Provider Services Molina Healthcare of Florida

Transcription

1 Provider Services Molina Healthcare of Florida

2 History & Organization 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.

3 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 Time Magazine recognized Dr. J. Mario Molina, CEO of Molina Healthcare, as one of the 25 most influential Hispanics in America.

4 NCQA Accreditation in 8 States of Florida

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6 Molina Healthcare of Florida NHD Service Area Region 5 Pasco, Pinellas Region 6- Hardee, Highlands, Hillsborough, Manatee, Polk Region 11 Miami-Dade, Monroe

7 What to Expect as You Transition to Molina Healthcare of Florida? Neighborly provider contracts have been assigned to Molina effective July 1 st, Neighborly providers should expect the following: Recredentialing Recontracting New Authorization procedures New Claim guidelines

8 Recontracting and Recredentialing

9 Recontracting and Recredentialing Molina will honor the Neighborly rates. If a contract with Molina exists today, we will be evaluating both contractual terms and if there is a difference in the reimbursement rate, Molina will be reaching out to each provider individually. Molina will be reaching out to providers to recontract on Molina paper. Providers will require recredentialing at the time of recontracting.

10 Contracts Molina has received assignment of all Neighborly NHD contracts. Contracts will as administered as follows: Neighborly Only Neighborly contracted rates will apply Neighborly and Molina Contract Neighborly rates will apply while we evaluate each contract

11 Questions

12 Authorizations

13 Authorizations All covered services must be authorized by Molina Healthcare of Florida Community Plus Program case managers. Existing Neighborly authorizations will be honored for a minimum of 90 days. Case managers will reassess members during the 90 day period, and extend authorizations as needed. Case managers work closely with members and will proactively be reaching out to them to ensure that needed services are approved. Neighborly case managers are now Molina case managers! Neighborly authorizations are being loaded in our processing system. Molina has implemented a process to ensure no claims are denied incorrectly for lack of authorization.

14 Questions

15 Case Management

16 Role of Case Managers 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 Manager may be contacted at (866)

17 Case Management Assessments Case managers will routinely assess member needs and perform interventions as necessary. Face to Face home visits Communicate with service providers Interventions Telephonic follow-up Provide educational materials

18 Questions

19 Claims

20 Claim Form Requirements Providers must submit claims to Molina Healthcare of Florida Community Plus on paper or electronically, using a current version CMS-1500 or the electronic equivalent. Providers may also use our Web Portal to submit claims. Molina does not accept invoices, rosters, or superbills as substitutes for a CMS-1500 form. Claims Submission Address: Molina Healthcare of Florida P.O. Box Long Beach, CA EDI Claims Submission: Emdeon Payor ID# Emdeon Telephone (877) Web Portal: For claims prior to 7/1/2013, submit to Neighborly for processing.

21 Field Description/Comment 1 Check the Medicaid box 1a Enter the Member s Molina Healthcare of Florida Community Plus ID Number 2 Enter the Member s Name 3 Enter the Member s Date of Birth and Sex 5 Enter the Member s Address and Telephone Number 21 Enter the diagnosis code of Enter the Prior Authorization Number provided by Molina Healthcare of Florida Community Plus Case Manager(s) 24a Enter the Date(s) of Service Note: if the charge spans more than one date of service, remember to enter a valid To date 24b Enter the Place of Service 24d Enter appropriate CPT/HCPCS and Modifier Note: Ensure that the code billed is an approved CPT/HCPCS on the NHD Fee Schedule. 24e Enter the number 1 24f CMS 1500 Form Instructions Enter the customary Charge for the CPT/HCPCS, Modifier for the Days or Units 24g Enter Days or Units of Service Notes: Ensure that the units billed comply with the HCPCS description, i.e., S5135- Adult Companion Services, every 15 minutes. Bill 4 units for one hour of service. If multiple units of the same procedure were performed on the same date of service, enter the total number of units. If the date of service covers a span of time, i.e., a month, enter the total number of units for that span of time, i.e. 30 for 30 days. 25 Enter Federal Tax I.D. Number 26 Enter Member Account Number 28 Enter Total Charge for all line items 31 Signature of Provider s Representative 33 Provider Billing Name, Address, Zip Code

22 NHD Fee Schedule

23 Code Mod 1 Service Unit increments Max Limit S5135 U2 Adult Companion Services 15 minute = 1 unit 32 units (8 hrs) per day S5100 U2 Adult Day Health Care 15 minute = 1 unit 40 units (10 hrs) per day T1020 U3 Assisted Living Per day = 1 unit 31 days per month S5120 U2 Chore 15 minute = 1 unit 32 units (8 hrs) per day S5120 TS Chore - Enhanced 15 minute = 1 unit 32 units (8 hrs) per day S5125 U2 Attendant Care Services 15 minute = 1 unit 40 units (10 hours) per day S5199 U2 Consumable Medical Supplies Per authorization Per authorization S5199 TS Consumable Medical Supplies - Enhanced Per authorization Per authorization S5165 U2 Environmental Adaptation Accessibility Services Per job= 1 unit 5 jobs per year T2001 U2 Escort 15 minute = 1 unit 32 units (8 hrs) per day S5110 U2 Family Training Services - Group 15 minute = 1 unit 16 units (4 hrs) per day with max monthly total of 80 units (20 hrs) per month U2 Family Training Services - Individual 15 minute = 1 unit 16 units (4 hrs) per day with max monthly total of 80 units (20 hrs) per month H2011 U2 Financial Assessment/Risk Reduction Services 15 minute = 1 unit 16 units (4 hrs) per day with max monthly total of 32 units (8 hrs) per month H2011 U2 Financial Management/Risk Reduction Services 15 minute = 1 unit 16 units (4 hrs) per day with max monthly total of 64 units (16 hrs) per month S5170 U2 Home Delivered Meals Per meal = 1 unit Per authorization S5130 U2 Homemaker 15 minute = 1 unit 32 units (8 hrs) per day U2 Nutritional Risk Assessment/Risk Reduction Services 15 minute = 1 unit 16 units (4 hrs) per day with max monthly total of 64 units (16 hours) per month U2 Occupational Therapy 15 minute = 1 unit 8 units (2 hours) per day T1019 U2 Personal Care 15 minute = 1 unit 48 units (12 hours) per day S5160 U2 Personal Emergency Response System (PERS) Installation Per installation = 1 unit 3 installations per lifetime S5161 U2 Personal Emergency Response System (PERS)Maintenance Per day = 1 unit 31 days per month G9004 U2 Pest Control - Initial Visit Per visit = 1 unit Per authorization G9005 U2 Pest Control - Maintenance Per day = 1 unit 1 service per month U2 Physical Therapy 15 minute = 1 unit 16 units (4 hours) per day S5180 U2 Respiratory Therapy - Evaluation Per evaluation= 1 unit 1 per day U2 Respiratory Therapy - Treatment 15 minute = 1 unit 1 per day T1005 U2 Respite - Facility Based 15 minute = 1 unit 96 units per day (24 hours) with max 60 full days per year S5150 U2 Respite - In Home 15 minute = 1 unit 96 units per day (24 hrs) with max 60 full days per year T1001 U2 Skilled Nursing - LPN, RN Per visit = 1 unit 2 visits per day E1399 U2 Specialized Medical Equipment and Supplies Per authorization 1 purchase per month U2 Speech-Language Pathology Therapy 15 minute = 1 unit 16 units (4 hours) per day

24 Timely Filing F.S 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.

25 Balance Billing 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 require authorization. In the event of a denial of payment, providers shall look solely to Molina Healthcare of Florida for compensation for services rendered..

26 Provider Disputes 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) , 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 Miami, FL Fax: 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.

27 Electronic Funds Transfer & Remittance Advice (EFT & ERA) Participating providers are encouraged to register with FIS ProviderNet for Electronic Funds Transfer and Electronic Remittance Advice. You may register after you have received your first check from Molina Healthcare. Below are the step-by-step registration instructions. If you have never registered with FIS ProviderNet, perform the following steps: 1. Go to 2. Click Register 3. Accept the Terms 4. Verify your information 4a. Select Molina Healthcare from the Payers list 4b. Enter your primary NPI 4c. Enter your primary Tax ID 4d. Enter a recent Claim Number and/or Check Number associated with this Tax ID and Molina Healthcare 5. Enter your User Account Information 5a. Use your address as your user name 5b. Strong passwords are enforced (at least 8 characters consisting of letters and numbers) 6. Verify your Contact Information 7. Verify your Bank Account Information 8. Verify your Payment Address 8a. Note: any changes to this address may interrupt the EFT process 9. Be sure to add any additional payment addresses, accounts, and Tax IDs once you have logged in. If you are associated with a Clearinghouse, perform the following steps: 1. Go to Connectivity 2. Click the Clearinghouses tab 3. Select the Tax ID for which this clearinghouse applies 4. Select a Clearinghouse 5. If applicable, enter your Trading Partner ID 5. Select the File Types you would like to send to this clearinghouse 7. Click Save If you are a registered FIS ProviderNet user: 1. Log in to ProviderNet 2. Click Provider Info 3. Click Add Payer 4. Select Molina Healthcare from the Payers list 5. Enter a recent check number paid by Molina Healthcare that is associated with your primary Tax ID (as indicated on the Provider Info form)

28 Web Portal Molina Healthcare of Florida participating providers may register for access to our Web Portal for self service activities. Some of the tools available on the portal are: Verifying member eligibility Submitting Professional claims Checking claims status Submitting authorization requests Checking authorization status Provider Searches Downloading frequently used forms Downloading manuals, and formularies Self Service registration instructions and a complete training guide for the Web Portal are available online. Register online at,

29 Questions

30 Benefits

31 Verifying Member Eligibility 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 : Customer Service: (866) IVR Automated System: (866)

32 Molina Healthcare Sample Community Plus ID Card 22812

33 Covered Health Services Molina Healthcare of Florida members have access to community based services through its NHD program. All covered services must be authorized by Molina Healthcare prior to being rendered. Community Based Services include: Adult Companion Services Adult Day Health Services Assisted Living Services Chore Services Consumable Medical Supplies Family/Caregiver Training Environmental Accessibility Adaptation Escort Services Financial Assessment/Risk Reduction Services Home-delivered meals Home Health Services Homemaker Services Nursing Facility Nutritional assessment/risk reduction services Personal Care Services Personal emergency response systems (PERS) Pest Control Services Respite care Specialized Medical Equipment and Supplies Therapies, occupational, physical, speech, and respiratory

34 Home and Community Services: Scope of Covered Health Services Adult Companion Services are services such as non-medical care, supervision and socialization. This service does not include hands-on nursing care Adult Day Health Center provides social and health activities in an organized day program at a center. Assisted Living Services are services such as personal care, housekeeping, medication oversight, and social programs to assist the member in an assisted living facility. Chore Services assist with heavy household chores and services to maintain your home as a clean and safe living environment Consumable Medical Supplies are disposable supplies necessary to appropriately care for the needs of the member such as disposable diapers, gloves, gauze, tape. Does not include items covered under the Medicaid home health services such as personal toiletries and household items. Environmental Accessibility Adaptation Services are changes to the member s home to ensure safety. They can also help the member to function with greater independence in the home.

35 Scope of Covered Health Services (cont.) Home and Community Services: Escort Services assists members who require an individual to accompany them to a medical appointment. Escorts are not permitted to transport members in an individual vehicle. Family Training Services will help train family members who provide care for you. Financial Assessment/Risk Reduction gives guidance regarding financial activities such as bill paying Home Delivered Meals are for members who have difficulty preparing food and nutritional supplements for members who have a medical need. Home Health Services are nursing visits by a licensed nursing professional, which include therapies, home health aide visits, and skilled nursing. Homemaker Services are household activities, such as meal preparations and routine chores.

36 Scope of Covered Health Services (cont.) Home and Community Services: Nursing Facility Services are available for members who require such services. Medicare covers skilled nursing home services. Nutritional Assessment/Risk Reduction gives guidance and education about nutrition to you and your family. Personal Care Services is in-home assistance with bathing, dressing, eating and personal hygiene. Personal Emergency Response Systems is an electronic device that helps a member at high risk to get help at home in an emergency. Limited to members who live alone or who are alone for significant parts of the day and who would otherwise require extensive supervision Pest control is a service for the home and available for members who require such services. Respite Care Services is personal care or supervision provided to a member on a short-term basis due to the need for relief or absence of a family member or caregiver.

37 Scope of Covered Health Services (cont.) Home and Community Services: Specialized Medical Equipment and Supplies are medically prescribed to enable patients to function with greater independence. Occupational, Physical, Speech & Respiratory Therapy Services are treatments to restore, improve or maintain impaired functions. Respiratory therapy is treatment of conditions that interfere with respiratory functions or other deficiencies of the cardiopulmonary system

38 Member Referrals to the Program Members may be referred to Molina Healthcare of Florida s Community Plus Program by contacting the local CARES offices below: Central and South Pinellas Hillsborough and Manatee North and Central Miami-Dade Polk, Hardee, and Highlands South Miami-Dade and Monroe North Pinellas and Pasco

39 Questions

40 Provider Resources

41 Provider Responsibilities 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

42 Admission Notifications 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 24 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)

43 All Molina Healthcare of Florida Community Plus providers must ensure that its direct service personnel complete Abuse, Neglect, and Exploitation training. This training may be provided by the Department of Children and Families, the local area agency on aging, or the Department of Elder Affairs. Department of Children and Families Central Region: Brevard, Citrus, Hardee, Hernando, Highlands, Lake, Marion, Orange, Osceola, Polk, Seminole, and Sumter. 400 West Robin Street Suite 1129 Orlando, Florida Department of Children and Families Suncoast Region: Charlotte, Collier, DeSoto, Glades, Hendry, Hillsborough, Lee, Manatee, Pasco, Pinellas, Sarasota 9393 North Florida Avenue Tampa, Florida Department of Children and Families Southern Region: Miami- Dade, Monroe 401 NW 2nd Avenue Suite N1007 Miami Florida Link to DCF Training Materials: Department of Elder Affairs 4040 Esplanade Way Tallahassee, FL Abuse, Neglect, and Exploitation

44 Translation Services 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) or for the hearing impaired, (800) , to make an appointment with a qualified interpreter.

45 Fraud, Waste, and Abuse

46 Fraud, Waste & Abuse Molina Healthcare of Florida seeks to uphold the highest ethical standards for the provision of health care services to its members, and supports the efforts of federal and state authorities in their enforcement of prohibitions of fraudulent practices by providers or other entities dealing with the provision of health care services. Abuse means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary costs to the Medicare and Medicaid programs, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Medicare and Medicaid programs. (42 CFR 455.2) Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law. (42 CFR 455.2)

47 Examples of Fraud & Abuse Health care fraud includes but is not limited to the making of intentional false statements, misrepresentations or deliberate omissions of material facts from, any record, bill, claim or any other form for the purpose of obtaining payment, compensation or reimbursement for health care services. By a Member Lending an ID card to someone who is not entitled to it. Altering the quantity or number of refills on a prescription Making false statements to receive medical or pharmacy services Using someone else s insurance card Including misleading information on or omitting information from an application for health care coverage or intentionally giving incorrect information to receive benefits Pretending to be someone else to receive services Falsifying claims By a Provider Billing for services, procedures and/or supplies that have not been actually been rendered Providing services to patients that are not medically necessary Balancing Billing a Medicaid member for Medicaid covered services Double billing or improper coding of medical claims Intentional misrepresentation of manipulating the benefits payable for services, procedures and or supplies, dates on which services and/or treatments were rendered, medical record of service, condition treated or diagnosed, charges or reimbursement, identity of Provider/Practitioner or the recipient of services, unbundling of procedures, non-covered treatments to receive payment, upcoding, and billing for services not provided Concealing patients misuse of Molina Health card Failure to report a patient s forgery/alteration of a prescription

48 False Claims Act, 31 USC Section 3279 The False Claims Act is a federal statute that covers fraud involving any federally funded contract or program, including the Medicare and Medicaid programs. The act establishes liability for any person who knowingly presents or causes to be presented a false or fraudulent claim to the U.S. government for payment. The term knowing is defined to mean that a person with respect to information: Has actual knowledge of falsity of information in the claim; Acts in deliberate ignorance of the truth or falsity of the information in a claim; or Acts in reckless disregard of the truth or falsity of the information in a claim. The act does not require proof of a specific intent to defraud the U.S. government. Instead, health care providers can be prosecuted for a wide variety of conduct that leads to the submission of fraudulent claims to the government, such as knowingly making false statements, falsifying records, double-billing for items or services, submitting bills for services never performed or items never furnished or otherwise causing a false claim to be submitted.

49 Reporting Fraud and Abuse You may refer cases of suspected fraud and abuse to Molina s Compliance Officer, or directly to the Florida Agency for Healthcare Administration. You have the right to report your concerns anonymously. Molina Confidential Voice Mail: (866) In writing: mhfcompliance@molinahealthcare.com Compliance Officer Molina Healthcare of Florida 8300 NW 33 Street, Suite 400 Doral, FL Fax: (866) AHCA Hotline: (888)

50 Questions