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PROVIDER ORIENTATION – HOME DELIVERED MEALS/PEST CONTROL
PROVIDER ORIENTATION – HOME DELIVERED
MEALS/PEST CONTROL
Molina Healthcare began 30 years ago in a small medical clinic in Long Beach, California. It was there that the Molina family children swept the floors, stocked shelves and filed medical
records. That year was 1980 and the healthcare environment was similar to that of today. Patients without a family physician would flock to emergency departments complaining of a sore throat or the flu. As an emergency room physician, Dr. C. David Molina knew that treating patients for simple everyday ailments in the emergency room cost more and caused longer
waits for people with true emergencies. As a result, Dr. Molina established a medical office to help those who were uninsured, non-English speaking or low income. This “medical home” enabled patients to access regular preventive care and a physician who was familiar with their health history who could provide the personalized care they couldn’t get anywhere else.
Three decades later, Molina Healthcare is still led by a physician--but not any physician, the founder's son – Dr. J. Mario Molina. He and his siblings have gone from sweeping the floors of the first clinic to running the multi-state healthcare company.
History
Molina Healthcare currently has eight NCQA accredited health
plans. Therefore, Molina Healthcare is placed among the national
leaders in quality Medicaid accreditations.
For six years in a row, Molina Healthcare plans have been ranked
among America’s top Medicaid plans by U.S. News & World Report
and NCQA.
Fortune 500 Company
Hispanic Business magazine ranked Molina Healthcare as the nation’s
largest Hispanic owned company in 2009.
Time Magazine recognized Dr. J. Mario Molina, CEO of Molina
Healthcare, as one of the 25 most influential Hispanics in America.
Recognition
NCQA Accreditation
Membership
Long Term Care Service Area
Region 5 – Pasco, Pinellas
Region 6- Hardee, Highlands, Hillsborough, Manatee, Polk
Region 11 – Miami-Dade, Monroe
Case management services facilitate member access to needed
medical, social, and educational services. Each Community Plus
Program member will be assigned to a case manager that will
coordinate and ensure delivery of medical care and services
available under the program.
Molina Healthcare of Florida Community Plus case managers will:
• Develop individual plans of care that address identified programs,
needs, and conditions
• Coordinate the delivery of covered services
• Issue authorizations for covered services
• Coordinate and integrate acute and long term care services
• Collaborate with member’s physicians and other providers to
arrange for needed care
• Provide frequent communication with members to evaluate and
discuss needed care
• Promote independent living and quality of life
Case Managers
Authorization Requests
To request authorization for additional services:
Contact the Member’s Case
Manager at:
(866) 472-4585
or
Submit a Prior Authorization Request
Form via fax at:
(877) 902-6825
Molina Healthcare of Florida offers various tools for
verifying member eligibility. Providers may use our online
self-service Web Portal, integrated voice response system
(IVR), or speak with a Customer Service Representative.
Web Portal :
https://eportal.molinahealthcare.com/Provider/login
Medicaid Customer Service: (866) 472-4585
Medicaid IVR Automated System: (866) 472-4585
Verifying Eligibility
Molina ID Card
Molina Healthcare of Florida Community Plus offers various oral and written
translations services to assist members in communicating with providers,
Molina Customer Service representatives, and case managers.
These services include:
Oral and written translation services for members with low English
proficiency
Sign language interpretation services for the hearing impaired
Member materials in Spanish, Braille, or in audio format.
Providers may request interpreter services for any Molina Healthcare of
Florida Community Plus member, at no cost to the provider or the member.
If you require translation services for a Molina member, please contact
Member Services at (866) 472-4585 or for the hearing impaired, (800)955-
8771, to make an appointment with a qualified interpreter.
Translation Services
Credentialing
The Molina Healthcare Credentialing Department is responsible for
performing, tracking or monitoring all aspects of the credentialing
and re-credentialing process under the purview of the Quality
Management Department for providers joining or participating in
the Molina Healthcare network. The credentialing process is
designed to meet the State of Florida Requirements and NCQA
Standards.
Providers have the right to review their credentials file at any time.
The provider must notify the Molina Healthcare Credentialing
Department in writing and request an appointed time to review their
file and allow up to seven calendar days to coordinate schedules.
Verification and Approval
The Credentialing Department will verify the following provider information
that includes but is not limited to:
• Current, unrestricted license
• Criminal history
• All professional and/or general liability claims history
• References (if applicable)
• Appropriate 24 hour coverage
• Identify any disciplinary actions and/or sanctions
Background Checks
Any provider meeting the definition of a “direct service provider” must complete
a Level II criminal history background screening to determine whether the
provider, or any employees or volunteers of the provider have disqualifying
offenses as provided for in s. 430.0402 F.S. and s. 435.04, F.S. Direct service
providers are persons eighteen (18) years of age or older who, pursuant to a
program to provide services to the elderly or disabled, has direct, face-to-face
contact with a client while providing services to the client and has access to the
client’s living areas, funds, personal property, or personal identification
information as defined I s. 817.568, F.S The term includes coordinators, managers,
and supervisors of residential facilities and volunteers (see s. 430.0402(1)(b), F.S.)
Any provider, or any employees or volunteers of the provider who has a
disqualifying offense is prohibited from contracting with Molina Healthcare of
Florida.
Provide all services in an ethical, legal, culturally competent manner, free of discrimination against members based on
age, race, creed, color, religion, gender, national origin, sexual orientation, marital, physical, mental, or socio-economic
status
Participate in and cooperate with Quality Improvement, Utilization Review, and other similar programs established by
Molina Healthcare of Florida
Participate in and cooperate with Molina Healthcare of Florida’s grievance procedures
Never balance bill Molina Healthcare of Florida members
Comply with all federal and state laws regarding confidentiality of member records
Participate in and cooperate with Molina Healthcare of Florida’s Quality Management program to ensure the delivery of
quality care in the most cost effective manner
Have in place, and follow, written policies and procedures for processing requests for initial and continuing authorization
of services
Immediately report knowledge or reasonable suspicion of abuse, neglect, or exploitation of a child, aged person, or
disabled adult to the Florida Abuse Hotline toll-free telephone number, (800) 96ABUSE
Maintain communication with appropriate agencies, such as local police, poison control, and social service agencies to
ensure members receive quality care
Contact a Molina Healthcare case manager if a member exhibits a significant change, is admitted to a hospital or
hospice program.
Provider Responsibilities
Providers will immediately notify Molina Healthcare of Florida, if any of the following events occur:
• Provider’s business license to practice in any state is suspended, surrendered, revoked, terminated, or subject to terms of probation or other restrictions.
• Provider has any malpractice claim asserted against it by a Molina Healthcare of Florida Community Plus member, or any payment made by or on behalf of Provider in settlement or compromise of such a claim, or any payment made by or on behalf of provider pursuant to a judgment rendered upon such a claim
• Provider is the subject of any criminal investigation or proceeding • Provider is convicted for crimes involving moral turpitude or felonies • Provider is named in any civil claim that may jeopardize Provider’s financial soundness
• There is a change in provider’s business address, telephone number, ownership, or Tax Identification Number
• Provider’s professional or general liability insurance is reduced or canceled
• Provider becomes incapacitated such that the incapacity may interfere with member care for 24 hours
• Any material change or addition to the information submitted as part of provider’s application for participation with Molina Healthcare of Florida Community Plus
• Any other act, event or occurrence which materially affects provider’s ability to carry out its duties under the Provider Services Agreement
Provider Notifications
Outreach and Marketing
•Providers may display Molina Healthcare of Florida specific materials in their own offices.
•Providers may announce a new affiliation with a plan and give their patients a list of plans with which they contract
•Providers may distribute information about non-plan specific health care services and the provision of health, welfare, and social services by the State of Florida and local communities. The members should be referred to Member services of the plan.
DOs
•Providers cannot orally or in writing compare benefits or provider networks among plans, other than to confirm whether they participate in the plan’s network.
•Providers cannot give lists of their Medicaid patients to the plan with which they are contracted.
•Providers cannot give other plans’ membership list to plan nor assist with plan enrollment.
•Providers may not conduct health screenings as a Marketing activity.
Don’ts
Molina Outreach will be happy to provide:
EDUCATION on benefits, nutrition, exercise, or a chosen subject of health
interest…
Entertainment for your residents.
Examples of past events include:
Live Music
Magician Magic Show
Card Tournaments/ Dominos/ Game Day
Movie Night
Healthy Snacks may be included and served by Dr. Cleo!
Molina Outreach
Our provider handbook is issued to providers after successful
credentialing is completed. Providers can also request a hard copy of the handbook at no charge. From time to time, the provider
handbook and bulletins will be updated and revised as our policies,
or state and federal regulatory requirements change.
If a section is updated or changes are made to the content, the
materials will be provided to you to replace the relevant section.
Providers may also call Provider Services and speak with a
representative who will address any questions or concerns.
On the web: www.molinahealthcare.com
Provider Services Toll-Free Line: (866) 472-4585
Provider Handbook
Providers must immediately notify a Molina Healthcare of Florida
Community Plus case manager when a member requires hospitalization or has been admitted to the hospital, assisted living
facility (ALF), or nursing home (NH). Notification must be given within
48 hours of knowledge of hospitalization.
The case manager will proactively assist the member with discharge
planning needs prior to returning to the community by collaborating
with family/caregiver(s), inpatient discharge planner and the facility.
Inpatient hospitalizations are covered by Medicare fee-for-service
program or the member’s Medicare Advantage plan.
For additional information regarding hospital admissions and coverage, please contact Case Management at (866) 472-4585.
Admission Notification
Molina Healthcare has a critical and adverse incident reporting
and management system for incidents that occur in a home and community-based long-term care service delivery setting.
Providers are required to report adverse incidents to Molina
Healthcare within twenty-four (24) hours of the incident.
The incident shall be reported using the Critical Incident
Reporting Form (available online)and submitted confidentially
via fax.
Confidential fax number: (866) 472-6402
Critical Incidents
Participating providers shall accept Molina Healthcare of Florida’s
payments as payment in full for covered services. Providers may not balance bill the Member for any covered benefit, except for
applicable copayments and deductibles, if any.
As a Molina Healthcare of Florida participating provider, your office is responsible for verifying eligibility and obtaining approval
for those services that the event of a denial of payment, providers
shall look solely to Molina Healthcare of Florida for compensation
for services rendered.
Balance Billing
Any disagreement regarding the processing, payment or non-payment of a claim is considered a Provider Dispute. To file a Provider Dispute, providers may contact Customer Service at (866) 472-
4585, or send the request for review in writing, along with any supporting documentation to the address below: Molina Healthcare of Florida Community Plus Attn: Provider Disputes P.O. BOX 52740
Miami, FL 33152-7450 Fax: 877-553-6504 Provider Disputes must be received within one (1) year of the date of payment or denial of the claim. All provider disputes will be reviewed confidentially, and the outcome will be communicated in writing within sixty (60) days or receipt of the Provider Dispute.
If the Provider Dispute results in an unfavorable decision, and the provider has additional documentation supporting their position, the provider may resubmit the Provider Dispute for secondary review. In the alternative, providers may also request a review of their original appeal by the State’s independent dispute resolution organization, listed below:
Maximus Federal Services State Appeals Process 50 Square Drive Suite 120 Victor, NY 14564 Tel. (866) 763-6395 Fax (585) 425-5296
Provider Disputes
Claims
Providers may submit claims to Molina in the following
ways:
•On paper, using a current version CMS-1500 form, to:
Molina Healthcare PO Box 22812
Long Beach, CA 90801
•Electronically, via a clearinghouse, Payer ID #51062
•Electronically, via the Molina Web Portal
Submitting Claims
F.S. 641.3155 requires that providers submit all claims within six (6)
months of the date of service. Network providers must make every
effort to submit claims for payment in a timely manner, and within the
statutory requirement.
If Molina Healthcare of Florida Community Plus is not the primary payer
under coordination of benefits (COB), providers must submit claims for
payment to Molina Healthcare of Florida Community Plus within ninety
(90) days after the final determination by the primary payer.
Except as otherwise provided by law or provided by government
sponsored program requirements, any claims that are not submitted to
Molina Healthcare of Florida Community Plus within these timelines will
not be eligible for payment, and provider thereby waives any right to
payment.
Timely Filing
Providers are encouraged to enroll in Electronic Funds
Transfer (EFT) in order to receive payments quicker.
Molina Healthcare’s EFT provider is ProviderNet.
To enroll, visit https://providernet.alegeus.com
Step-by step registration instructions are included in your
training materials.
Direct Deposit of Funds
Billing Using a CMS 1500 Form
Resident Information is entered in Fields 1 - 11
Only Fields 1 – 6 are required
All other fields are optional
Billing Using a CMS 1500 Form
Resident’s authorization for Provider to bill and release
information is entered in Fields 12 -13
Both fields are required
Enter “Signature on File” and the date in Field 12
Enter “Signature on File” in Field 13
SIGNATURE ON FILE SIGNATURE ON FILE 12/15/2013
Billing Using a CMS 1500 Form
Diagnosis Code is entered in Field 21
This is a required field
Enter number 9 in the ICD Ind. for ICD 9.
Enter 780.99 in position A (new CMS1500 Form version 02/12
effective for submission dates starting on 4/1/2014)
Enter letter A in 24E to “point” the charges to the diagnosis
780.99 an unspecified code which will enable your claim to process
9 780.99
A 03 01 14 03 07 14 12 S5170 00 55 10
Charges are entered in Fields 24A – 24J
The date of service is entered in Field 24A.
Home Delivered Meals and Pest Control may bill for services
on a daily, weekly or monthly basis.
Dates of service may span over various days, but cannot
include future dates. Date spans cannot overlap each other.
Daily
Weekly
Billing Using a CMS 1500 Form
03 01 14 03 01 14 12 S5170 A 11 2 00
A 10 00 55 S5170 03 01 14 03 05 14 12
Billing Using a CMS 1500 Form
The billing code and modifiers (if any are required) is
entered in Field 24D
S5170 A 10 55 00 12 03 01 14 03 03 14
Home Delivered Meals may bill for the following service:
HCPC S5170- Home Delivered Meals
Pest Control may bill for the following services:
HCPC G9004 – Pest Control Initial Visit
HCPC G9005 – Pest Control Maintenance
Billing Using a CMS 1500 Form
The Place of Service for Member’s Home is 12
The billed charges for all units is entered in 24F
Remember the A in the Diagnosis Pointer!
Billing Using a CMS 1500 Form
12 A 10 S5170 03 01 14 03 05 14 55 00
Billing Using a CMS 1500 Form
The total units are entered in Field 24G
Home Delivered Meals are billed per unit. ( 1 unit = 1 meal).
Pest Control services are billed per visit. ( 1 visit = 1 unit).
Units billed must be the total amount of meals delivered or pest control visit.
10 03 01 14 03 05 14 A 00 55 12 S5170
The Tax ID is entered in Field 25
Yes is checked in Field 27
Total charges for all lines are entered in Field 28 and 30
The signature of the representative completing the claim is
entered in Field 31
The Provider Name, Address, & Phone Number are entered in
Field 33
The NPI # (if facility has one) is entered in Field 33A
Billing Using a CMS 1500 Form
The following fields on the claim must match the
information in our records in order for payment to be
issued.
Box 25 – Tax ID must match W9 on file
Box 33 - Provider Name and Address must match W9
on file
Box 33A – No NPI is required for Home Delivered Meal
or Pest Control Providers
Please notify Molina immediately, if any of these
change.
Billing Using a CMS 1500 Form
Web Portal Tools
•Verify effective dates
•Verify patient demographics
Member Eligibility
• Check claim status
• Submit claims (professional only) Claims
• Check status of an authorization
• Request authorization Authorizations
Billing Using the Molina Web Portal
Select Create Professional Claim from the Claims drop-
down menu.
Billing Using the Molina Web Portal
Insured Information
Enter the following:
Member ID #
Last Name
First Name
DOB
Date of Service
The portal will fill in
the Patient Information
section
Billing Using the Molina Web Portal
Patient Condition
This section is not
required. Leave this
section BLANK
:
Billing Using the Molina Web Portal
Verify Required Information
Enter the following:
Place of Service = 12 Home
Patient Account Number =
(your internal acct number)
Another Health Plan = No
Member Authorized
Assignment of Benefit = Yes
Release of Information = Yes
Other Insurance & Other
Information sections are not
required. Leave these sections
blank.
Choose NEXT (bottom left
corner)
Billing Using the Molina Web Portal
Submitter Contact Information
Enter the following:
Your Last Name
Your First Name
Your Contact Phone Number
Your Fax Number
Billing Provider Information is
completed automatically
Rendering Provider = Your
facility
Facility Information is not
required. Leave this section
blank.
Billing Using the Molina Web Portal
Diagnosis Code & Claim Line Details
Enter the following:
Dx No. 1 = 780.99
Service From Date
Service To Date
Place of Service = 12 (Portal
will complete automatically)
Procedure Code
Modifier if required
Diagnosis Code Ref.= 1
Unit of Measurement = UN-
Unit
Quantity = Total units for the
dates/service being billed
Charges = Charges for all
units of the specified service
Leave all other sections
blank
Choose NEXT (bottom left
corner)
Billing Using the Molina Web Portal
Submit Claim
Review your entries and:
Choose SUBMIT (bottom
right corner
•Place of Service for Member’s Home is 12
•Diagnosis code is 780.99
•Dates of service cannot include future dates
•Date spans cannot overlap each other
•DO NOT 12/1/2013 -12/7/2013 & 12/7/2013 – 12/14/2013.
•DO 12/1/2013 – 12/7/2013 & 12/8/2013 – 12/14/2013
Reminders
Questions
