Transcription
Psychiatric Residential TreatmentFacilities (PRTF) Provider Orientation
The Molina StoryThree Decades of DeliveringAccess to Quality CareMolina Healthcare’s history andmember-focused approach began withthe vision of Dr. C. David Molina, anemergency department physician, whosaw people in need and opened acommunity clinic where caring forpeople was more important than theirability to pay.Today Molina Healthcare serves the diverse needs of 4.5 million plan members andbeneficiaries across the United States through government-funded programs.Molina Healthcare provides NCQA-accredited care and services that focus onpromoting health, wellness and improved patient outcomes. While the companycontinues to grow, we always put people first. We treat everyone like family, just asDr. Molina did – making Molina Healthcare your extended family.2
Molina Healthcare of South CarolinaServing since 20142014MHSC SnapshotBegan serving South Carolina’s Medicaid population in all46 counties.2015Membership: 110,000Employees: 269Statewide MHSC Offices: 220152015Began serving South Carolina’s Dual EligiblepopulationObtained Interim Evaluation Accreditation forNCQA.Began contracting efforts to enter the HealthInsurance Marketplace for 2017. Potential of 15 core(enrollment) counties and 4 border counties.Current Provider Network Details:20172,087 PCPs7,293 Specialists74 Hospitals3
Psychiatric Residential TreatmentFacilities Services (PRTF)4
Behavioral Health Provider InformationAs of July 1, 2017, Molina Health Care will beginmanagement of Psychiatric Residential TreatmentFacilities (PRTF) previously administered bySCDHHS.The following types of service are included forPRFT; psychiatric and psychological sessions,screenings, medication training and support, crisisintervention, alcohol and drug services, monitoringof medical conditions such as diabetes and waiverservices not otherwise specified5
Behavioral Health Changes Psychiatric Residential Treatment Facilitieswill need to contract with each members MCO ifthey are providing PRTF services Psychiatric Residential Treatment FacilitiesServices on or after July 1, 2017 will be coveredwill be covered by the MCO’s6
Why Carve in Behavioral HealthThe coordination of services Ensures both the physical and mental health ofour members are being coordinated andmanaged Prevents duplication of services, medicationissues and poor member outcomes Allows members to receive the full service arrayfrom their chosen Managed Care Organization(MCO)7
Behavioral Health Changes (cont’d.) Members who received medically necessaryservices between 7/1/17 – 7/31/17 will be allowedto continue services with their current provider. Effective 8/1/2017, medically necessary serviceswill need to be authorized through a contractedprovider with Molina Effective dates of service on or after July 1, 2017claims are submitted to Molina for the enrolledmembers8
Molina Health Care of South Carolina ProviderResources9
Provider ServicesSatisfactionCommunicationTechnology Provider representatives, advocates andengagement teams Annual assessment of provider satisfaction Provider Bulletin and Partners in Care newslettersOnline Provider ManualsOnline trainings and Molina Web PortalInteractive Voice Response (IVR) Provider ServiceLine 24-hour Web Portal Electronic Funds Transfer and ElectronicRemittance Advice10
Provider BulletinTo keep you up-to-date on system improvements, process enhancements, requiredguidelines and more, Provider Bulletins are sent to Molina Healthcare’s provider network.Prior authorizationchangesUpdates to the Preferred Drug List (PDL)Provider Bulletin coversthese topics, and moreProvider training opportunitiesChanges in policies that effect claimsubmission, billing procedures or appealsUpdates to the Provider Web Portal11
Provider Online Resources Provider ManualsProvider Online DirectoriesWeb PortalPreventive & Clinical Care GuidelinesPrior Authorization InformationAdvanced DirectivesPharmacy InformationHIPAAFraud, Waste and Abuse InformationFrequently Used FormsCommunications & NewslettersMember Rights & Responsibilities12
www.MolinaHealthcare.com13
www.MolinaHealthcare.com14
Provider /medicaid/manual/Pages/provd.aspx15
Provider Manual and HighlightsMolina Healthcare of South Carolina’s Provider Manual is written specifically to address therequirements of delivering health care services to our members, including your responsibilities as aparticipating provider. Providers may view the manual on our provider website dicaid/PDF/manual sc ProviderHandbook.pdfProvider Manual HighlightsBenefits and Covered Services OverviewInterpreter ServicesClaims, Encounter Data and CompensationMember Grievances and AppealsCompliance and Fraud, Waste and AbuseProgramMember’s Rights and ResponsibilitiesCredentialing and Re-credentialingPreventive Health GuidelinesUtilization Management, Referral andAuthorizationProvider ResponsibilitiesEligibility, Enrollment, and DisenrollmentQuality ImprovementHealth Care ServicesTransportation ServicesHealth Insurance Portability andAccountability Act (HIPAA)Utilization Management, Referral andAuthorization 16
Frequently Used medicaid/forms/Pages/fuf.aspx17
Web er/login18
Register for Web PortalVisit www.MolinaHealthcare.com toregister. You will need the TIN and yourProvider Identification number or three ofthe following: NPI, State License Number,Medicaid Number or DEA Number.Beginregistration Click “NewRegistrationProcess” Select “OtherLines ofBusiness” Select State Select roletype “Facilityor Group” Click “Next”Required fields Enter firstname Enter lastname Enter emailaddress Enter emailaddress againto confirmUsername andpassword Create aunique user IDusing 8-15characters Create auniquepasswordusing 8-12characters Select threesecurityquestions andenter answers 19CompleteregistrationAccept“ProviderOnline UserAgreement”by clicking onthe check box Enter thecode in thetextbox asshown in theimage Click“Register”
Web PortalMolina Healthcare participating providers may register for access to our Web Portalfor self-service functions 24 hours a day, seven days a week, like:Web Portal HighlightsMember eligibility verification andhistoryClaims status inquiryView coordination of benefits (COB)informationView Nurse Advice Line call reports formembersUpdate provider profileView HEDIS missed service alerts formembersView PCP member rosterStatus check of authorization requestsSubmit online service and priorauthorization requestsSubmit claims onlineRegister online at n.20
Web Portal21
Member Eligibility SearchClick Member Eligibility from the main menu. Search for a Member using MemberID, First Name, Last Name and/or Date of Birth. When a match is found, the WebPortal will display the member’s eligibility and benefits page.22
Verifying Member EligibilityMolina Healthcare offers various tools to verify member eligibility. Providersmay 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 hisor her name does not appear on the eligibility roster. If a member doesnot appear on the eligibility roster, please contact Molina Healthcare forfurther verification.Web Portal: nProvider Services Contact Center: (855) 237-617823
Molina Healthcare Medicaid ID Card24
Molina Dual Options ID Cards (MMP)25
Web PortalCreate new or trackpreviously submitted claimsand prior authorizations.Customize your favorites forquick access.26
Web PortalYou can also build claims and submit a batch of claims all at once. Complete a claim following the normal process. Then, instead of submitting, select “Save for Batch.” Claims saved for a batch can be found in the “Saved Claims”section in the side menu. Ready-to-batch claims need to be selected and then can besubmitted all at once.You will still receive an individualclaim number for each claimsubmitted.27
Web PortalEnter Claim IDnumber here.Submit corrected claims or void aclaim through the Web Portal.First select “Create Claim,” thenselect the “Correct Claim” or“Void Claim” feature and enterthe previously assigned Claim IDnumber.28
Claims and Payment Information29
ClaimsPayment MethodologyFacility Services - reimbursed based on flat per diem rate UB Form Facility NPI / Medicaid ID # beginning with RTF General Room and Board ( Semi-Private, Ward) Psychiatric, Psychological sessions, screenings, medication trainings, support, crisisintervention, alcohol and drug services as well as monitoring of medical conditions suchas diabetes and waiver services not otherwise specified POS – 56 Psychiatric Residential Treatment CenterAncillary Services – reimbursed based on FFS rates 1500 Form Group NPI / Medicaid ID # beginning with GP Ancillary Provider Services should be submitted separately on a CMS-1500 claim form. POS -56 If services are rendered at the PRTF POS -11 If services are rendered at the ancillary’s provider's officeNote: Prior Authorization may be required for some Ancillary Services30
ClaimsBillable Codes Effective dates of service on or after July 1, 2017 claims aresubmitted to Molina for the enrolled members using the followingcodes31
Claims Processing StandardsClaims Processing Standards: Claim payment willbe made to contracted providers in accordancewith the provisions set forth in the provider’scontract. Further, payment is subject to thefollowing minimum standards as set forth by SCDHHS.30 days90 days 90 percent of the monthly volume of cleanclaims will be adjudicated within 30 calendardays of receipt by Molina Healthcare. 99 percent of all claims shall be paid or deniedwithin 90 calendar days of receipt by MolinaHealthcare.32
Claims Submission OptionsClearinghouse EDI or electronic claims are processed faster than paper claims Emdeon is the outside vendor used by Molina HealthcareProviders may use any clearinghouse. Note that fees may apply.Use payer ID: 46299Emdeon phone: (877) 389-1160Provider Web Portal Online submission through the Web Portal at www.MolinaHealthcare.comPaper claims directly to Molina Healthcare Attn: Molina Healthcare of South Carolina PO Box 22664, Long Beach, CA 9080133
Claims Customer ServiceCorrected ClaimsEDI Submission IssuesClaims ReconsiderationsCan be submittedthrough theProvider Web Portalor EDICall the EDIcustomer serviceline at (866) 409 2935Use the ClaimsReconsiderationForm on ourwebsiteProviders have 120days from the dateof originalremittance adviceEmail to:EDI.Claims@MolinaHealthcare.comRequests must bereceived within 90days from the dateof originalremittance adviceMail completedform and correctedclaim to: P.O. Box22712, Long BeachCA 90801Contact yourProvider ServicesRepresentativeFor help with any claims related process, contactProvider Services at (855) 237-6178.Fax (877) 901-8182Mail – Attn: PIRRP.O. Box 40309N. Charleston SC29423-030934
Electronic Payments and Remittance AdviceMolina Healthcare partnered with our payment vendor, Change HealthcareProviderNet , for Electronic Funds Transfer (EFT) and Electronic Remittance Advice(ERA). Access to ProviderNet is FREE to our providers. We encourage you to registerafter receiving your first check from Molina Healthcare. Here’s how:Register forProviderNetonline Go to: http://providernet.adminisource.com Click“Register” Accept thetermsVerify yourinformation Select MolinaHealthcarefrom thepayers list Enter yourprimary NPI Enter yourprimary Tax ID Enter recentclaim and/orcheck numberEnter yourUser AccountInformationVerifypaymentinformation Use your emailaddress as theusername Strongpasswords areenforced (eightor morecharacters ofletters/numbers)35 Bank accountand paymentaddress Changes topaymentaddress mayinterrupt EFTprocess Add additionaladdresses,accounts, &Tax IDs afterlogin
Electronic Payments and Remittance AdviceIf you areassociatedwith aclearinghouse Go to“Connectivity”and click the“Clearinghouses”tab Select the Tax IDfor thisclearinghouse Select aclearinghouse (ifapplicable, enteryour TradingPartner ID) Select the FileTypes you wouldlike to send andclick “Save”If you are aregisteredProviderNetuser Log in toProviderNet andclick “ProviderInfo”Click “Add Payer”and select MolinaHealthcareEnter recentcheck number Benefits of ProviderNetAdministrative rights to signup/manage your own EFT accountAbility to associate new providerswithin your organization to receiveEFT/835sView/print/save PDF versions ofyour Explanation of Payment (EOP)Historical EOP search by variousmethods (i.e. claim number,member name)Ability to route files to your FTPand/or clearinghouseIf you have any questions about the registration process, contactProviderNet at (877) 389-1160 or emailProvider.Services@fisglobal.com.36
Utilization Management37
Prior Authorizations (PA)Prior Authorization (PA) 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 Identify care management and disease management opportunities Improve coordination of careRequests for services on the Molina Healthcare Prior Authorization Guide areevaluated by licensed nurses and trained behavioral health staff. A list of servicesand procedures that require prior authorization is in the Provider Manual and onour website at www.MolinaHealthcare.com. (See the “MSC Prior AuthorizationList” on the Policies tab.)38
Prior AuthorizationSimply put: We are looking for enough clinical information tobe able to follow the treating provider’s clinicallogic. Remember this from Medical School?– “If you didn’t write it down, you didn’t do it.”39
Prior Authorization (PA)Information generally required to support decision making includes: Current (up to six months), adequate patient history related to the requested services Progress notes or consultations Any other information or data specific to the requestMolina Healthcare will process all “non-urgent” requests in no more than 14calendar days from the initial request. “Urgent” requests will be processedwithin 72 hours of the initial request. If we require additional information, wewill attempt to contact you (if timeframes allow).Note: Turnaround time for PA’s is far less than 14 days, however, we suggestsubmission of newly needed prior authorizations well in advance of any currentauthorizations’ expiration.In 2015 we processed 13,362 non-urgent PA requests and 3,679 urgent PArequests for Medicaid members with an overall turnaround time compliance rateof 99.8% ( Non Urgent ) and 99.4% (Urgent Request)40
Documenting Medical Necessity A licensed psychologist or a school psychologist certified by the South CarolinaDepartment of Education to perform such evaluations and acting within the scope oftheir competency must certify and document through a Comprehensive PsychologicalAssessment/Testing Report that the beneficiary meets the medical necessity criteriafor services via a DSM or ICD-10 ASD diagnosis.For new beneficiaries receiving ASD services, Psychological Assessments/Testing mustinclude:1. A clinical interview with the beneficiary and/or family members orguardians as appropriate.2. A review of the presenting problems, symptoms and functional deficits,strengths and history, including past psychological assessment reports andrecords.3. Assessments also include a behavioral observation in one or more settings.4. Autism Diagnostic Observation Schedule (ADOS)5. A standardized measure of intelligence (e.g., WISCor WAIS, Stanford-Binet, Bayley Scales, etc.)41
Prior AuthorizationYou can also submit PAs using the PriorAuthorization Request Form on our website atwww.MolinaHealthcare.com under the formstab.Fax the Service Request Forms to theUtilization Management department usingthe numbers listed below, or submit via ourProvider Web Portal.PA Fax #:(866) 423-3889Note: Under Provider information, be sure toindicate: Group Name/Group NPI (TreatmentProvider) Individual Provider NPI/ Group Tax ID (Provider NPI)Web Portal Link in42
Prior AuthorizationPRTF Services Quick ReferenceGuide43
PriorAuthorizationPRTF Services Quick Reference Guide –Continued44
Care Coordination Focused Team for MMP &Medicaid Members Initial and follow-up HealthRisk Assessments Coordination of needs Link Members withCommunity ResourcesRNs & MSWs provide education, coordination and support forSouth Carolina members with complex medical and socialneeds and partner with the member and doctorsComplex CaseManagementCareCoordination High Touch Management Psychiatrist Available Nurses and LCSWsBehavioral HealthCase ManagementHealth &ConditionManagement Health Management forthings like smokingcessation, nutrition, highblood pressure orcholesterol or cancerscreenings Assessment for high-riskpregnancy Disease Managementprograms for Asthmaand Depression Reduce unnecessary ERvisits and readmissionsCare Transitions andCommunity ConnectionsDirect Case Management Referral # (843) 740-177945 Transition from hospitalto home Community Connectorsextend care managementinto the community Nurse Lineavailable 24/7
Molina Reminders46
Access to Care StandardsIn applying access standards, providers agreed they will not discriminate against any memberon the basis of age, race, creed, color, religion, sex, national origin, sexual orientation, maritalstatus, physical, mental or sensory handicap, place of residence, socioeconomic status, orstatus as a recipient of Medicaid benefits. Provider and contracted medical groups may notlimit the practice because of a member’s medical (physical or mental) condition or theexpectation of frequent or high-cost care. If a PCP chooses to close his/her panel to newmembers, Molina Healthcare must receive 30 days advance written notice from the provider.Office Wait Times Not to exceed 30 minutes PCPs are required to monitorwaiting times and adhere tostandardsAfter Hours Care Providers must have backup (oncall) coverage 24/7 May be an answering service orrecorded message Must instruct members with anemergency to hang up and call 911or go to the nearest emergencyroom47
Access to Care StandardsCategoryBehavioral HealthType of CareAccess StandardRoutine CareWithin ten (10) calendar daysUrgent CareWithin forty-eight (48) hoursNon-Life ThreateningEmergencyWithin six (6) hours48
Preferred Drug List (PDL)The Molina Healthcare PDL was created to help manage the quality ofour members’ pharmacy benefit.The PDL is the cornerstone for a progressive program of managedcare pharmacotherapy.Prescription drug therapy is an integral component of yourpatient's comprehensive treatment program.The PDL was created to ensure that members receive high quality,cost-effective and rational drug therapy.The Molina Healthcare of South Carolina PDL is available on our websiteat: www.MolinaHealthcare.com.49
Preferred Drug List The PDL is determined by a National Pharmacy andTherapeutics Committee which meets Quarterly.– Pharmacy staff– Chief Medical Officers– Participating Providers from the Molina Requests for review for additions or changes– Email those to your provider services representative. The SCCMO of Director of Pharmacy will submit to the committee– Please send supporting articles50
PharmacyPrescriptions for medications requiring prior approval or formedications not included on the Molina Healthcare Preferred Drug Listmay be approved when medically necessary and when PDL alternativeshave demonstrated ineffectiveness.When these exceptional needs arise, providers may fax a completedPrior Authorization/Medication Exception Request.PA Fax – Medicaid:(888) 858-3090PA Fax – Medicare:(866) 290-130951
Americans with Disabilities Act (ADA)The ADA prohibits discrimination against people with disabilities, includingdiscrimination that may affect employment, public accommodations (includinghealth care), activities of state and local government, transportation, andtelecommunications. The ADA is based on three underlying values:Compliance with the ADAextends, expands, andenhances the experience forALL Americans accessinghealth care and ensures thatpeople with disabilities willreceive health and preventivecare that offers the same fulland equal access as is providedto n52
HIPAAThe Health Insurance Portability and Accountability Act (HIPAA) requires providers toimplement and maintain reasonable and appropriate safeguards to protect the confidentiality,availability, and integrity of a member’s protected health information (PHI). Providers shouldrecognize that identity theft is a rapidly growing problem and that their patients trust them tokeep their most sensitive information private and confidential.Molina Healthcare strongly supports the use of electronic transactions to streamline healthcare administrative activities. Providers are encouraged to submit claims and othertransactions using electronic formats. Certain electronic transactions are subject toHIPAA’s Transactions and Code Sets Rule including, but not limited to, the following: Claims and encounters Member eligibility status inquiries and responses Claims status inquiries and responses Authorization requests and responses Remittance advicesMolina Healthcare is committed to complying with all HIPAA Transaction and Code Setsstandard requirements. Providers who wish to conduct HIPAA standard transactions withMolina Healthcare should refer to: HIPAA Transactions53
Fraud, Waste & AbuseMolina Healthcare seeks to uphold the highest ethical standards for the provision of healthcare services to its members, and supports the efforts of federal and state authorities in theirenforcement of prohibitions of fraudulent practices by providers or other entities dealing withthe provision of health care services.AbuseProvider practices that are inconsistentwith sound fiscal, business, or medicalpractices, and result in unnecessary coststo the Medicare and Medicaid programs,or in reimbursement for services that arenot medically necessary or that fail tomeet professionally recognized standardsfor health care. It also includes recipientpractices that result in unnecessary costto the Medicare and Medicaid programs.(42 CFR § 455.2)FraudAn intentional deception ormisrepresentation made by a personwith the knowledge that thedeception could result in someunauthorized benefit to himself orsome other person. It includes anyact that constitutes fraud underapplicable Federal or State law. (42CFR § 455.2)Do you have suspicions of member or provider fraud? The Molina HealthcareAlertLine is available 24 hours a day, seven days a week, and even on holidays at54 report anonymously.(866) 606-3889. Reports are confidential, but you may choose to
Examples of Fraud, Waste & AbuseHealth care fraud includes, but is not limited to, the making of intentional false statements,misrepresentations or deliberate omissions of material facts from, any record, bill, claim or anyother form for the purpose of obtaining payment, compensation or reimbursement for services.MemberProvider Lending an ID card to someone who is notentitled to it Altering the quantity or number of refills ona prescription Making false statements to receive medicalor pharmacy services Using someone else’s insurance card Including misleading information on oromitting information from an applicationfor health care coverage or intentionallygiving incorrect information to receivebenefits Pretending to be someone else to receiveservices Falsifying claims Billing for services, procedures or suppliesthat have not actually been rendered Providing services to patients that are notmedically necessary Balance billing a Medicaid member forMedicaid covered services Double billing or improper coding ofmedical claims Intentional misrepresentation of benefitspayable, dates rendered, medical record,condition treated/diagnosed, charges orreimbursement, provider/patient identity,“unbundling” of procedures, non-coveredtreatments to receive payment, “upcoding,”and billing for services not provided Concealing patients misuse of ID card Failure to report patient’s forgery/alterationof a prescription 55
Frequently Used Phone NumbersDEPARTMENTNUMBERPrior Authorizations(855) 237-6178 Fax (866) 423-3889Radiology Authorizations(855) 714-2415 ext. 72Fax (877) 731-7218NICU Authorizations(888) 562-5442 ext. 117453 or 114768Fax (877) 731-7218Pharmacy Authorizations(866) 467-5551 Fax (855) 571-3011Behavioral Health Authorizations(855) 237-6178 Fax (866) 423-3889Member Customer ServiceBenefits/Eligibility(855) 882-3901 TTY/TDD 711Provider Customer Service(855) 237-6178 Fax (877) 901-818224 Hour Nurse Advice LineEnglish (888) 275-8750TTY 711Spanish (866) 648-3537TTY 711Vision CareMarch Vision: (888) 493-4070DentalDentaQuest (888) 307-65528:00 a.m. – 5:00 p.m.8:00 a.m. – 5:00 p.m.Provider Services(855) 237-61788 a.m. to 6 p.m.Monday – FridayMember Services8 a.m. to 6p.m.Monday – FridayTo receive our ProviderBulletin via email, contactSC ProviderServices@MolinaHealthcare.com56
Provider Service Representative(ASD Services)Lisa 80 x 310081 (Office)803-600-2733 (Cell)57
Questions and Comments58
(enrollment) counties and 4 border counties. Molina Healthcare of South Carolina Serving since 2014. Began serving South Carolina’s Medicaid population in all 46 counties. Obtained Interim Evaluation Accreditation for NCQA. Current Provider Network Details: 2,087 PCPs 7,293 Specialists 7
