2018 Provider Manual - Molina Healthcare

1 2018 Provider Manual Centennial care 2 Thank you for being a partner with Molina Healthcare of New Mexico! Dear Practitioner/ Provider : Thank you for your active participation in the delivery of quality Healthcare s ervices to Molina Healthcare of New Mexico, Inc. ( Molina Healthcare ) Members. The Provider Manual was designed to provide you with assistance in understanding Molina Healthcare s program, processes, and policies as they pertain to all areas of your practice. This Manual may be revised as Molina Healthcare s policies, program or regulatory requirements change. All changes and revisions will be updated and posted to the Molina Healthcare website located at as they occur. Contracted practitioners and organizational providers are an essential component in helping Molina Healthcare deliver quality care to our Members.

2 We deeply value our partnership with you, and appreciate the compassionate delivery of care you provide to our Members. As our partner, assisting you in understanding Molina Healthcare better, is one of our highest priorities. We welcome your feedback and support your efforts to provide quality care . Sincerely, Provider Services Molina Healthcare of New Mexico, Inc. 3 TABLE OF CONTENTS Section 1 Background and Overview 4 Section 2 Contact Information 7 Section 3 Provider Responsibilities/Participation Requirements 14 Section 4 Cultural Competency and Linguistic Services 35 Section 5 Member Eligibility, Enrollment and Health Assessment 39 Section 6 Member Rights and Responsibilities 49 Section 7 Centennial care Covered Services 53 Section 8 Medical Management Program and Prior Authorization 59 Section 9 Behavioral Health Medical Management Program Level of care Guidelines 71 Section 10 care Management/ care Coordination 109 Section 11 Disease/Health Management 112 Section 12 Pharmacy Management 115 Section 13 Credentialing/Recredentialing 117 Section 14 Delegation 168 Section 15 Fraud.

3 Waste and Abuse 175 Section 16 Preventive Health Guidelines and Clinical Practice Guidelines 184 Section 17 Privacy Practices and Health Insurance Portability and Accountability Act (HIPAA) 190 Section 18 Claims and Reimbursement 195 Section 19 Member Advocacy Grievance, Appeal and Fair Hearing Process 208 Section 20 Provider Grievance, Reconsideration and Appeal Processes 215 4 Section 1 Background and Overview of Molina Healthcare , Inc. Introduction to Centennial care This Manual serves as a guide for providing covered services to Molina Healthcare Members enrolled in Centennial care . The cornerstone of this program is a, comprehensive network, delivering medical, behavioral, and long-term support services (LTSS), with an emphasis on Member care coordination. This ensures that Member s receive the right care , in the right place, at the right time, ensuring better health outcomes.

4 Quality care and improved health outcomes are determined by: Assessing each Member s physical, behavioral, functional, and psychosocial needs; Identifying the medical, behavioral, or LTSS Provider ; Ensuring timely access to care , and provision, coordination, and monitoring of services necessary to help each Member maintain or improve physical and/or behavioral health status; and Facilitating Member access to other social support services, and assistance needed to promote Members health, safety, and welfare. Molina Healthcare updates and publishes its Provider Manual once a year. All contracted practitioners or organizational providers ( Provider or Providers) will be notified of any additional updates or changes that occur via the Provider Newsletter or by letter. To receive a printed version of the Molina Healthcare Provider Manual , please contact your Provider Services Representative at (505) 342-4660, toll free at (800) 377-9594.

5 This Manual is supplemented by the following additional Provider Reference Manuals: Molina Medicare - Molina Medicare Provider Manual Molina Healthcare Marketplace - Molina Healthcare Marketplace Provider Manual Company Profile Molina Healthcare , Inc. (MHI) is headquartered in Long Beach, California. Founded more than thirty years ago, MHI has grown to serve approximately 5 million Members across the nation. MHI and its affiliated health plans, focus on providing Healthcare services to people who receive benefits through government-sponsored programs such as Medicaid and Medicare. MHI strives to break down the financial, cultural and linguistic barriers that prevent low-income families and individuals from accessing appropriate Healthcare and does so by collaborating with state and federal government programs. MHI is an exceptional health care organization, emphasizing on improving access to quality care , increasing care coordination, and improving health outcomes for Members; while cultivating a culturally sensitive, and Provider -friendly environment.

6 C. David Molina , , founded Molina in 1980 as a Healthcare delivery system encompassing a 5 network of primary care clinics in California. As the need for effective patient management and delivery of Healthcare services to underserved populations continued to grow, MHI became licensed as a Health Maintenance Organization (HMO) in California. Dr. Molina believed that people should be treated like family, and that every person deserves affordable quality health care . Molina is devoted to its mission and vision of providing quality health care to people receiving government assistance. MHI is committed to quality and has made achieving accreditation a strategic goal for each of its health plans. Year after year, Molina health plans have successfully received accreditation from the National Committee for Quality Assurance (NCQA). The NCQA accreditation process sets the industry standard for quality in health plan operations.

7 Network Management and Operations Department The Network Management and Operations Department (NM&O) is devoted exclusively to the needs of contracted providers. Provider Contracting. The staff in this area builds the contracted network by negotiating agreements with practitioners and organizational providers in New Mexico primarily, bordering states, and across the nation. Contracting works with providers to help them understand both their contract language terms and reimbursement fee schedules. They may also amend agreements as needed due to regulatory or program requirements. This department also provides geo-access analysis reporting to ensure Members have access to an adequate network of providers of all specialties. Provider Inquiry, Research and Resolution (PIRR). PIRR addresses Provider inquiries, research and resolution. Provider Reconsideration Review (PRR) addresses Provider reconsiderations, appeals, grievances and the reconsideration processes regarding claims payments and/or denials.

8 Member Advocacy - Grievances, Appeals and Fair Hearings (MIRR). MIRR helps Members resolve their health plan concerns and disagreements with coverage decisions Provider Services. This area has dedicated Provider Service Representatives (PSRs) to conduct visits to Provider offices, provide training, answer questions and serve as the plan point of contact for all Provider needs. The PSR Territory Map depicts the plan service areas, and the PSR responsible for each of the geographic areas. The r contact information for individual PSRs may be found in the Contact Information for Providers section below. Provider Credentialing & Delegation. The primary responsibility of the Credentialing and Delegation departments are to adhere to NCQA Quality metrics in credentialing or delegating plan functions to providers. The departments conduct collection of practitioner and facility credentialing documents, ensure quality assessments of providers, perform ongoing monitoring of network providers, and conduct the Credentialing Committee.

9 The Delegation section ensures that Molina s 6 delegated providers are compliant to regulatory requirements by auditing the delegates periodically, and assessing their performance relative to NCQA and Molina s Quality standards. Provider Network Administration (PNA).The PNA department ensures that Provider data collected from all areas of the health plan is entered accurately in Molina s Provider database. This data can range from the data entry of a Provider s practice address to the complex configuration of Provider contract reimbursement. PNA also oversees the Molina Provider Directory data and ensures its accuracy. Encounters. The Encounter department ensures that Molina s data is compliant to its agreement with Centennial Medicaid. The Encounter team performs retrospective review to ensure that Member s received the right care , in the right place, at the right time, with the right Provider specialty.

10 7 Section 2 Contact Information Provider Services Provider Services and other areas within Network Management and Operations including Provider Contracting, Provider Inquiry, Research and Resolution and Provider Reconsideration Review/Appeals. Provider Services Provider Services and Engagement Representative Territory Grid PSR Territory Grid Address: Molina Healthcare of New Mexico, Inc. 400 Tijeras NW, Suite 200 Albuquerque, NM 87102 Phone: (855) 322-4078 Fax: (505) 798-7313 Member Services Member Services for Member benefits, eligibility, selecting or changing primary care practitioner (PCP) and Member complaints. Member Services Address: Molina Healthcare of New Mexico, Inc. 400 Tijeras NW, Suite 200 Albuquerque, NM 87102 Phone: (855) 322-4078 TTY/TDD: 711 Member Appeals and Grievances Services Available in English and Spanish In Albuquerque: (505) 342-4663 Toll Free: (800) 723-7762 Fax: (505) 342-0583 TTY/TDD: 711 Relay Claims Department Molina requires Participating Providers to submit Claims electronically (via a clearinghouse or Molina s Provider Portal).