Molina Healthcare

1 Molina Healthcare PROVIDER MANUAL May 2017 Service Areas: STAR Dallas, El Paso, Harris, Hidalgo and Jefferson Service Areas STAR+PLUS Bexar, Dallas, El Paso, Harris, Hidalgo and Jefferson Service Areas CHIP & CHIP Perinate Dallas, Harris, Hidalgo, Jefferson and Rural Service Areas Molina Dual Options STAR+PLUS MMP (Medicare-Medicaid Plan) Bexar, Dallas, El Paso, Harris and Hidalgo Service Areas Provider Services (855) 322-4080 MHT2017 PROVMN030317 ii Molina Healthcare Provider Manual and Orientation Acknowledgement Please sign and return to Molina Healthcare Provider Services acknowledging receipt of the Molina Healthcare Edition of the Provider Manual and Orientation Molina Healthcare History and Overview Molina Product Lines Molina Healthcare Service Delivery Areas Molina Benefits by Product Line Eligibility, Claims, Appeals & Reimbursement Children of Migrant Farm Workers (FREW) THSteps Medical Management (Quality Improvement, Disease Management, Case Management & Utilization Management) Long Term Support Services (if applicable)

2 Prior Authorization Out-of-Network Referrals Provider Complaint Process E-Portal Behavioral Health (if applicable) Group Practice Name: Provider Name: Address: City/ZIP: County: Phone: Date: Name (If not Provider): Signature: iii TABLE OF CONTENTS Content Introduction 1 Background 1 Continuing the Vision 1 Vision Statement 1 Core Values 1 Quick Reference Phone List 2 Objectives of the STAR and STAR+PLUS programs 3 Objectives of the CHIP program 3 Objectives of the Molina Dual Options STAR+PLUS MMP (MMP) Program 3 Role of Primary Care Provider (STAR, STAR+PLUS, CHIP & MMP) 3 Role of Specialty Care Provider (STAR, STAR+PLUS, & CHIP) 4 Specialist as a PCP (STAR, STAR+PLUS, & CHIP) 4 Role of Long Term Services & Supports Providers (LTSS) for STAR+PLUS Members and MMP Enrollees 4 Role of Molina Service Coordination for STAR+PLUS Members and MMP Enrollees 5 Role of CHIP Perinatal Provider 5 Role of Pharmacy (STAR, STAR+PLUS, MMP & CHIP) 6 Role of Main Dental Home 6 Hospital Responsibilities (STAR, STAR+PLUS, & CHIP)

3 6 Network Limitations ( PCPs, Specialists, OB/GYN) (STAR, STAR+PLUS, & CHIP) 6 Provider Advisry Groups 7 Chapter 1 - Benefits and Covered Services 8 Texas Health Steps Services (THSteps) (STAR and STAR+PLUS) 8 o Timely Medical Checkups 8 o Children Of Migrant Farm Workers 8 o Who Can Perform THSteps Examinations? 8 o How Do I Become a THSteps Provider? 9 o Documentation of Completed Texas Health Steps Components and Elements 9 o Reimbursement 11 o Adult Accompaniment to Medical Checkup 12 o Oral Evaluation and Fluoride Varnish Benefit (OEFV) 12 o Newborn Examination 12 o Immunizations 14 o THSteps Benefits and Limitations 14 Medicaid Covered Benefits for STAR and STAR+PLUS 15 o Early Childhood Intervention (ECI) 15 o Comprehensive Care Program (CCP) 16 o Pediatric Therapies 17 o Prescribed Pediatric Extended Care Cetners and Privte Duty Nursing o 17 o Service Coordinator s Role 18 Emergency Prescription Supply (STAR, STAR+PLUS, & CHIP)

4 18 CHIP Member Prescriptions 18 Additional Benefits to STAR+PLUS Members and MMP Enrollees 18 Service Coordination for STAR+PLUS Members and MMP Enrollees 18 iv Content o Level 1 Health Management 19 o Level 2 Case Management 19 o Level 3 Complex Case Management 20 Medicaid Program Limitations and Exclusions (STAR & STAR+PLUS) 20 Spell of Illness Limitation STAR+PLUS Only 21 STAR + PLUS Covered Services 21 o Long Term Support Services 21 Supported Employment Services 22 Employment Assistance Services 26 Mental Health Rehabilitative and Mental Health Targeted Case Management (TCM) Services Managed Care Billing 31 Mental Health Rehabilitative Services 31 Targeted Case Management 33 Intellectual Developmental Disability 34 Behavioral Health and Substance Abuse Services for MMP Enrollees 35 New Cognitive Rehabilitation Therapy Benefits for Home Community Bases Services (HCBS) STAR+PLUS Waiver Members Only 36 CHIP Perinate Newborn Benefits and Covered Services 38 CHIP Covered DME/Supplies 47 Limited Home Health Supplies for CHIP 52 CHIP Exclusions from Covered Services 54 Definitions 55 CHIP Perinate Unborn Covered Services 56 CHIP Perinate Exclusions from Covered Services 61 Medicare-Medicaid Plan (MMP) Benefit Design 63 Medicare-Medicaid Plan (MMP) Flexible Benefits 64 Medicare-Medicaid Plan (MMP) Rewards and Incentives 64 Nominal Gifts (MMP)

5 64 Chapter 2 Claims and Billing 65 Billing, Claims, and Encounter Data Administration 65 Claims and Encounter Data Guidelines 65 o Paper Claims and Encounter Data Guidelines 65 o Electronic Claims Submission Guidelines 65 o Coordination of Benefits and Third Party Claims 66 Physicians and Non- Institutional Providers 67 o Requirements for a Clean Claim 67 o Required NPI Fields 69 Institutional Providers 69 o Requirements for a Clean Claim 69 UB-04 71 Molina Required/Requested NPI Fields 71 Emergency Services Claims 71 Claims Codes 71 Billing Members 72 Member Acknowledgement Statement 72 v Content Private Pay Agreement 73 Member Acknowledgement Statement - SAMPLE 74 Special Billing 75 o Newborns 75 Claims Review and Audit 75 Partially Payable Claims 75 Timely Claim Filing (MMP) 76 Timely Claim Processing (MMP) 76 Changes to Claims Guidelines 76 Claims Questions, Re-Consideration and Appeals 76 How to file a claims determination appeal 77 Overpayments and Refund Requests (MMP)

6 77 CHIP Cost Sharing Schedule 78 Chapter 3 Credentialing 80 Credentialing and Recredentialing 80 Criteria for Participation in the Molina Network 80 Burden of Proof 84 Provider Termination and Reinstatement 84 Providers Terminating with a Delegate and Contracting with Molina Directly 84 Credentialing Application 84 o Inability to Perform Essential Functions and Illegal Drug Use 85 o History of Actions Against Applicant 85 o Current Malpractice Coverage 85 o Correctness and Completeness of the Application 86 o Meeting Application Time Limits 86 The Process for Making Credentialing Decisions 86 Process for Delegating Credentialing and Recredentialing 87 Non-Discriminatory Credentialing and Recredentialing 88 Notification of Discrepancies in Credentialing Information 88 Notification of Credentialing Decisions 88 Confidentiality and Immunity 88 Providers Rights to Correct Erroneous Information 90 Providers Right to be Informed of Application Status 91 Credentialing Committee 91 o Committee Composition 92 o Committee Members Roles and Responsibilities 92 Excluded Practitioner Providers 93 Ongoing Monitoring of Sanctions 93 o Medicare and Medicaid Sanctions 93 o Sanctions or Limitations on Licensure 94 o NPDB Continuous Query 94 o Member Complaints/Grievances 94 o Adverse Events 94 o Medicare Opt-Out 94 o Social Security Administration Death Master File 95 vi Content o System for Award Management (SAM) 95 Program Integrity (Disclosure of Ownership/Controlling Interests)

7 95 Office Site and Medical Record Keeping Practices Review 96 Range of Actions, Notifications to Authorities and Provider Appeal Rights 96 o Criteria for Denail or Termination Decisions by the Credentialing Committee 97 o Monitoring on a Committee Watch Status 98 o Corrective Action 98 o Summary Suspension 99 o Denial 100 o Termination 100 o Termination Based on Unprofessional Conduct or Quality of Care 100 Reporting to Appropriate Authorities 101 Fair Hearing Plan Policy 101 Chapter 4 Member Eligibility 114 Medicaid (STAR and STAR+PLUS) Eligibility 114 o Medicaid Eligibility Determination 114 Verifying Member Medicaid Eligibility 114 o Medicaid (STAR and STAR+PLUS) Eligibility 114 o Medicaid Identification 115 o Providers can verify eligibility 115 Temporary ID Card 116 o Overview 116 About the Your Texas Benefits Medicaid Card 116 o Manual input 117 o Basic magnetic stripe card reader 117 o Integrated point-of-sale (POS) devices 117 o Electronic transactions 118 o Does having a card mean the patient is eligible for Medicaid?

8 118 o What if the member doesn t bring the card to my office? 118 o How am I supposed to use the Your Texas Benefits card? 118 o What if I don t have a swipe style card reader? 119 o What if I have questions about the card, card reader or the provider website? 119 o What will I be able to do with the new provider website? 119 o When will I be able to use the provider website? 119 o Is e-prescribing available on the provider website? 120 CHIP Eligibility 120 o Who is Eligible? 120 o Verifying CHIP Member Eligibility 120 CHIP Perinate Eligibility 120 o Who is Eligible? 120 Molina Dual Options STAR+PLUS MMP Eligibility 121 o Who is Eligible? 121 o Verifying Eligibility 121 vii Content Continuity of Care 121 o What if a member moves? 122 Molina ID Cards 122 Provider Panels 128 Chapter 5 - Enrollment, Disenrollment and Member Transfers 129 STAR Members 129 o STAR Member Enrollment 129 o Enrollment of Pregnant Women 129 o Enrollment of Newborns 130 o Health Plan Changes 130 Member initiated change/Span of Eligibility 130 Health Plan Initiated Change (Disenrollment) 130 Disenrollment 131 Automatic Disenrollment/Re-enrollment 131 STAR+PLUS Members 132 o STAR+PLUS Member Enrollment 132 o Enrollment of Newborns 132 o Health Plan Changes 133 Member initiated change/Span of Eligibility 133 Health Plan Initiated Change (Disenrollment)

9 133 Disenrollment 134 Automatic Disenrollment/Re-enrollment 134 CHIP Members 135 CHIP Enrollment 135 o Applying for CHIP 135 o Enrollment/Disenrollment for Pregnant Members and Infants 136 o Re-enrollment 136 o Health Plan Changes 136 Member Initiated 136 Health Plan Initiated Disenrollment 137 Disenrollment 138 CHIP Perinate Enrollment and Disenrollment 138 o Enrollment 138 o Newborn Process 139 o Health Plan Changes 139 Member Initiated 139 Health Plan Initiated Disenrollment 140 Disenrollment 140 Molina Dual Options STAR+PLUS MMP 141 o Effective Date of Coverage 141 o Disenrollment 141 Members with Special Needs (STAR, STAR+PLUS, & CHIP) 143 o Overview 143 o Medical Transportation Program 143 viii Content Interpreter/Translation Services 144 Molina /Provider Coordination 145 Reading/Grade Level Consideration 145 Cultural Sensitivity 145 Chapter 6 - Prior Authorizations and Utilization Management 147 Care Access and Monitoring 148 Medical Necessity Review 148 Clinical Information c 149 The Authorization Process 149 Prior Authorizations 150 o How to Request an Authorization 151 o PA Not Required 152 o Web Portal/Clear Coverage 152 o Fax 153 Authorization Turn Around Times 154 Definitions 156 Hospital Admissions 156 Hospital Readmissions (MMP) 157 Notification of Denied Services 157 Continuity of Care and Transistion of Members 158 o What if a member moves?

10 158 Affimative Statement about Incentives 158 Open Communication about Treatment 159 Utilization Management Performed Exclusively by Molina 159 Delegated Utilization Functions 160 Communication and Availability to Members and Practitioners 160 Levels of Administrative and Clinical Review 160 Prospective/Pre-Service Review 161 Inpatient Review 161 NOTICE Act 162 Inpatient Status Determination 162 Inpatient Facility Admission 162 DischargePlanning 162 Post-Service Review 163 Readmission Policy 163 Organization Determinations 163 Emergency and Post Stabilization Services 166 Primary Care Physicians 167 Speciality Providers 167 Case Management 167 Molina Special Needs Plan Model of Care (MMP) 168 Healthcare Services 147 o Utilization Management 147 Chapter 7 - Coordination of Care, Complex Case Management and Disease Management 186 Coordination of Covered Services Not Directly Provided by the Molina Network 186 ix Content o Case Management Services 186 Coordination with Non-CHIP Covered Services 187 Complex Case Management (CCM) 187 Case Management for Children and Pregnant Women 187 Disease Management (DM) 188 Chapter 8 - Member Rights and Responsibilities 189 STAR and STAR+PLUS Member Rights and R