MS Medicaid Provider Manual - molinahealthcare.com

1 Provider Manual . Molina healthcare of Mississippi, Inc. (Molina healthcare or Molina). MississippiCAN. 2020. The Provider Manual is customarily updated annually but may be updated more frequently as policies or regulatory requirements change. Providers can access the most current Provider Manual at Last Updated: 04/2020. Molina healthcare of Mississippi MississippiCAN Provider Manual Any reference to Molina healthcare Members means Molina healthcare MississippiCAN Members. 2. Contents Section 1. Addresses and Phone Numbers ..13. Provider Services Member Services Department ..14. Claims Claims Recovery Compliance and Fraud AlertLine ..15. Credentialing Nurse Advice Line ..15. healthcare Services (HCS) Department ..15. Health Management (Health Education/Disease Management) ..16. Behavioral Health ..17. Pharmacy Quality Molina Service Area.

2 18. Section 2. Provider Nondiscrimination of healthcare Service Delivery ..19. Section 1557 Investigations ..19. Role of Primary Care Provider (PCP) ..19. Facilities, Equipment and Provider Data Accuracy and Molina Electronic Solutions Electronic Solutions/Tools Available to Electronic Claims Submission Electronic Payment (EFT/ERA) Provider Portal ..22. Balance 3. Reimbursement of Non-Participating Providers ..23. Member Information and Marketing ..24. Member Rights and Member Eligibility Verification ..24. healthcare Services (Utilization Management and Case Management)..24. In Office Laboratory Tests ..24. Referrals ..25. Treatment Alternatives and Communication with Pharmacy Participation in Quality Compliance ..26. Confidentiality of Member Protected Health Information (PHI) and HIPAA Participation in Grievance and Appeals Programs.

3 26. Participation in Credentialing ..26. Delegation ..27. Non-Exclusivity Provider Services ..27. Section 3. Cultural Competency and Linguistic Services ..28. Background ..28. Nondiscrimination of healthcare Service Delivery ..28. Cultural Competency ..29. Provider and Community Training ..29. Integrated Quality Improvement Ensuring Access ..29. Program and Policy Review Guidelines ..29. 24 Hour Access to Interpreter Members who are Deaf or Hard of Nurse Advice Line ..31. 4. Section 4. Member Rights and Responsibilities ..32. Second Section 5. Enrollment, Eligibility and Disenrollment ..33. Enrollment ..33. Enrollment in Medicaid Programs ..33. Effective Date of Newborn Enrollment ..33. Inpatient at time of Eligibility Eligibility Listing for Medicaid Programs ..34. Identification Cards ..34. Disenrollment.

4 35. Voluntary Disenrollment ..35. Involuntary PCP Missed Appointments ..36. PCP Assignment ..36. Specialists as PCP Section 6. Benefits and Covered Services ..37. Service Covered by Link(s) to Summary of Benefits ..37. Mississippi Youth Programs Around the Clock (MYPAC) ..37. Psychiatric Residential Treatment Facilities (PRTF)..38. Obtaining Access to Certain Covered Services ..38. Durable Medical Equipment (DME) ..38. Indian Health Care Services ..38. Access to Behavioral Health 5. Emergency Mental Health or Substance Abuse Emergency Transportation ..39. Non-Emergency Medical Transportation ..39. Preventive Care ..40. Immunizations ..40. Well Child Visits and EPSDT Guidelines ..40. Prenatal Emergency Nurse Advice Line ..41. Health Education ..42. Disease Management ..42. Member Newsletters ..42. Member Health Education Materials.

5 42. Program Eligibility Criteria and Referral Source ..42. Provider Participation ..43. Section 7. healthcare Services (HCS) ..44. Utilization Management (UM) ..44. UM Decisions ..45. Medical Necessity ..46. Medical Necessity Review ..46. Levels of Administrative and Clinical Review ..47. Clinical Information ..47. Prior Authorization ..47. Requesting Prior Emergency Services ..49. Inpatient Management ..50. Elective Inpatient Emergent Inpatient 6. Inpatient/Concurrent Review ..50. Inpatient Status Determinations ..51. Discharge Planning ..51. Readmissions ..51. Post Service Affirmative Statement about Incentives ..52. Open Communication about Treatment ..52. Delegated Utilization Management Functions ..53. Communication and Availability to Members and Providers ..53. Out-of-Network Providers and Services.

6 53. Out of Network Services ..53. Coordination of Care and Services ..54. Continuity of Care and Transition of Members ..54. Reporting of Suspected Abuse and/or Neglect ..55. Continuity and Coordination of Provider Communication ..56. Case Management ..56. Care Management (CM) ..56. PCP Responsibilities in Care Management Referrals ..57. Care Manager Responsibilities ..57. Health Management ..57. Health Education/Disease Management ..57. Member Newsletters ..58. Member Health Education Materials ..58. Program Eligibility Criteria and Referral Source ..58. Provider Participation ..59. Section 8. Quality ..60. Patient Safety Program ..61. Quality of Care ..61. 7. Medical Medical Record Keeping Content ..62. Organization ..63. Retrieval ..63. Confidentiality ..63. Access to Care ..64. Appointment Access ..64. Office Wait Time.

7 65. After Appointment Scheduling ..65. Women's Health Access ..66. Monitoring Access Standards ..66. Quality of Provider Office Sites ..66. Physical accessibility ..66. Physical Adequacy of waiting and examining room Administration & Confidentiality of Facilities ..67. Advance Directives (Patient Self-Determination Act) ..67. EPSDT Services to Enrollees Under Twenty-One (21) Well child / adolescent visits ..69. Monitoring for Compliance with Standards ..70. Quality Improvement Activities and Programs ..70. Health Care Management ..70. Clinical Practice Preventive Health Guidelines ..71. Cultural and Linguistic Services ..71. 8. Measurement of Clinical and Service healthcare Effectiveness Data and Information Set (HEDIS) ..72. Consumer Assessment of healthcare Providers and Systems (CAHPS) ..72. Behavioral Health Provider Satisfaction Survey.

8 73. Effectiveness of Quality Improvement Initiatives ..73. What Can Providers Do? ..73. Section 9. Fraud, Waste, and Abuse ..74. Regulatory Requirements ..74. Examples of Fraud, Waste and Abuse by a Provider ..76. Examples of Fraud, Waste, and Abuse by a Member ..77. Review of Provider Claims and Claims Prepayment Fraud, Waste, and Abuse Detection Post-payment Recovery Activities ..78. Claim Auditing ..78. Provider Reporting Fraud, Waste and Abuse ..79. HIPAA Requirements and Information ..80. Molina's Commitment to Patient Privacy ..80. Provider Health Information Technology for Economic and Clinical Health Act, ( HITECH Act )..80. Applicable Laws ..80. Uses and Disclosures of Confidentiality of Substance Use Disorder Patient Records ..82. Inadvertent Disclosures of Written Authorizations ..82. Patient Rights.

9 82. 9. HIPAA Security ..83. HIPAA Transactions and Code Sets ..83. National Provider Identifier ..84. Additional Requirements for Delegated Providers ..84. Reimbursement for Copies of Information Section 10. Claims and Compensation ..90. Hospital-Acquired Conditions and Present on Admission Program ..90. What this means to Providers: ..91. Claim Submission ..91. Required Elements ..92. National Provider Identifier (NPI) ..92. Electronic Claims Submission ..92. EDI Claims Submission Issues ..93. Paper Claim Submissions ..94. Coordination of Benefits (COB) and Third Party Liability (TPL) ..94. COB ..94. TPL ..94. Timely Claim Filing ..94. Reimbursement Guidance and Payment General Coding Requirements ..96. CPT and HCPCS Codes ..96. ICD-10-CM/PCS codes ..96. Place of Service (POS) Codes ..96. Type of Bill ..97.

10 Revenue Codes ..97. Diagnosis Related Group (DRG) ..97. 10. Coding Definitions ..97. Claim Auditing ..98. Corrected Claims ..98. Timely Claim Processing ..99. Electronic Claim Overpayments and Incorrect Payments Refund Claim Reconsiderations and Appeals ..100. Billing the Member ..101. Fraud and Encounter Data ..101. Section 11. Complaints, Grievance and Appeals Process ..103. Member Complaints, Grievance and Appeals Process ..103. Member Complaint and Grievance Process ..103. Member Appeals Process ..104. Expedited Review Process ..106. Review by State Fair Reporting ..107. Provider Complaints, Grievance and Appeals Processes ..108. Provider Complaint and Grievance Process ..108. Claim Reconsiderations/Disputes ..108. Provider Appeals Process ..109. Expedited Review Process ..110. Review by State Administrative Hearing.