|
Provider updates & resources from Molina Healthcare of South Carolina
June 2024
| |
Provider Highlights and Important Information | |
|
No Copays or Cost Sharing
In accordance with SCDHHS requirements, Molina Healthcare will move to no copays or cost sharing for all Medicaid, MMP, and DSNP members, effective July 1, 2024.
| |
|
Single Preferred Drug List
Effective July 1, 2024, the South Carolina Department of Health and Human Services (SCDHHS) will implement a single, state-directed pharmacy benefit preferred drug list (PDL) for all providers enrolled in the Healthy Connections Medicaid program. Please click here for the full article from SCDHHS.
| |
|
Prior Authorization Coding Changes
Starting August 1, 2024, Molina is entering into a collaboration with Evolent Health, which will manage the Oncology and Cardiology Quality Management programs and handle specific code reviews on Molina's behalf. The managed codes will be available through the Prior Authorization Code Lookup Tool by clicking here.
Searches will show a note that Evolent provides services for these codes on behalf of Molina.
For questions or concerns regarding changes to the code list, feel free to contact Evolent Health
directly at (888) 999-7713, selecting option 6, or connect with Molina Provider Services at
(855) 237-6178.
| |
|
Prior Authorization (PA) Required for Medicaid Kidney Transplants
Effective Thursday, July 18, 2024, Molina Healthcare will require Prior Authorization (PA) for kidney transplants and related services for Medicaid members.
Please note that Molina does not require PA for corneal transplants as of February 1, 2024, except for specific special needs that arise after the transplant procedure, such as a wheelchair or home health services. PA requirements for all other transplants will remain unchanged.
| |
|
Molina Medicaid Quality Incentive 2024 UPDATE - Comprehensive Well-Care Visit
Molina’s Medicaid Quality Incentive Program offers a $75.00 Incentive Payment (in addition to your current contract rate) for conducting a comprehensive well-care visit for members ages 1-21 years of age.
Claim must include one of each code:
- Well-Care CPT/HCPCS
- Well-Care ICD-10
- G9153 (code required for incentive)
- BMI Percentile ICD-10. BMI Percentile ICD-10 code only required for members ages 3-21 years.
Click here to review all incentive eligibility requirements and billing criteria.
| |
|
Providers Impact Patient Satisfaction
The impact of healthcare providers on patient satisfaction is significant. Patient satisfaction measures how happy a patient is with the care they receive. The outcomes of the patience’s experience and satisfaction are assessed through the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey. It includes all interactions with health care providers, staff, and the physical environment. Some specific composites measured are Rating of Personal Doctor, Rating of Specialist, How Well Doctors Communicate, Getting Needed Care, and Coordination of Care. While patient satisfaction is multi-faceted and influenced by various factors, providers have a significant role to play in delivering quality care and creating a satisfactory healthcare experience.
| |
|
ECHO Remits
Sign up for Providerpayments.com to access your remits. If you have trouble understanding your EOP and locating advances, email SCProvider.Services@MolinaHealthcare.com for our user guide.
| |
|
Provider and Member Rights and Responsibilities
As a contracted provider with Molina Healthcare, all participating providers are expected to adhere to a set of responsibilities. To review these provider responsibilities, please refer to the Molina Healthcare Provider Manual.
For your reference, we have also included Molina’s Member Rights and Responsibilities as a section in the Provider Manual. As a Molina provider, you and your staff agree to follow and comply with Molina’s administrative, medical management, quality assurance, and reimbursement policies and procedures.
| |
|
Provider Manual Summary of Recent Changes
Updates have been made to our 2023 Provider Manuals for Medicaid, Medicare and MMP. Click here to find these changes outlined. You may view these changes at MolinaHealthcare.com.
| |
|
Model of Care
Our Medicare Model of Care training must be completed and attested before 12/31/2024. It can be found on our Medicare home page towards the middle of the page. Your provider rep can send you the training and attestation if needed.
| |
|
Lab Redirection
Our preferred lab is Quest Diagnostics. We have identified some providers who are referring members to out-of-network labs. We will be doing outreach to understand why and help providers understand the importance of referring to Quest or another in-network lab.
| |
|
Appeals Process
Please be sure to check your remits for denial reasons. If a corrected claim is not needed, then file a formal appeal. Instructions can be found in the corresponding product manual. If you still do not agree with the outcome, you may escalate to your Provider Relations representative for further research.
| |
|
Credentialing Updates
Please note that we will no longer accept a SCDHHS Medicaid ID reference number to begin credentialing. A provider must receive a full South Carolina Medicaid ID to proceed with a credentialing application. Check with your rep or our website to ensure you use the latest credentialing forms.
| |
|
Medical Record Review and Supplemental Data Feed
It is HEDIS season. Please be on the lookout for Medicare records requests from Molina. We also offer remote EMR, where we will pull the records for you if you want to explore this option. Supplemental data may be the answer if your Quality Scores are not where they need to be.
| |
|
Medical Director Availability
Our Molina Medical Director can to speak with a provider about any utilization management decision from 8 a.m. to 5 p.m., Monday through Friday, by calling our Provider Relations team at (855) 237-6178. First, select your requested line of business and follow the prompts for “Authorization” to reach the Utilization Management department.
| |
Continuity and Coordination of Provider Communication
Molina stresses the importance of timely communication between providers involved in a member's care. This is especially critical between specialists, behavioral health providers, and the member's PCP. Information should be shared in such a manner as to facilitate communication of urgent needs or significant findings.
| |
General Billing Requirements Reminder
Prior authorized codes/services that are manually priced on the Medicaid Fee Schedule will be reimbursed at 35% of billed charges for covered benefits.
| |
Molina Help Finder
Do you know any members who need help finding basic needs such as housing, food, clothing and job training? Molina Help Finder can help members get connected with the resources they need to help them. Send them to MolinaHelpFinder.com for more information. | |
Access To Care Standards
Molina is committed to providing timely access to care for all members in a safe and healthy environment. Molina will ensure providers offer hours of operation no less than offered to commercial members. Access standards have been developed to ensure that all health care services are provided in a timely manner.
The PCP or designee must be available 24 hours a day, seven days a week, to members for emergency services. This access may be by telephone. Appointment and waiting time standards are shown below. Any member assigned to a PCP is considered his or her patient. Molina may also assist with scheduling preventative health care appointments for our members. All specialty referrals should be coordinated by the primary care provider. To view the latest appointment standards, refer to the Quality section in Molina's Medicaid Provider Manual.
| |
Join Our Email List
Sign up for Molina's provider email list here. Be the first to receive our provider newsletters, news, and updates about Molina services, delivered automatically to your inbox. We will not spam your inbox but just send important information and updates.
For other questions or inquiries regarding this newsletter, please email us at:
| |
Verify Your Fax Number
Molina sends out other important communications to providers by fax. We'd like to ensure we have your most up-to-date fax numbers and information.
| | |
The Molina Communications team produced this e-newsletter, which is designed for South Carolina health care providers. We welcome your feedback, news and ideas for content.
|
|
PO Box 40309
North Charleston, SC 29423-0309
| | |
CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
All summaries of the measures contained herein are reproduced with permission from HEDIS Volume 2: Technical Specifications for Health Plans by the National Committee for Quality Assurance (NCQA).
The information presented herein is for informational and illustrative purposes only. It is not intended, nor is it to be used, to define a standard of care or otherwise substitute for informed medical evaluation, diagnosis and treatment which can be performed by a qualified medical professional. Molina Healthcare, Inc. does not warrant or represent that the information contained herein is accurate or free from defects.
COPYRIGHT NOTICE AND DISCLAIMER
The HEDIS® measures and specifications were developed by and are owned by NCQA. The HEDIS measures and specifications are not clinical guidelines and do not establish a standard of medical care. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures and specifications. NCQA holds a copyright in these materials and can rescind or alter these materials at any time. These materials may not be modified by anyone other than NCQA. Use of the Rules for Allowable Adjustments of HEDIS to make permitted adjustments of the materials does not constitute a modification. Any commercial use and/or internal or external reproduction, distribution and publication must be approved by NCQA and are subject to a license at the discretion of NCQA. Any use of the materials to identify records or calculate measure results, for example, requires a custom license and may necessitate certification pursuant to NCQA’s Measure Certification Program. Reprinted with permission by NCQA. © [current year] NCQA, all rights reserved.
Limited proprietary coding is contained in the measure specifications for convenience. NCQA disclaims all liability for use or accuracy of any third-party code values contained in the specifications.
The American Medical Association holds a copyright to the CPT® codes contained in the measure specifications.
The American Hospital Association holds a copyright to the Uniform Billing Codes (“UB”) contained in the measure specifications. The UB Codes in the HEDIS specifications are included with the permission of the AHA. The UB Codes contained in the HEDIS specifications may be used by health plans and other health care delivery organizations for the purpose of calculating and reporting HEDIS measure results or using HEDIS measure results for their internal quality improvement purposes. All other uses of the UB Codes require a license from the AHA. Anyone desiring to use the UB Codes in a commercial product to generate HEDIS results, or for any other commercial use, must obtain a commercial use license directly from the AHA. To inquire about licensing, contact ub04@aha.org.
| | | | |
