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PROVIDER MANUALMolina Healthcare of Texas(Molina Healthcare or Molina)Medicaid, CHIP,Molina Dual Options STAR PLUS MMP2021STAR Dallas, El Paso, Harris, Hidalgo, JeffersonSTAR PLUS Bexar, Dallas, El Paso, Harris, Hidalgo, JeffersonCHIP/CHIP Perinate Dallas, Harris, Hidalgo, Jefferson, RuralService AreaMMP Bexar, Dallas, El Paso, Harris, HidalgoProvider Services (855) 322-4080 MolinaHealthcare.comThe Provider Manual is customarily updated annually but may be updated more frequently as policies orregulatory requirements change. Providers can access the most current Provider Manual atwww.MolinaHealthcare.comLast Updated: October 2021Molina Healthcare of Texas Medicaid, CHIP, MMP Provider ManualAny reference to Molina Healthcare Members means Molina Healthcare Medicaid, CHIP or MMP Members.MHTPROVMN042021
Addendum to: Provider Roles and ResponsibilitiesApplicable to Medicare-Medicaid Plan (MMP) ProvidersEnsuring Adequate COVID-19 Safety Protocols for Federal Contractors forSubcontracts Over the Simplified Acquisition Threshold of 250,000(a)(b)(c)(d)Definition. As used in this clause “United States or its outlying areas” means:(1)The fifty States;(2)The District of Columbia;(3)The commonwealths of Puerto Rico and the Northern Mariana Islands;(4)The territories of American Samoa, Guam, and the United States VirginIslands; and(5)The minor outlying islands of Baker Island, Howland Island, Jarvis Island,Johnston Atoll, Kingman Reef, Midway Islands, Navassa Island, PalmyraAtoll, and Wake Atoll.Authority. This clause implements Executive Order 14042, Ensuring AdequateCOVID Safety Protocols for Federal Contractors, dated September 9, 2021(published in the Federal Register on September 14, 2021, 86 FR 50985).Compliance. The Provider, a subcontractor, shall comply with all guidance,including guidance conveyed through Frequently Asked Questions, as amendedduring the performance of this Agreement, for contractor or subcontractorworkplace locations published by the Safer Federal Workforce Task Force (TaskForce Guidance) at Subcontracts. The Provider shall include the substance of this clause, includingthis paragraph (d), in subcontracts at any tier that exceed the simplifiedacquisition threshold, as defined in Federal Acquisition Regulation 2.101 on thedate of subcontract award, and are for services, including construction,performed in whole or in part within the United States or its outlying areas.”
Molina Healthcare Provider Manual and Orientation AcknowledgementPlease sign and return to Molina Healthcare Provider Services acknowledging receipt oftheMolina Healthcare Edition of the Provider Manual and OrientationMolina Healthcare History and OverviewMolina Product LinesMolina Healthcare Service Delivery AreasMolina Benefits by Product LineEligibility, Claims, Appeals & ReimbursementChildren of Migrant Farm Workers (FREW)THStepsMedical Management (Quality Improvement, Disease Management,Case Management & Utilization Management)Long Term Support Services (if applicable)Prior AuthorizationOut-of-Network ReferralsProvider Complaint ProcessE-PortalBehavioral Health (if applicable)Group Practice Name:Provider Name:Address:City/ZIP:County:Phone:Date:Name (If not Provider):Signature:ii
TABLE OF CONTENTSContentIntroductionBackgroundContinuing the VisionVision StatementCore ValuesQuick Reference Phone ListObjectives of the ProgramsRole of Primary Care Provider (STAR, STAR PLUS, CHIP & MMP)Role of Specialty Care Provider (STAR, STAR PLUS, & CHIP)Specialist as a PCP (STAR, STAR PLUS, & CHIP)Role of Long-Term Services & Supports Providers (LTSS) for STAR PLUS Membersand MMP EnrolleesRole of Molina Service Coordination for STAR PLUS Members and MMP EnrolleesRole of CHIP Perinatal ProviderRole of Pharmacy (STAR, STAR PLUS, MMP & CHIP)Role of Main Dental HomeHospital Responsibilities (STAR, STAR PLUS, & CHIP)Network Limitations (i.e. PCPs, Specialists, OB/GYN) (STAR, STAR PLUS, & CHIP)Provider Advisory GroupsChapter 1 - Benefits and Covered Services1111123344Texas Health Steps Services (THSteps) (STAR and STAR PLUS) Timely Medical Checkups Children of Migrant Farm Workers Who Can Perform THSteps Examinations? How Do I Become a THSteps Provider? Documentation of Completed Texas Health Steps Components and Elements Reimbursement Adult Accompaniment to Medical Checkup Environmental Lead Investigation (ELI) Lead Screening and Testing Oral Evaluation and Fluoride Varnish Benefit (OEFV) Newborn Examination THSteps Benefits and Limitations ImmunizationMedicaid Covered Benefits for STAR and STAR PLUS Early Childhood Intervention (ECI) Comprehensive Care Program (CCP) Pediatric Therapies Prescribed Pediatric Extended Care Centers and Private Duty NursingDrug Benefits (STAR, STAR PLUS, CHIP)1. Emergency Prescription Supply (STAR, STAR PLUS, & CHIP)CHIP Member PrescriptionsAdditional Benefits to STAR PLUS Members and MMP EnrolleesService Coordination for STAR PLUS Members and MMP Enrollees Service Coordinator’s 81819iii455666678
Content Level 1 – Health ManagementLevel 2 – Case ManagementLevel 3 – Complex Case ManagementMedicaid Program Limitations and Exclusions (STAR & STAR PLUS)Spell of Illness Limitation STAR PLUS OnlySTAR PLUS Covered Services Long Term Support Services Medicaid for Breast Cancer and Cervical Cancer (MBCC) ProgramSupported Employment ServicesEmployment Assistance ServicesMental Health Rehabilitative and Mental Health Targeted Case Management (TCM)Services – Managed Care BillingMental Health Rehabilitative ServicesTargeted Case ManagementIntellectual Developmental DisabilityBehavioral Health and Substance Abuse Services for MMP EnrolleesNew Cognitive Rehabilitation Therapy Benefits for Home Community Bases Services(HCBS) STAR PLUS Waiver Members OnlyBreast Pump Coverage in Medicaid and CHIPCHIP Perinate Newborn Benefits and Covered ServicesCHIP Covered DME/SuppliesLimited Home Health Supplies for CHIPCHIP Exclusions from Covered ServicesDefinitionsCHIP Perinate Unborn Covered ServicesCHIP Perinate Exclusions from Covered ServicesMedicare-Medicaid Plan (MMP) Benefit DesignMedicare-Medicaid Plan (MMP) Flexible BenefitsMedicare-Medicaid Plan (MMP) Rewards and IncentivesNominal Gifts (MMP)Chapter 2 – Claims and BillingClaims and Encounter Data Guidelines Claims Submission National Provider Identifier (NPI) Paper Claims and Encounter Data Guidelines Encounter Data Electronic Claims Submissions Electronic Claims Submission Guidelines Provider Portalo Clearinghouseo EDI Claims Submission IssuesElectronic Claims PaymentsCoordination of Benefits (COB) and Third-Party Liability Claims - MedicaidCoordination of Benefits (COB) and Third-Party Liability Claims - MMPRequirements for a Clean Claim - Physicians and Non- Institutional Providers Required NPI 5657626465656566666666676768686869696970707072
ContentRequirements for a Clean Claim - Institutional ProvidersUB-04Molina Required/Requested NPI FieldsTimely Claim FilingTimely Claim Processing (Medicaid)Timely Claim Processing (Medicare)Reimbursement Guidance & GuidelinesEmergency Services ClaimsClaims Coding General Coding RequirementsCoding Sources DefinitionsCorrected Claims Requirements EDI (Clearinghouse Submission)Billing MembersMember Acknowledgement StatementPrivate Pay AgreementPrivate Pay Form AgreementMember Acknowledgement Statement - SAMPLESpecial Billing NewbornsClaims Review and AuditPartially Payable ClaimsOverpayments and Incorrect Payments Refund RequestsClaims Appeals/ReconsiderationsFraud and AbuseHospital-Acquired Conditions and Present on Admission ProgramChanges to Claims GuidelinesClaims Questions, Re-Consideration and AppealsCHIP Cost Sharing ScheduleChapter 3 – CredentialingDefinitionsCriteria for Participation in the Molina NetworkBurden of ProofProvider Termination and ReinstatementCredentialing ApplicationNon-Discriminatory Credentialing and RecredentialingNotification of Discrepancies in Credentialing InformationNotification of Credentialing DecisionsProviders’ Rights During the Credentialing ProcessProviders’ Rights to Correct Erroneous InformationProviders’ Right to be Informed of Application StatusExcluded ProvidersOngoing Monitoring of SanctionsChapter 4 – Member EligibilityMedicaid (STAR and STAR PLUS) 9595
Content Medicaid Eligibility DeterminationVerifying Member Medicaid Eligibility Medicaid (STAR and STAR PLUS) EligibilityTemporary ID CardAbout the Your Texas Benefits Medicaid CardCHIP EligibilityCHIP Perinate EligibilityMolina Dual Options STAR PLUS MMP EligibilityContinuity of Care What if a member moves?Molina ID CardsProvider PanelsChapter 5 - Enrollment, Disenrollment and Member TransfersEnrollment in Medicaid ProgramsSTAR Members STAR Member Enrollment Enrollment of Pregnant Women Enrollment of Newborns Health Plan Changes Member initiated change/Span of Eligibility Health Plan Initiated Change (Disenrollment) Disenrollment Automatic Disenrollment/Re-enrollmentSTAR PLUS Members STAR PLUS Member Enrollment Enrollment of Newborns Health Plan Changes Member initiated change/Span of Eligibility Health Plan Initiated Change (Disenrollment) Disenrollment Automatic Disenrollment/Re-enrollmentCHIP MembersCHIP Enrollment Applying for CHIP Enrollment/Disenrollment for Pregnant Members and Infants Re-enrollment Health Plan Changes Member Initiated Health Plan Initiated Disenrollment DisenrollmentCHIP Perinate Enrollment and Disenrollment Enrollment Newborn Process Health Plan Changeso Member Initiatedo Health Plan Initiated 113113113113114115115115116117117117117118118118
Content DisenrollmentMolina Dual Options STAR PLUS MMP Effective Date of Coverage DisenrollmentInpatient at Time of EnrollmentMembers with Special Needs (STAR, STAR PLUS, & CHIP) Overview Medical Transportation ProgramInterpreter/Translation ServicesMolina/Provider CoordinationReading/Grade Level ConsiderationCultural SensitivityIndian Health Care ProvidersChapter 6 - Prior Authorizations and Utilization ManagementHealthcare ServicesUtilization ManagementMedical Necessity ReviewClinical InformationCPrior Authorizations How to Request an Authorization PA Not RequiredAuthorization Turn – Around TimesDefinitionsHospitals AdmissionsInpatient Management Elective Inpatient Admission Emergent Inpatient AdmissionProspective/Pre-Service ReviewInpatient ReviewInpatient Status DeterminationDischarge PlanningPost-Service ReviewReadmissionsNon-Network Providers and ServicesAvoiding Conflict of InterestNotification of Denied ServicesCoordination of Care and ServicesContinuity of Care and Transition of MembersAffirmative Statement about IncentivesOpen Communication about TreatmentClinical Trials (MMP Only)Delegated Utilization Management FunctionsCommunication and Availability at Members and PractitionersLevels of Administrative and Clinical ReviewNOTICE Act (MMP 8138138139139140140140141141142142142142143143
ContentUM DecisionsUM Decisions (MMP Only)Emergency ServicesContinuity and Coordination of Provider CommunicationCare ManagementPCP Responsibilities in Care Management ReferralsCare Manager ResponsibilitiesHealth Management Health Education/Disease Management Member Newsletters Member Health Education Materials Program Eligibility Criteria and Referral Source Provider ParticipationCase ManagementCCaseManagement (MMP)Medical Record StandardsMedical Necessity StandardsSpecialty Pharmaceuticals/Injectables Infusion ServicesMolina Special Needs Plan Model of Care (MMP Only)Chapter 7 - Coordination of Care, Complex Case Management and DiseaseManagementCoordination of Covered Services Not Directly Provided by the Molina Network Case Management ServicesCoordination with Non-CHIP Covered ServicesComplex Case Management (CCM)Case Management for Children and Pregnant WomenDisease Management 51151152152Chapter 8 - Member Rights and Responsibilities172STAR and STAR PLUS Member Rights and Responsibilities Member ResponsibilitiesCHIP Member Rights and Responsibilities Member ResponsibilitiesCHIP Perinate Member Rights and Responsibilities Member ResponsibilitiesMembers’ Right to Designate an OB/GYN (STAR, STAR PLUS & CHIP)Women’s Health AccessChapter 9-Provider Roles and ResponsibilitiesNon-Discrimination of Healthcare Service Delivery Section 1557 InvestigationsProvider Responsibilities PCP Duties and Responsibilities Specialty Care Provider ResponsibilitiesLong Term Services & Support Provider Responsibilities Long Term Services & Support RoleEarly Childhood Intervention Case Management/Service Coordination & the CaseManagement for Children and Pregnant Women 0180181viii169169169170170170171181
Content Early Childhood Intervention (ECI) Comprehensive Care Program (CCP)Pharmacy Provider ResponsibilitiesFacilities, Equipment and PersonnelProvider Data Accuracy and ValidationMolina Electronic Solutions Requirements Electronic Tools/Solutions Available to Providers Electronic Claims submissions Electronic Payment (EFT/ERA) Requirements Provider Web Portal Electronic Process and Initiatives & the Medicare Quality Partner Bonus PaymentProgramMember Information and MarketingMember Eligibility VerificationProvider Termination and DismissalRequests to Discharge a MemberHealthcare Services (Utilization Management and Case Management) In Office Laboratory Tests Referrals Referrals to Network Facilities and ContractorsAdmissions Admissions for Inpatient Hospital CareRequired NotificationsParticipation in Utilization Review and Case Management ProgramsContinuity and Coordination of Provider Communications Coordination with Texas Department of Family and Protective Services (TDPS) Coordination and Referral to Other Health and Community ResourcesTreatment Alternatives and Communications with MembersPrescriptions Pain Safety Initiative (PSI) ResourcesParticipation in Quality Programs Molina’s Quality Assurance Program and Provider ResponsibilitiesAvailability and Accessibility/Access to Care Standards Emergency and After-Hours Access Acceptable after-hours coverage Unacceptable after-hours coverageAppointment Availability/Waiting Times for Appointments (Medicaid & CHIP)Appointment Availability/Waiting Times for Appointments (MMP)Appointment SchedulingMonitoring Access for Compliance with StandardsSite Medical Record Keeping Practice Reviews Medical Record Keeping Practices Medical Record Content and DocumentationMedical Record ConfidentialityDelivery of Patient Care InformationCompliance Confidentiality of Member Health Information and HIPPA 0191191191191192192192193194194195198198199199199
ContentParticipation in Grievance and Appeals ProgramParticipation in CredentialingDelegationPCP Patient CapacitySecond OpinionsAdvance DirectivesBalanced Billing (Medicaid & CHIP)Balanced Billing (MMP)Personal Attendant Services (PAS) Documentation RequirementsAppropriate PAS Billing PracticesElectronic Visit Verification (EVV) Provider Compliance Requirements EVV Billing RequirementsRoutine, Urgent and Emergent Services DefinitionsMedicaid Emergency Dental ServicesMedicaid Non-Emergency Dental ServicesCHIP Emergency Dental ServicesCHIP Non-Emergency Dental ServicesHow to Help a Member Find Dental CareChapter 10 – Cultural CompetencyBackgroundNon-Discrimination of Healthcare Service DeliveryMolina Institute for Cultural Competency Provider and Community TrainingIntegrated Quality Improvement – Ensuring AccessProgram and Policy Review GuidelinesMeasures Available Through National Testing Programs such as National Health andNutrition Examination (NHANES) Linguistic Services 24-Hour Access to Interpreter Services Documentation Members with Hearing Impairment Nurse Advice LineChapter 11-Complaints and AppealsMedicaid Member Complaints and Appeals DefinitionsMedicaid Managed Care and Medicare-Medicaid Plan (MMP) Member ComplaintProcess What should members do if they have a complaint? Who do they call? Can someone from Molina help members file a complaint? How long will it take to process a complaint? Requirements and timeframes for filing a Complaint Information on how to file a complaint with HHSCMedicaid and MMP Member Appeal Process What do I do if the MCO denies my Member’s request for a Covered Service? How will members find out if services are denied? What happens after a member files an 2212213213213214214214214215215215215215215
Content Who Do Members Call? Can someone from Molina help members file an appeal?Expedited MCO Appeal What is an expedited appeal? How do members ask for an expedited appeal? Do requests have to be in writing? What are the time frames for an expedited appeal? What happens if Molina denies the request for an expedited appeal? Who can help members file an Expedited Appeal?State Fair Hearing Can a member ask for a State Fair Hearing?Member Complaint Process (CHIP & CHIP Perinate) What should members do if they have a complaint? If a member is not satisfied with the outcome, who else can they contact? Who do members call? Can someone from Molina help members file a complaint? How long will it take to handle a member’s complaint? What do members need to do to file a complaint? How long do members have tofile a complaint? Do members have the right to meet with a complaint appeal panel?Process to Appeal a CHIP Adverse Determination (CHIP & CHIP Perinate) What can members do if the MCO denies or limits my patient's request for acovered service? How will members be notified if services are denied? How long does the appeals process take? When do members have the right to request an appeal? Do requests have to be in writing? Can someone from Molina help members file an appeal?Expedited Appeal (CHIP & CHIP Perinate) What is an expedited appeal? How do members ask for an expedited appeal? Do requests have to be in writing? How long will it take to handle an expedited appeal? What happens if Molina denies the request for an expedited appeal? Who can help members in filing an appeal?Independent Review Organization (IRO) Process (CHIP & CHIP Perinate) What is an Independent Review Organization (IRO)?External Review by Independent Review Organization (CHIP & CHIP Perinate) How do members request an IRO review? How long will the IRO review take?Appeals of Medicare Benefits (MMP Only)Provider Complaints and Appeals Provider Complaints How to file a Medicaid Complaint How to file a CHIP Complaint Complaint TimeframesProvider Appeal 22222222222222222222222223223223223224224225
Content How to file an appeal Appeal TimeframesProvider Appeal Process to HHSC (Related to Claim Recoupment due to MemberDisenrollment)Expedited Appeals (Medicaid) How to File an Expedited AppealExpedited Appeal Process (CHIP)Expedited Appeal TimeframesExternal Review by Independent Review Organization (CHIP) What is an Independent Review Organization (IRO)? How to Request an IRO Review IRO Review TimeframesAdditional Resolution Options Dissatisfied with STAR, STAR PLUS Complaint or Appeal Outcome? Dissatisfied with CHIP Complaint or Appeal Outcome?Chapter 12 – Electronic Visit Verification (EVV)DefinitionsWhat is EVV?Do Providers have a choice of EVV Vendors?Can a Provider Elect Not to Use EVV?Is EVV Required for CDS Employers?How do Providers with Assistive Technology (ADA) Need to Use EVV?EVV Use of Small Alternative Device (SAD) Process & Required SAD FormsWhat is the HHSC Compliance Plan?EVV ComplianceEVV Complaint ProcessEVV Refusal Process Will there be a cost to the provider for access and use of the selected EVVvendor?Providersof Home Health Service Responsibilities Use of Reason Codes Will training be offered to providers? Will claim payment be affected by the use of EVV? What if I need assistance?MCO Contracting for Electronic Visit VerificationMCO Member Education RequirementsMCO EVV Reporting RequirementsChapter 13- Quality ImprovementMaintaining Quality Processes and Program ImprovementsProgram ComponentsHealth ManagementCare ManagementProgram Compliance with Regulatory and Accrediting BodiesFocus Studies, Utilization Management and Practice GuidelinesUsing Performance DataPatient Safety ProgramQuality of CareQuality of Provider Office SitesPhysical 1242242
ContentPhysical AppearanceAdequacy of Waiting and Examining Room SpaceAdequacy of Medical Record-Keeping PracticesMonitoring Office Site Review Guidelines and Compliance StandardsAdmission and Confidentiality of FacilitiesImprovement Plans/Corrective Action PlansMonitoring for Compliance StandardsEPSDT Service to Enrollees Under Twenty-One (21) YearsWell Child/Adolescent VisitsCultural and Linguistics ServicesMeasurement of Clinical and Service QualityHealthcare Effectiveness Data and Information Set (HEDIS)Consumer Assessment of Healthcare Providers and Systems (CAHPS)Experience of Care and Health Outcomes (ECHO ) SurveyProvider Satisfaction SurveyEffectiveness of Quality Improvement InitiativesWhat Can Providers Do?Medicare Quality Partner Program (MMP)Chapter 14 – DelegationDelegation Criteria Sanction Monitoring (MMP Only) CredentialingDelegation Reporting RequirementsChapter 15- Behavioral HealthWhat is Behavioral Health?Behavioral Health Care Management TeamBehavioral Health for STAR, STAR PLUS, MMP, CHIP & CHIP Perinate NewbornMembers Behavioral Health Services HotlineNurse Advice LineCoordination, Self-Referral, PCP ReferralMember Access to Behavioral Health ServicesCovered Behavioral Health ServicesScreening, Brief Intervention and Referral to Treatment (SBIRT) Screening Brief Intervention Referral to TreatmentCourt Ordered CommitmentsCoordination with the Local Mental Health AuthorityMedical Records and Referral DocumentationMissed AppointmentsRoutine, Urgent and Emergent ServicesAuthorizations Information How to Request an AuthorizationConsent for Disclosure of InformationFocus StudiesUtilization Management Reporting 6256
ContentQuick Reference Phone List for BH ServicesChapter 16- Nursing Facility BenefitNursing Facility Benefits for STAR PLUS Members and MMP EnrolleesNursing Facility Covered ServicesNursing Facility Excluded ServicesClaims and Submission Process and GuidelinesNursing Facility Unit RateNursing Facility Medicare Coinsurance Claim (MMP Only)Nursing Facility Medicare Coinsurance Claim Deadlines (MMP Only)Nursing Facility Complaints and AppealsChapter 17 – Long-Term Services and Supports (LTSS)LTSS OverviewLTSS Services and Molina HealthcareLTSS Benefits and Approved ServicesGetting Care, Getting StartedCare Management Team or Integrated Care TeamIndividual Service Plan Coordination (Available for Waiver Services)Transition of Care ProgramsContinuity of Care (COC) Policy and RequirementsCredentialingAppeals, Grievances and State HearingsClaims for LTSS Services Billing Molina Atypical Providers Claims Submission: Web PortalAppendix: HCBS CodesAppendix: Nursing Facility Billing GuidanceChapter 18 – Community First Choice (CFC)Community First ChoiceEligibility for Community First Choice ServicesCommunity First Choice ServicesCFC Service LocationsProvider BaseGeneral Provider Requirements for ParticipationQualifications for PAS SupervisorsQualifications for Emergency Response Service ProvidersQualifications for Financial Management Services Agency (FMSA)Qualified Habilitation Provider Role of the Qualified Habilitation ProviderDirect Service Staff QualificationsHabilitation Billing and Record KeepingStandards of CFC CFC Program Provider ResponsibilitiesReporting Abuse, Neglect or Exploitation (ANE) – Medicaid Managed Care Report Suspect Abuse, Neglect, and Exploitation Report to the Health and Human Services Commission (HHSC) Report to the Department of Family and Protective Services 68270270270271271272272273273273274274275275275275
Content Report to Local Law EnforcementChapter 19- Intellectual and Developmental Disability (IDD) ServicesIntellectual and Developmental Disability (IDD) ServicesClaims Submission Process and GuidelinesChapter 20- Compliance276277277277278Fraud, Waste and Abuse Introduction MissionRegulatory Requirements Federal False Claims Act Deficit Reduction ActDefinitionsExamples of Fraud, Waste and Abuse by a ProviderExamples of Fraud, Waste and Abuse by a MemberReview of Provider claims and Claims SystemsPrepayment Fraud, Waste and Abuse Detection ActionsPost-Payment Recovery ActivitiesProvider EducationFraud Information – Reporting Waste, Abuse or Fraud by a Provider or Client –Medicaid Managed Care and CHIPDo You Want to Report Waste, Abuse or Fraud?HIPAA Requirements and Information HIPAA (Health Insurance Portability and Accountability Act) Requirements Provider/Practitioner Responsibilities Applicable Laws Uses and Disclosures of PHI Confidentiality of Substance Use Disorder Patient Records Inadvertent Disclosures of PHI Written AuthorizationsPatient RightsHIPAA Security HIPAA Transactions and Code Sets Code Sets National Provider Identifier Additional Requirements for Delegated Providers and PractitionersChapter 22- TelehealthTelehealth and Telemedicine Services DefinitionsBenefitsMember Eligibility and Consent for Telehealth ServicesPrivacy and SecurityGeography and Physical Environment for Telehealth ServicesContingency Support for MemberFraud and Abuse ProtocolsProvider Directory 92292293294296296296296297
ContentClaims and BillingSubcontract Relationships for Telehealth ServicesAdministrative Standards For Organizations For Health PlansClinical StandardsTechnical StandardsGlossaryResources for Telehealth Policies, Best Practices and RegulationsChapter 22- Pharmacy Benefit297297298298298299301301302303Prescription Drug Benefits (STAR, STAR PLUS, CHIP) How do I find a list of covered drugs? How do I find a list pf preferred drug? How do members find a network drug store? What if a member goes to a drug store not in the network? What do members bring with them to the drug store? What if members need their medications delivered to them? Who do members call if they have problems getting their medications? What if members can’t get their prescriptions approved? What if members lose their medication(s)? What if a member needs an over the counter medication for CHIP? What if a member needs more than 34 days of a prescribed medication? What if a member needs birth control pills?CHIP Perinate How do CHIP Perinate members get their medications?Durable Medical Equipment and Other Products Normally Found in a PharmacyForms 05305305Clinical Practice Guidelines306Non-Discrimination Notification308xvi
Quick Reference Guide Provider Services/Relations (Medicaid, CHIP &MMP)Claims Status, Complaint & Appeals StatusMember Eligibility, Benefit VerificationUtilization Management, Quality ImprovementPrior Authorization, Referrals(855) rovider Online Portal Relations (Medicaid, CHIP &MMP)Member Eligibility, Claims Submission and Status,Authorization Request Submission and Status, rovider/LoginBehavioral Health Services (Medicaid, CHIP & MMP)Crisis HotlineBehavioral Health Services Contracting (Medicaid, CHIP & MMP)How to join the networkContract ClarificationsFee Schedule Inquiries(800) 818-5837(866) .comProvider Complaints and Appeals (Medicaid, CHIP& MMP)Phone: (866) 449-6849/ Fax: (877) 319-6852Molina Healthcare of TexasAttn: Provider Complaints & AppealsP.O. Box 165089Irving, Texas 75016Electronic Claims Submission Vendors (Medicaid,CHIP & MMP)Availity, Zirmed, Practice Insight, SSI & ChangeHealthcarePayor Identification for All: 20554Paper & Corrected Claims (Medicaid, CHIP & MMP)P.O. Box 22719Long Beach, CA 90801Pharmacy (Medicaid, CHIP & MMP)Prior Authorizations, Assistance/Inquiries(866) 449-6849 (Voice)(888) 487-9251 (Fax)24-hour Nurse Advice Line (Medicaid, CHIP & MMP)Clinical Support for MembersSTAR PLUS Service Coordination(888) 275-8750 (English)(866) 648-3537 (Spanish)LTSS Rate GridEnrollee Services (MMP)www.MolinaHealthcare.com(866) 449-6849(877) 319-6826 (CHIP Rural Service Area)(866) 856-8699Medicaid Managed Care Helpline(866) 556-8989Compliance/Anti-Fraud Hotline (Medicaid, CHIP &MMP)(866) ) 409-0039Member Services (Medicaid & CHIP)1
IntroductionBackgroundMolina Healthcare of Texas (Molina) is a for-profit corporation in the State of Texas,and a subsidiary of Molina Healthcare, Inc. Molina Healthcare, Inc. (MHI) is a publiclytraded, multi-state managed care organizati
Providers’ Rights During the Credentialing Process 92 Providers’ Rights to Correct Erroneous Information 93 Providers’ Right to be Informed of Application Status 93 Excluded Providers 94 Ongoing Monitoring of Sanctions 94 Chapter 4 – Member El
