submitted electronically with the appropriate fields on the 837I or 837P completed.
Corrected claims must include the correct coding to denote if the claim is Replacement of Prior Claim or Corrected Claim for an 837I or the correct Resubmission Code for an 837P.
EDI (Clearinghouse) Submission: 837P
• In the 2300 Loop, the CLM segment (claim information) CLM05-3 (claim frequency type code) must indicate one of the following qualifier codes:
– “1”-ORIGINAL (initial claim) – “7”–REPLACEMENT (replacement of prior claim)– “8”-VOID (void/cancel of prior claim)
• In the 2300 Loop, the REF *F8 segment (claim information) must include the original reference number (Internal Control Number/Document Control Number ICN/DCN).
837I • Bill type for UB claims are billed in loop 2300/CLM05-1.
– In Bill Type for UB, the “1” “7” or “8” goes in the third digit for “frequency”• In the 2300 Loop, the REF *F8 segment (claim information) must include the original
reference number (Internal Control Number/Document Control Number ICN/DCN)
***Corrected claims MUST also include the original claim number ***Claims submitted without the correct coding will be returned to the Provider for resubmission
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Corrected Claims via Clearing House
Molina’s Provider Portal includes functionality to submit corrected Institutional and Professional claims:
Click on Corrected Claim
Enter the original claim number
Correct information on claim
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Corrected Claims via Provider Web Portal
All appeals must be submitted via E-mail or fax
Providers must file an appeal regarding all provider claim disputes
• A claim dispute is defined as any denied service, incorrect payment, administrative, claim denials, etc.
• If the case is not appealed within the applicable timeframe, it will be denied for untimely filing
Molina Healthcare of Wisconsin will review the case for medical necessity and conformity to Molina Healthcare guidelines. Appeals lacking necessary documentation will be denied.
When submitting an appeal:
• Complete the appeal form
• Supply specific, pertinent documentation that supports the appeal
• Include all medical records that apply to the service
• Submit the appeal & accompanying documentation via:
• Fax: 844-254-1446
• Provider Portal: MolinaHealthcare.com
• Email: [email protected]
Upon review of the appeal, Molina Healthcare will either reverse or affirm the original decision and notify the provider within 60 days.
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Claim Appeals/Disputes
Claims Timely filing:• PAR Providers: 180 days from date of service unless otherwise
indicated in your provider contract,
• Non PAR Providers: 365 days from the date of service
• Primary Ins: 180 days from the date on the remit from the primer payer unless otherwise indicated in your provider contract
Claims Appeals timely filing: • 90 days
Authorization Timely filing: • Prior to services being rendered (Molina will not backdate)
Corrected Claims timely filing: • 180 days from the date of service unless otherwise stated in your
provider contract
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Timely Filing Limits
Participating providers are required to enroll for Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA). Providers who enroll in EFT payments will automatically receive ERAs as well.
Molina supports our providers, and as such would like to highlight the many benefits ERA/EFT:
• Providers get faster payment (processing can take as little as 3 days from the day the claim was submitted)
• Providers can search for a historical Explanation of Payment-EOP (aka Remittance Advice) by claim number, member info, or provider info
• Providers can view, print, download and save a PDF version of the Explanation of Payment for easy reference with no paperwork to store
• Providers can have files routed to their ftp and/or their associated clearinghouse.
• There is no cost to the provider for EFT enrollment, and providers are not required to be in-network to enroll
Molina has partnered with Change Healthcare for Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA). Access is FREE for participating providers
• Go to https://secure.adminisource.com/Login.aspx to register after getting first paper check from Molina Healthcare
• Contact your Provider Service Rep if you have any questions about the registration process
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ERA/EFT
Provider Services:
A Provider Service Representative is here to support you with:
• Plan guidelines, polices, and procedures
• Assistance with claims submission and claims payment issues
• Assistance with authorization and status
• Questions regarding contracting and credentialing a new provider or making a change to existing provider in your group
• EDI/ERA/EFT
• Healthcare updates and education
• Provider office staff education and onsite visits
• Provider Web Portal training
• Provider Newsletters and other communications
• Provider satisfaction surveys
• And much more…
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Additional Resources
Important links:
• Molina Healthcare website: https://Molinahealthcare.com
• Provider Services General e-mail: [email protected]
• Provider Contracting e-mail : [email protected]
• Provider Credentialing e-mail : [email protected]
• Provider EFT/ERA website: https://secure.adminisource.com/Login.aspx
• Provider Appeals e-mail : [email protected]
• ForwardHealth website: https://www.forwardhealth.wi.gov/WIPortal/
Important Contact Numbers:
• Provider Contact Center: (855) 326-5059
• Member Service Department/IVR: (888)999-2404
• Web Portal Help Desk: (866) 449-6848
• TTY: (800) 866-4889
• Fax: (877) 556-5863
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Additional Resources Continued…
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Questions and Comments
