Molina Healthcare Prior Authorization Prior Authorization is a - PowerPoint PPT Presentation

Molina Healthcare

Prior Authorization Prior Authorization is a request for prospective review. It is designed to : • Assist in benefit determination • Prevent unanticipated denials of coverage • Create a collaborative approach to determining the appropriate level of care for Members • Identify Case Management and disease Management opportunities • Improve coordination of care Molina requires prior authorization for specified services as long as the requirement complies with Federal or State Molina requires prior authorization for specified services as long as the requirement complies with Federal or State regulations and the Molina Hospital or Provider Network Management Agreement. Requests for services on the Molina Healthcare Prior Authorization Guide are evaluated by licensed nurses and trained staff that have authority to approve services. A list of services and procedures requiring prior authorization is available in narrative form, along with a more detailed list by CPT and HCPCS codes. Services performed without authorization may not be eligible for payment.

Prior Authorization Request Authorization requests for elective services should be requested with supporting clinical documentation. Information required generally includes: • Current (up to six months), adequate patient history related to the requested services • Physical examination that addresses the problem • Lab or radiology results to support the request (including previous MRI, CT, lab or x-ray) • PCP or specialist progress notes or consultations • Any other information or data specific to the request Molina Healthcare of Illinois will process all routine requests within 4 days of the initial request. Urgent requests will be processed within 48 hours of the initial request. Services provided emergently (as defined by Federal and State law) are excluded from the prior authorization requirements. Molina does not “retroactively” authorize services that require prior authorization. Providers may review the Prior Authorization Codification List for a comprehensive listing of Healthcare (HCPCS) codes that require a prior authorization at: http://www.molinahealthcare.com/providers/il/PDF/Medicaid/PA-Codification-2018-q1.pdf

Requesting Prior Authorization Prior Authorization Request Options • Web Portal : Providers are encouraged to use the Molina Web Portal for prior authorization submission. Instructions for how to submit a Prior Authorization Request are available on the Web Portal. • Fax : The Molina Prior Authorization form can be faxed to Molina at: (866) 617-4971. • Phone : Prior Authorizations can be initiated by contacting Molina’s Health Care Services Department at (855) 866-5462. It may be necessary to submit additional documentation before the authorization can be processed. • • Mail : Prior Authorization requests and supporting documentation can be submitted via mail at the following Mail : Prior Authorization requests and supporting documentation can be submitted via mail at the following address: Molina Healthcare of Illinois Attn: Health Care Services Dept. 1520 Kensington Road Suite 212 Oak Brook, IL 60523

Request for Authorization Providers who request prior authorization can request to review the criteria used to make the final decision. Providers may request to speak to the Medical Director who made the determination. Upon receipt of prior authorization, Molina Healthcare will provide you with a Molina Healthcare unique authorization number which must be used on all claims related to the service authorized. Our goal is to ensure our Members are receiving the right services at the right time and in the right place. Providers can help us meet this goal by sending all appropriate information that supports the Member’s need for services. services. The Prior Authorization (PA) form is available to providers at: http://www.molinahealthcare.com/providers/il/medicaid/forms/Pages/fuf.aspx

Billing Members Providers contracted with Molina cannot bill the Member for any covered benefits. The provider is responsible for verifying eligibility and obtaining approval for those services that require prior authorization. • Providers agree that under no circumstance shall a Member be liable to the provider for any sums owed by Molina to the provider • Provider agrees to accept payment from Molina as payment in full, or bill the appropriate responsible party • Provider may not bill a Molina Member for any unpaid portion of the bill or for a claim that is not paid with the following exceptions: following exceptions: The Member has been advised by the provider that the service is not a covered benefit and the provider has o documentation. The Member has been advised by the provider that he/she is not contracted with Molina and has o documentation. The Member agrees in writing to have the service provided with full knowledge that they are financially o responsible for payment.

Claim Standards Molina Healthcare processes more than 90% of claims received within 30 calendar days, and 99% of claims are processed within 90 days following receipt. These standards must be met in order for Molina Healthcare to remain compliant with State requirements and ensure Providers are paid in a timely manner. The following information must be included on every claim: • Member name, date of birth and Molina Member ID • Place and type of service code. number. • Days or units as applicable. • Member’s gender. • Provider tax identification. • • Member’s address. Member’s address. • • National Provider Identifier (NPI). National Provider Identifier (NPI). • Date(s) of service. • Rendering provider as applicable. • Valid International Classification of Diseases diagnosis • Provider name and billing address. and procedure codes. • Place of service and type (for facilities). • Valid revenue, CPT or HCPCS for services or items • Disclosure of any other health benefit plans. provided. • E-signature. • Valid Diagnosis Pointers. • Service Facility Location. • Total billed charges for service provided.

Claim Submission Claims Submission Options • EDI Clearinghouse – Change Healthcare is Molina’s gateway clearinghouse. Change Healthcare is contracted with hundreds of other clearinghouses. Providers may submit claims directly to their EDI clearinghouse for submission . • Molina’s Provider Portal – Molina’s Provider Portal is available to providers at no cost. The online provider tool offers easy submission of attachments. Providers also may submit corrected claims, void claims, check claims status and receive notifications regarding claims status.

Electronic Funds Transfer (EFT) Participating providers are required to enroll for Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA). Providers who enroll in EFT payments will automatically receive ERAs as well. EFT/ERA services allow providers to reduce paperwork, provides searchable ERAs, and providers receive payment and ERA access faster than the paper check and RA processes. There is no cost to the provider for EFT enrollment, and providers are not required to be in-network to enroll.

Timely Claim Filing Providers shall promptly submit to Molina Claims for Covered Services rendered to Members. All Claims shall be submitted in a form acceptable to and approved by Molina, and shall include any and all medical records pertaining to the Claim if requested by Molina or otherwise required by Molina’s policies and procedures. Claims must be submitted by provider to Molina within 180 calendar days after the discharge for inpatient services or the Date of Service for outpatient services. If Molina is not the primary payer under coordination of benefits or third party liability, provider must submit Claims to Molina within 90 calendar days after final determination by the primary payer.

Coding Requirements Correct coding is required to properly process claims. Molina requires that all claims be coded in accordance with the HIPAA transaction code set guidelines and follow the guidelines within each code set. CPT and HCPCS Codes Codes must be submitted in accordance with the chapter and code-specific guidelines set forth in the current/applicable version of the AMA CPT and HCPCS codebooks. In order to ensure proper and timely reimbursement, codes must be effective on the date of service (DOS) for which the procedure or service was rendered and not the date of submission. ICD-10-CM/PCS Codes Molina utilizes ICD-10-CM and PCS billing rules, and will deny claims that do not meet the Plan’s ICD-10 Claim Submission Guidelines. In order to ensure proper and timely reimbursement, codes must be effective on the dates of service (DOS) for which the procedure or service was rendered and not the date of submission.