Transcription
Provider Handbook
Molina Healthcare of Florida, Inc. - Provider HandbookTable of ContentsSection 1.Section 2.Section 3:Section 4.Addresses and Phone Numbers .7Member Services Department .7Claims Department .7Claims Recovery Department.7Credentialing Department.8Health Line (24-Hour Nurse Advice Line).8Healthcare Services Department.8Health Education & Health Management Department .9Behavioral Health .9Pharmacy Department.9Provider Services Department. 10March Vision Care . 10DentaQuest. 10Enrollment, Eligibility and Disenrollment . 11Enrollment in Medicaid Programs . 12Express Enrollment . .13Enrollee Plan Changes .13Newborn Enrollment . 13Inpatient at time of Enrollment . 14Eligibility Verification . 14Medicaid Programs. 14Eligibility Listing for Medicaid Programs . 14Disenrollment. 15Disenrollment for No Cause . 16Disenrollment for Good Cause . 16Involuntary Disenrollment . 17PCP Dismissal . 18Missed Appointments . 18PCP Assignment . 19PCP Changes . 19Member Rights & Responsibilities. .19Molina Healthcare Member Rights & Responsibilities Statement . 20Member Responsibilities . 21Benefits and Covered Services . 22Covered Services . 22Transportation. 24Expanded Benefits . 24Child Health Check-Up (formerly EPSDT) . 26Vaccines for Children . 28Immunization Services . 28Eligible Recipients . 29Vaccines for Recipients Birth through (18) Years . 29Vaccines for Recipients (19) through (20) Years . 30Vaccines for Recipients (21) Years and Older . 302
Section 5.Section 6.Section 7.Vaccines Excluded from VFC Program . 31Vaccine for Children Program (VFC). 31Administration Fee Reimbursement . 31Vaccine Reimbursement . 31Child Health Check-Up . 31Evaluation and Management Services . 31Immunization Schedule . 31Procedure Codes and Fees. 31Urgent Care Services . 32(24) Hour Nurse Advice Line . 32Health Education Programs - Healthy Behaviors . 32Disease Management Programs . 33Pregnancy Health Management Program . 33SMMotherhood Matters Program Activities . 34SMAdditional Motherhood Matters Program Benefits: . 34Health Management Programs. 35Breathe with ease . 35Breathe with ease Program Activities:. 35Additional Asthma Program Benefits:. 35Healthy Living with Diabetes . 36The Healthy Living with Diabetes program includes: . 36Transportation . 37Non-Emergency Transportation . 37Provider Responsibilities . 38Access to Care Standards . 38PCP Responsibilities . 39Site and Medical Record-Keeping Practice Reviews . 40Adequacy of Medical Record-Keeping Practices . 41Improvement Plans/Corrective Action Plans . 41Relocations and Additional Sites . 42Compliance Standards . 42Site and Medical Record-Keeping Practice Guidelines. 42Facility. 42Safety. 43Administration & Confidentiality . 43Medical Record-Keeping Practices . 44Medical Record Documentation . 44Medical Record Retention . 44Confidentiality of Medical Records . 45Site Review Nurse (SRN) . 45Compliance Standards . 45Medical Record Documentation Includes: . 45Medical Record Standards . 45Newborn Notification Process . 48Reporting Abuse, Neglect and Exploitation . 48Member Information and Marketing. 49Medical Management . 52Utilization Management – Prior Authorization Process . 52Referral versus Prior Authorization . 52Wrong Site Surgery . 543
Section 8.Section 9.Section 10.Section 11.Avoiding Conflict of Interest . 54Coordination of Care . 54Continuity of Care . 55Continuity and Coordination of Provider Communication . 55Case Management . 55PCP Responsibilities in Case Management Referrals . 57Case Manager Responsibilities . 57Health Education and Disease Management Programs . 57Emergency Services. 57Medical Necessity Standards . 58Quality Improvement .58Quality Improvement Program Goals . 58Preventive Care and Clinical Practice Guidelines . 59Measurement of Clinical and Service Quality:. 60HEDIS . 60 CAHPS . 61Provider Satisfaction Survey . 61Effectiveness of Quality Improvement Initiatives . 62Quality Enhancement Program . 63Claims. 65Claim Submission . 65NPI Requirement . 66Electronic Claim Submissions . 66Timely Claim Filing . 66Timely Claim Processing . 67Fraud and Abuse . 67Claim Editing Process . 68Coordination of Benefits and Third Party Liability . 68COB: . 68TPL: . 68Overpayments and Incorrect Payment Refund Requests . 69Billing the Member . 69Encounter Data. 69Hospitals . . 71Emergency Services. 71Post-Stabilization Care Services . 73Admissions . 73Newborn Reporting Requirements . 73Claims Submission . 73Claim Editing Process . 75Overpayments and Incorrect Payments Refund Requests . 75Billing the Member . 76HIPAA . 77HIPAA (The Health Insurance Portability and Accountability Act) . 77Molina Healthcare’s Commitment to Patient Privacy . 77Provider/Practitioner Responsibilities . 77Applicable Laws . 77Uses and Disclosures of PHI . 78Written Authorizations . 78Patient Rights . 794
Section 12.Section 13.Section 14.Section 15.HIPAA Security . 79HIPAA Transactions and Code Sets . 80National Provider Identifier . 80Additional Requirements for Delegated Providers/Practitioners . 81Fraud, Waste and Abuse . 81Regulatory Requirements . 81Federal False Claims Act . 81Florida False Claims Act . 82Deficit Reduction Act . 82Examples of Fraud, W aste and Abuse by a Provider . 83Review of Provider . 84Provider Profiling . 85Provider/Practitioner Education . 85Review of Provider Claims and Claims System . 85Cooperating with Special Investigation Unit Activities . 85Reporting Fraud, W aste and Abuse . 86Credentialing . 87Level II Background Screening. 87Site Review. 88Professional Review Committee (PRC) . 88Verification and Approval. 89Re-credentialing . 89Provider’s Right to Review . 90Provider’s Right to Notification and Correction of Erroneous Information . 90Providers Right to be Informed of Application Status . 91Corrective Action, Fair Hearing Plan, and Reporting to the Florida Division of Medical QualityAssurance, Department of Health (Licensing Board) and the NPDB: . 91Complaints, Grievance and Appeals Process. 91Member Complaints, Grievance & Appeals Process . 91Expedited Appeal . 94Reporting . 94Record Retention. 94Second Opinion . 94Provider Complaints . 94Provider Disputes . 95Medical Group/IPA Operations .96Delegation of Administrative Functions .96Delegation Criteria .965
Credentialing.96Additional Requirements for Delegated Providers/Practitioners .97Utilization Management .97Claims.98Quality Improvement/Preventive Health Activities:.99Delegation Reporting Requirements .99Section 16. Cultural Competency . 100Provider and Community Training . 100Communication Access . 101Program and Policy Review Guidelines . 101Glossary of Terms . 102
Section 1. Addresses and Phone NumbersMember Services DepartmentThe Member Services Department handles all telephone and written inquiries regarding Member claims,benefits, eligibility/identification, selecting or changing Primary Care Providers (PCPs), and Membercomplaints. Member Services Representatives are available 8:00 AM to 7:00 PM EST/EDT Mondaythrough Friday, excluding State holidays.Member ServicesAddress:Molina Healthcare of Florida8300 NW 33rd Street, Suite 400Doral, FL 33122Phone:(866) 472-4585TTY:(800) 955-8771 (English)(800) 955-8773 (Spanish)Claims DepartmentThe Claims Department is located at our corporate office in Long Beach, CA. All hard copy (CMS-1500, UB04) claims must be submitted by mail to the address listed below. Electronically filed claims must useEmdeon EDI Claims/ Payor ID number - 51062. To verify the status of your claims, please call our ProviderClaims Representatives at the numbers listed below.ClaimsAddressMolina Healthcare of FloridaPO BOX 22812Long Beach, CA 90801Phone:(866) 472-4585Claims Recovery DepartmentThe Claims Recovery Department manages recovery for overpayment and incorrect payment of claims.Claims RecoveryAddressMolina Healthcare of FloridaPO BOX 22812Long Beach, CA 90801Phone:(866) 472-45857
Credentialing DepartmentThe Credentialing Department verifies all information on the Practitioner Application prior to contracting andre-verifies this information every three years. The information is then presented to the Professional ReviewCommittee to evaluate a Provider’s qualifications to participate in the Molina Healthcare network. TheCredentialing Department also performs office and medical record reviews.CredentialingAddress:Molina Healthcare of Florida8300 NW 33rd Street, Suite 400Doral, FL 33122Phone:(866) 472-4585Fax:(866) 422-6445Health Line (24-Hour Nurse Advice Line)This telephone-based nurse advice line is available to all Molina Healthcare Members. Members may callanytime they are experiencing symptoms or need health care information. Registered nurses are available(24) hours a day, seven (7) days a week to assess symptoms and help make good health care decisions.HEALTHLINE(24-Hour Nurse Advice Line)English Phone:Spanish Phone:TTY:(888) 275-8750(866) 648-3537(866) 735-2929 (English)(866) 833-4703 (Spanish)Healthcare Services DepartmentThe Healthcare Services Department conducts concurrent review on inpatient cases and processesPrior Authorization requests.Healthcare ServicesAuthorizations & Inpatient CensusAddress:Molina Healthcare of Florida8300 NW 33rd Street, Suite 400Doral, FL 33122Phone:Fax:(866) 472-4585(866) 440-4791 (Medicaid)(866) 472-9509 (Florida Medicare)8
Health Education & Health Management DepartmentThe Health Education and Health Management Department provides education and health information toMolina Healthcare Members and facilitates Provider access to the programs and services.Health Education & ManagementAddress:Molina Healthcare of Florida8300 NW 33rd Street, Suite 400Doral, FL 33122Phone:(866) 472-4585Fax:(866) 422-6445Behavioral HealthPsychcare manages all components of behavioral health for Molina Healthcare Members.PsychCare*Medicaid Regions 4, 6, 7, 8, 9, and 11Address:PsychcareAccess Behavioral Health*Medicaid Region 1Address:Access Behavioral HealthAttn: Claims Department10200 Sunset DriveMiami, FL 33173Phone:Attn: Claims Department1221 W. Lakeview AvenuePensacola, FL 325011-855-371-3945Phone:(24) Hours per day, (365) day per year1-866-477-6725(24) Hours per day, (365) day per yearPharmacy DepartmentMolina Healthcare’s drug formulary requires Prior Authorization for certain medications includinginjectable medications. The Pharmacy Department can answer questions regarding the formularyand/or drug Prior Authorization requests. They will a
Miami, Florida 33122 Phone: (888) 493-4070 Phone: (855) 373-7627 DentaQuest Molina Healthcare is contracted with DentaQuest to provide dental services for our Members. Members who are eligible may directly access DentaQuest network Providers. DentaQuest Address:
