Transcription
Provider ManualMolinaHealthcare ofFlorida, Inc.12/2011
8300 NW 33rd Street, Suite 400Doral, FL 33122Phone:(866) 472-4585Fax:(866) 422-6445Dear Provider:I would like to extend a personal welcome to Molina Healthcare of Florida, Inc. Enclosed is your MolinaHealthcare Provider Manual, written specifically to address the requirements of delivering health careservices to Molina Medicaid members.This manual is designed to provide you with assistance in all areas of your practice, from makingreferrals to receiving payment for your services. In some cases, you may have developed internalprocedures that meet the standards set out in this manual. In these instances you do not need tochange your procedures - as long as they adhere to the standards outlined in this manual.Also included are samples of the forms needed to fulfill your obligations under your Molina Healthcarecontract. The sample forms are included to illustrate what is needed for appropriate documentation.From time to time we will need to update and revise this manual as our policies or regulatoryrequirements change. All changes will be sent to you as additions to or deletions from this manual. Yousimply need to replace old pages with the new ones.Thank you for your active participation in the delivery of quality health care services to our membersand we look forward to a long and mutually rewarding experience.Sincerely,David PollackPresidentMolina Healthcare of Florida, Inc.Page 2 of 120
Molina Healthcare of Florida, Inc. - Provider ManualTable of ContentsSection 1.Addresses and Phone Numbers. 7Section 2.Enrollment, Eligibility and Disenrollment. 12Member 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 .9March Vision Care .10ADI, Doral Dental .10TRS, Therapy Review Systems .10Molina Healthcare of Florida, Inc. Service Area.11Enrollment:.12Enrollment in Medicaid Programs: .12Effective Date of Enrollment: .13Newborn Enrollment: .14Inpatient at time of Enrollment: .14Eligibility Verification: .15Medicaid Programs: .15Eligibility Listing for Medicaid Programs .15Identification Cards: .16Disenrollment: .17Involuntary Disenrollment: .19PCP Dismissal: .19Missed Appointments:.19PCP Assignment.20PCP Changes: .20Section 3: Member Rights & Responsibilities. 21Molina Healthcare Member Rights & Responsibilities Statement.21Section 4.Benefits and Covered Services: . 23State Children’s Health Insurance Plan – Florida Kidcare (Kidcare): .23Child Health Check-Up (formerly EPSDT) .23Vaccines for Children.25Urgent Care Services.28(24) Hour Nurse Advice Line.28Enhanced Benefit Rewards Program (Reform County Broward).29Member Information and Marketing .29Disease Management Programs .30Pregnancy Health Management Program.31Motherhood Matters SM Program Activities:.31Additional Motherhood Matters SM Program Benefits: .32Health Management Programs .3312/2011
Breathe with ease .33Breathe with ease Program Activities: .33Additional Asthma Program Benefits: .33Healthy Living with Diabetes .34The Healthy Living with Diabetes program includes: .34Reform County only .35Non Reform.35Section 6.Provider Responsibilities . 36Section 7.Medical Management. 48Section 8.Quality Improvement . 56Section 9.Claims . 62Access to Care Standards .36Improvement Plans/Corrective Action Plans.37Site and Medical Record-Keeping Practice Reviews.37Adequacy of Medical Record-Keeping Practices.38Newborn Notification Process .38Relocations and Additional Sites .38Compliance Standards.38Site and Medical Record-Keeping Practice Guidelines .38Facility .38Safety .39Administration & Confidentiality .39Medical Record-Keeping Practices.39Medical Record Documentation.40Confidentiality of Medical Records.40Site Review Nurse (SRN) .41Compliance Standards.41Medical Record Documentation Includes: .41Medical Record Standards.42Pediatric Standards.45Adults Standards.46Medical Records Review Tool .47Utilization Management – Referral Process.48Referral versus Prior Authorization: .48Wrong Site Surgery:.49Avoiding Conflict of Interest .50Coordination of Care .50Continuity of Care .50Continuity and Coordination of Provider Communication .51Case Management.51PCP Responsibilities in Case Management Referrals:.52Case Manager Responsibilities: .52Health Education and Disease Management Programs: .52Emergency Services .52Medical Necessity Standards.53CareMark Specialty Pharmaceuticals .53Quality Improvement Program Goals.56Preventive Care and Clinical Practice Guidelines.57Measurement of Clinical and Service Quality: .57HEDIS .58CAHPS .58Provider Satisfaction Survey.58Effectiveness of Quality Improvement Initiatives .59Quality Enhancement Program: .60Claim Submission .62Fraud and Abuse .6412/20114 Page
Claim Editing Process .64Coordination of Benefits and Third Party Liability .65COB: .65TPL: .65Claim Corrections/Adjustments.65Fraud and Abuse .66Overpayments and Incorrect Payments Refund Requests .66Billing the Member .66Encounter Data .67Section 10.Hospitals . 68Emergency Care .68Admissions.68Newborn Reporting Requirements.68Claims Submission .68Claim Editing Process .70Claim Corrections/Adjustments.70Overpayments and Incorrect Payments Refund Requests .71Billing the Member .71Section 11Florida Fraud and Abuse. 72Definitions: .72Federal False Claims Act, 31 USC Section 3279 .72Deficit Reduction Act.72Health care fraud is: .74Examples of Fraud and Abuse.74Preventing Fraud and Abuse .75Reporting Fraud and Abuse .75Section 12.Credentialing. 77Credentialing Process .77Forms .77Evaluation .77Site Review .78Professional Review Committee (PRC) .78Verification and Approval .78Re-credentialing .79Provider’s Right to Notification and Correction of Erroneous Information:.79Providers Right to be informed of Application Status:.80Corrective Action, Fair Hearing Plan, and Reporting to the Florida Division of Medical Quality Assurance,Department of Health (Licensing Board) and the NPDB:.80Section 13.Complaints, Grievance and Appeals Process. 81Member Complaints, Grievance & Appeals Process .81Second opinion: .82Grievance Process:.82Section 14.Medical Group/IPA Operations . 85Delegation of Administrative Functions.85Delegation Criteria .85Credentialing: .86Additional Requirements for Delegated Providers/Practitioners .86Utilization Management: .87Claims: .87Quality Improvement/Preventive Health Activities: .88Delegation Reporting Requirements .88Section 15.Cultural Competency . 89Background.89Provider and Community Training .89Integrated Quality Improvement Processes.90Program and Policy Review Guideline.9012/20115 Page
HIPAA Requirements and Information .90HIPAA (The Health Insurance Portability and Accountability Act) .90Molina Healthcare’s Commitment to Patient Privacy .90Provider/Practitioner Responsibilities .90Applicable Laws .90Uses and Disclosures of PHI .91Written Authorizations .92Patient Rights.92HIPAA Security .93HIPAA Transactions and Code Sets .93National Provider Identifier.94Glossary of Terms.95Appendix B.100Molina Healthcare Forms.10012/20116 Page
Section 1.Addresses and Phone NumbersMember Services DepartmentThe Member Services Department handles all telephone and written inquiries regarding Memberclaims, benefits, eligibility/identification, selecting or changing Primary Care Providers (PCPs), andMember complaints. Member Services Representatives are available 8:00 AM to 7:00 PM EST/EDTMonday through 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,UB-04) claims must be submitted by mail to the address listed below. Electronically filed claims mustuse Emdeon EDI Claims/ Payor ID number - 51062 or Availity Payor ID number - 51062. To verify thestatus of your claims, please call our Provider Claims 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 Recovery12/2011AddressMolina Healthcare of FloridaPO BOX 22812Long Beach, CA 90801Phone:(866) 472-45857 Page
Credentialing DepartmentThe Credentialing Department verifies all information on the Practitioner Application prior to contractingand re-verifies this information every three years. The information is then presented to the ProfessionalReview Committee to evaluate a Provider’s qualifications to participate in the Molina Healthcarenetwork. The Credentialing 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
DentaQuest Address: DentaQuest –Claims 12121 North Corporate Parkway Mequon, WI 53092 Phone: (888) 696-9541 TRS, Therapy Review Systems Molina Healthcare is contracted with TRS, Therapy Review Systems to provide PT, OT, ST services for our Members. Providers who have Members that are eligible pro
