Molina Healthcare of Illinois New Provider Orientation 2018
Table of Contents Molina Healthcare of Illinois, pages 3-7 Program Overview, pages 8-18 HealthChoice Illinois and HealthChoice Illinois MLTSS, pages 9-14 Enrollment and PCP Changes, pages 15-16 Credentialing and Effective Date, pages 17-18 Covered Services, pages 19-25 Covered Services, page 20 Delegated Vendor Relationships, pages 21-22 Nurse Advice Line and Pharmacy, pages 23-24 MLTSS Benefits, page 25 Eligibility/Authorization/Claims, pages 27-35 Eligibility and Member Cost Sharing, pages 27-28 Referrals and Prior Authorization, pages 29-32 Claims Submissions, page 33 Provider Disputes/Adjustments, pages 34-35 Provider Resources, pages 36-39 Online Provider Resources, page 37 Provider Online Directory and Web Portal, pages 38-39 Molina s Model of Care, pages 40-44 Model of Care, pages 41-42 Interdisciplinary Care Team and Care Management, pages 43-44 Quality Improvement, pages 45-55 Quality Improvement Program and Access Standards, pages 46-49 Disability Sensitivity, pages 50-52 Interpretive Services and Cultural Competency, pages 53-54 Fraud, Waste and Abuse, page 55 Key Contact Information, page 56
Our Vision, Mission and Core Values Mission To provide quality health care to people receiving government assistance Vision We envision a future where everyone receives quality health care Core Values Caring We care about those we serve and advocate on their behalf. We assume the best about people so that we can learn. Enthusiastic We enthusiastically address problems and seek creative solutions. Respectful We respect each other and value ethical business practices. Focused We focus on our mission. Thrifty We are careful with scarce resources. Little things matter and nickels add up. Accountable We are personally accountable for our actions and collaborate to get results. Feedback We strive to improve the organization and achieve meaningful change through feedback and coaching. Feedback is a gift. One Molina We are one organization. We are a team. 3
What Makes Us Unique The majority of Molina health plans are accredited and rated by the National Committee for Quality Assurance (NCQA) 11 of our 13 plans have earned the Multicultural Health Care Distinction from NCQA Ranked #156 on the FORTUNE 500 list for 2017 Ranked #31 on the FORTUNE 100 Fastest-growing Companies list for 2017 Molina Healthcare ranked #9 largest health insurer based on 2016 market share data provided by the U.S. Department of the Treasury s Annual Report on the Insurance Industry 4
Presence in Key Medicaid Markets More than 35 years of service and experience, wholly focused on government care. 5
Molina Healthcare of Illinois Molina Healthcare has been happily serving its Illinois Members since 2013 6
Molina Healthcare of Illinois Experienced leaders committed to your community s health. Pamela Sanborn Plan President Karen Babos, DO, MBA Chief Medical Officer Matt Wolf VP, Network and Operations Lynn Bree VP, Healthcare Services Dennis Akotia Regional VP, Finance and Analytics David Vinkler AVP, Government Contracts Kim Blackwell Regional Compliance Officer 7
Program Overview
HealthChoice Illinois HealthChoice Illinois is the state s managed care program for the 2.7 million Illinois residents who are enrolled onto Medicaid across all counties in Illinois. The mandatory program provides health care coverage for Medicaid enrollees previously under Family Health Plan (FHP) and Integrated Care Program (ICP). The mandatory program is designed to help Members reach their health goals and stay well. Individuals who do not select their own plan will be automatically assigned into a health plans. Members also select a primary care provider (PCP) to serve as their medical home. Molina Healthcare will coordinate a full range of medical, dental, vision, behavioral health and pharmacy benefits for Members. Members can access case management services, health management and disease management programs, a 24-hour nurse advice line, transportation and a network of hospitals and specialists in their communities. 9
HealthChoice Illinois HealthChoice Illinois eligible population includes: Families and children eligible for Medicaid through Title XIX or Title XXI (Children's Health Insurance Program) Affordable Care Act expansion Medicaid-eligible adults Medicaid-eligible adults with disabilities who are not eligible for Medicare Medicaid-eligible older adults who are not eligible for Medicare Dual-Eligible Adults receiving long-term services and supports (LTSS) in an institutional care setting or through an HCBS waiver Special Needs Children, defined as Medicaid-eligible enrollees under the age of 21 who are covered under Supplemental Security Income (SSI), a disability category of eligibility, or are receiving services from the Division of Specialized Care for Children (DSCC); Children formerly under the care of Department of Children and Family Services (DCFS) who have opted out of the DCFS-specific managed care program 10
HealthChoice Illinois Excluded Populations include: Dual-Eligible Adults enrolled in MMAI Dual-Eligible Adults not receiving nursing facility or waiver services Participants who are American Indian/Alaskan Natives unless they voluntarily enroll in a MCO DCFS Youth in Care children Participants only eligible with a Spend-Down All Presumptive Eligibility categories Participants who are incarcerated in a county jail, Illinois Department of Corrections facility, or federal penal institution Participants in a State facility operated as a psychiatric hospital as a result of a forensic commitment Participants enrolled in partial/limited benefits programs; Participants with comprehensive third-party insurance 11
Managed Long Term Services and Supports (MLTSS) HealthChoice Illinois also covers Medicaid Long Term Services and Supports (MLTSS) enrollees who qualify for Medicaid and Medicare, but who are not part of the Medicare- Medicaid Alignment Initiative. MLTSS includes both Long-Term Care (LTC) and Home and Community Based Services (HCBS). Long-Term Care is for an individual living in a facility-based care setting (such as a nursing home or intermediate care facility). Home and community-based services provide supportive services in the community so that individuals can continue to live in their home and empower them to take an active role in their health care. 12
Managed Long Term Services and Supports (MLTSS) Molina offers services to Members of the following waiver groups: Persons who are Elderly Persons with Disabilities Persons with HIV/Aids Persons with Brain Injury Supportive Living Facility Medically Fragile Technology Dependent Molina s MLTSS program only covers certain Medicaid services which include non-medicare long term services and supports, non-medicare behavioral health and non-emergency transportation. 13
HealthChoice Illinois and HealthChoice Illinois MLTSS Sample Member Identification Card HealthChoice Illinois Front Back HealthChoice Illinois MLTSS 14
Enrollment Eligible individuals may enroll in an HealthChoice Illinois program by contacting Illinois Client Enrollment Services. Illinois Client Services Enrollment will: Ensure impartial choice education Conduct all client enrollment activities, including mailing education and enrollment materials and providing information on each health plan Assist enrollees with the selection of a health plan and Primary Care Provider (PCP) in an unbiased manner Process requests to change health plan Members may visit the Client Enrollment Services website at www.enrollhfs.illinois.gov to access plan comparison information, answers to frequently asked questions and general information regarding managed care. Enrollees may also call Client Services at (877) 912-8880 (TTY: (866) 565-8576). 15
PCP Changes Members can change their PCP at any time. The new PCP will be effective no later than 31 days after the Member requests a new PCP. If a Member calls to make a PCP change on or before the 15th of the month, the Member will be effective with the new PCP on the first day of the next month. If a Member calls to change the PCP after the 15th of the month, the change will go into effect 30 days after the date the change was requested. If the Member was assigned to the incorrect PCP due to error by Molina Healthcare, the Member can retroactively change the PCP, effective the 1st of the current month. PCP assignment does not impact claims payment within the Molina Healthcare network. PCP-to-PCP referrals are not necessary. Transition of Care Non-contracted Providers can continue to see Molina Healthcare Medicaid Members with prior authorization for the first 90 days following a Member s effective date with Molina Healthcare to allow for continuity of care. 16
Simplified Credentialing Process Under the new program, registering with the HFS online provider enrollment program (IMPACT) will be the only requirement to begin developing a relationship with Molina Healthcare. Once an application is approved by HFS, the provider is considered credentialed with Molina Healthcare. Two important features: The change applies only to Medicaid, not Medicare or other products Although providers will be credentialed through IMPACT, they should continue to provide specific information requested by Molina Healthcare that is not included in the credentialing process but is needed for operations, such as provider office hours. Credentialing on its own does not mean a provider and a health plan will be doing business together. Provider and plans must still enter into contractual relationships and satisfy all necessary operational requirements. 17
Effective Date A provider s effective date as a participating provider under the HealthChoice Illinois program is noted as the following: Molina policy only allows a provider to have an effective date as the first of the month o Providers with credentialed dates or IMPACT effective dates starting after the 1 st of a month will have an effective date of the 1 st of the following month as long as notification of the provider was sent timely A provider must notify Molina of new providers and supply all required demographic information required to pay claims and load the provider in the directory o o Notification is required on or before the 15 th of each month to retroactively load to the 1 st of the same month Notification provided after the 15 th of the month will be loaded with an effective date of the 1 st of the following month 18
Covered Services 19
Covered Services Alcohol/substance abuse treatment Audiology Behavioral health Chiropractic Dental Durable and non-durable medical equipment and supplies Emergency services Family Planning Health education Home health care Hospice Hospital inpatient and outpatient Immunizations Laboratory services Mammograms Maternity care Pharmacy Physician services Physical, occupational, and speech therapy Podiatry Preventive services Private duty nursing Skilled nursing care Skilled nursing facility Speech and language therapy Transplant services (non-experimental) Transportation Non-emergency transportation Vision Services Whole blood and blood products X-ray services *Molina Healthcare s Benefits At-a-Glance Document is not currently accessible and will be made available soon 20
Delegated Vendor Relationships Transportation Services Molina Healthcare of Illinois provides non-emergent medical transportation for our Members. Secure Transportation is Molina s transportation vendor. Transportation can be scheduled on a recurring basis ahead of time. If your patients are in need of this service, please have them call Secure Transportation to schedule a ride. It is important to have Members call 72 hours in advance of the appointments to schedule transportation. Rides for hospital discharge require three (3) hours notice. Members can arrange for a ride to the pharmacy: o After a medical appointment o With advanced notification at any time HealthChoice Illinois: (844) 644-6354 MMP Duals: (844) 644-6353 21
Delegated Vendor Relationships Dental Services Routine dental services are coordinated through Molina s Dental vendor, Avesis. All medical/surgical services are covered and reimbursed directly by Molina. Contact information, dentist and oral surgeon locator or to schedule an appointment: Medicaid: (866) 857-8124 MMP: (855) 704-0433 Online at: www.avesis.com Vision Services MARCH Vision provides routine vision services and optical supplies to Molina Members. All medical/surgical services are covered and reimbursed directly by Molina. Contact information, to locate an Optometrist or Ophthalmologist or schedule an appointment: Medicaid and MMP: (844) 456-2742 Online at: www.marchvision.com 22
24-Hour Nurse Advice Line Molina Healthcare provides a 24-Hour nurse advice Line. Members may call any time they are experiencing symptoms or need health care information. Registered nurses are available 24 hours a day, seven days a week to assess medical and behavioral health symptoms and help direct Members where they can get the care they need. The Nurse Advice Line phone numbers are listed on the back of Member ID cards. English: (888) 275-8750 TTY: (866) 735-2929 Spanish: (866) 648-3537 TTY: (866) 833-4703 23
Pharmacy Prescription drugs are covered through Molina Healthcare. A list of in-network pharmacies is available online at www.molinahealthcare.com. The Molina Healthcare Drug Formulary was created to help manage the quality of our Members pharmacy benefit. The formulary is the cornerstone for a progressive program of managed care pharmacotherapy, and was created to ensure that our Members receive high quality, cost-effective, rational drug therapy. Medications requiring prior authorization, most injectable medications or medications not included on the formulary may be approved when medically necessary and when formulary alternatives have demonstrated ineffectiveness. The Prior Authorization Request Form is available at www.molinahealthcare.com. Medicaid Pharmacy: (855) 866-5462 Fax: (855) 365-8112 24
Managed Long Term Services and Supports (MLTSS) Benefits and Approved Services Adult Day Service Adult Day Health Transportation Environmental Accessibility Adaptations Environmental Accessibility Adaptations Home Delivered Meals Homemaker Personal Emergency Response System (PERS) Respite Nurse Training Family Training Skilled Nursing Services RN/LPN Specialized Medical Equipment Supported Employment Personal Care Services Home Health Aide Nursing, Intermittent Therapies Prevocational Services Placement Maintenance Counseling Medically Supervised Day Care Behavioral Health Services Assisted Living *HealthChoice Illinois Members, who are not part of MLTSS, may also qualify for waiver benefits. 25
Eligibility, Authorization and Claims 26
Verifying Member Eligibility Molina Healthcare offers various tools to verify Member eligibility. Providers may use our online self-service Web Portal, integrated voice response (IVR) system, eligibility rosters or speak with a Provider Network Manager. Providers can also verify eligibility and health plan assignment for HFS recipients through the Medical Electronic Data Interchange (MEDI) system. It is the responsibility of the provider to verify member eligibility prior to rendering services. At no time should a Member be denied services because his/her name does not appear on the eligibility roster. If a Member does not appear on the eligibility roster, please contact Molina Healthcare for further verification. Web Portal: https://eportal.molinahealthcare.com/provider Provider Services: (855) 866-5462 27
Member Cost Sharing Molina Healthcare Members never have a co-payment for covered services, with the exception of Medicare Part D co-payments for prescription drugs. Providers may not balance bill Members for any reason for covered services. The Molina Healthcare of Illinois Provider Agreement requires Provider offices to verify eligibility and obtain approval for those services that require prior authorization. In the event of a denial of payment, Providers shall look solely to Molina Healthcare of Illinois for compensation for services rendered. 28
Referrals and Prior Authorization Referrals are made when medically necessary services are beyond the scope of the PCP s practice. Referrals to in-network specialists do not require an authorization from Molina Healthcare. Information should be exchanged between the PCP and specialist to coordinate care of the patient. 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 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 included in your orientation packet, in our Provider Manual and also on our website at www.molinahealthcare.com. Service request Forms may be called in or faxed to the Health Care Services department to the numbers listed below, or submitted via our Web Portal. Web Portal: https://eportal.molinahealthcare.com/provider Health Care Services: (855) 866-5462 Prior Authorization Fax: (866) 617-4971 29
Requests for Authorization 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. If we require additional information, we will pend the case and provide written communication to you and the Member. 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 30
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 address: Molina Healthcare of Illinois Attn: Health Care Services Dept. 1520 Kensington Road Suite 212 Oak Brook, IL 60523 31
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. Please contact us with any questions/concerns. The Prior Authorization (PA) form is available to providers at: http://www.molinahealthcare.com/providers/il/medicaid/forms/pages/fuf.asp x 32
Claims Submissions Molina Healthcare is contractually required to process 90% of clean claims received within 30 calendar days, and 99% of clean claims are processed within 90 working days. 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) Molina Healthcare has partnered with Alegeus ProviderNet for electronic Funds Transfer (EFT) and Electronic Remittance Advice. Access is free for participating Providers Go to https://providernet.adminisource.com to register after getting first check from Molina Healthcare. Call (877) 389-1160 or send an email to WCO.Provider.Registration@alegeus.com if you have questions about the registration process 33
Provider Disputes and Adjustments Providers seeking a redetermination of a claim previously adjudicated must request such action within 90 days of Molina s original remittance advice date. Additionally, the item(s) being resubmitted should be clearly marked as a redetermination and must include the following: Claims Dispute Request Form The item(s) being resubmitted should be clearly marked as a Claim Dispute/ Adjustment. Payment adjustment requests must be fully explained. The previous claim and remittance advice, any other documentation to support the adjustment and a copy of the referral/authorization form (if applicable) must accompany the adjustment request. The claim number clearly marked on all supporting documents Providers will be notified of Molina s decision in writing within 30 business days of receipt of the Claims Dispute/Adjustment request. 34
Provider Disputes Claims Dispute Request Form Submission Options Web Portal: Providers are strongly encouraged to use the Molina Web Portal to submit Claims Dispute Request Forms. Fax: The Claims Dispute Request Form can be faxed to Molina at: (855) 502-4962. Mail: Claims dispute requests and supporting documentation can be submitted via mail at the following address: Molina Healthcare of Illinois Attn: Claims Disputes / Adjustments 1520 Kensington Road Suite 212 Oak Brook, IL 60523 35
Provider Resources 36
Online Provider Resources Provider Manual Provider Online Directories Web Portal Frequently Used Forms Preventive & Clinical Care Guidelines Prior Authorization Information Advanced Directives Model of Care training Pharmacy information HIPAA Fraud, Waste & Abuse Information Communications & Newsletters Member Rights & Responsibilities Contact Information News & Updates 37
Provider Directory Molina Healthcare of Illinois Providers may request a copy of our Provider Directory from their Provider Services Representative, or Providers may also use the Provider On-line Directory (POD) on our website. To find a Provider, visit us at www.molinahealthcare.com, select Find a Doctor or Pharmacy, then click Find a Provider or Find a Hospital or Find a Pharmacy 38
Web Portal Why register for Molina s Provider Web Portal? Molina s Provider Web Portal is an easy-to-use online tool designed to meet your needs Web Portal Features: Easily search for Member details, including eligibility status and covered benefits Create, submit, correct and void claims; plus submit attachments and receive notifications of status changes Inquire on current claim status and print your claims Create, submit and print Service Requests with notifications of status changes View Service Request approval status Track required HEDIS services for Members and compare your scores with national benchmarks View Member Personal Health Record Access account information, manage and add users and update your profile 39
Model of Care 40
Model of Care To ensure that members receive high quality care, Molina Healthcare uses an integrated system of care that provides comprehensive services to all members. Molina Healthcare strives for full integration of physical health, behavioral health, long term care services, and social support services. The goal is to eliminate fragmentation of care and provide an individualized plan of care for members. Molina Healthcare s Care Management program consists of three programmatic levels. This approach emphasizes a high touch, member centric care environment. We focus on activities that support better health outcomes and reduce the need for institutional care. 41
Model of Care As a network provider, you play a critical role in providing quality services to our members. This includes identifying members in need of services, making appropriate/timely referrals, collaborating with Molina Healthcare s case managers on the individualized Care Plan and interdisciplinary Care team meetings, reviewing/responding to patient specific communication, maintaining appropriate documentation in member s medical record, participating in Model of Care provider training and ensuring that our members receive the right care in the right setting at the right time. Please call Molina Healthcare when you identify a member who might benefit from such services. For additional Model of Care information, please visit our website at www.molinahealthcare.com. 42
Interdisciplinary Care Team Molina Healthcare s Interdisciplinary Care Team may include: Registered Nurses (RNs) Member s Primary Care Provider Social Workers Member and/or Designee Case Managers Care Transition Coach Utilization Management Staff Service Providers Molina s Medical Director Community Health Worker Pharmacy Staff Other entity that member selects Note: Molina Healthcare s care team is built around the member s preferences and decisions are made collaboratively and with respect to member s right to self-direct care. Members have the right to limit or decline to participate in: Case management The care team and/or approve all care team participants Care team meetings or brief telephonic communications 43
Care Management All Members have an initial and an annual health risk assessments and integrated care plans based on identified needs. Members are stratified at an appropriate level of care management based on the assessment, utilization history and current medical and psycho-social-functional needs. Molina Healthcare s Care Management program has three levels: Level 1: Health Management Level 2: Complex Case Management Level 3: Imminent Risk Case Management Based on the level of Care Management needed, outreach is made to the member to determine the best plan to achieve short and long-term goals. Each level of the program has its own specific health assessment used to determine interventions that support member achievement. The resulting care plan is approved by the member, reviewed by the Interdisciplinary Care Team and maintained and updated by the Case Manager as the member s condition changes. The Case Manager also addresses barriers with the member and/or caregiver, and collaborates with providers to ensure the member is receiving the right care in the right setting with the right provider. 44
Quality Improvement 45
Quality Incentive Program To achieve the highest levels of quality, Molina offers a Quality Incentive Program (QIP) for completing NCQA HEDIS and preventive measures. Bonus payments are calculated per roster member, per month on an annualized basis upon the provider group reaching the threshold goals for certain measure areas. Bonus payments are made to the group practice as a whole and will be made in accordance with strict HEDIS guidelines. Eligible Members are those individuals enrolled in Molina s HealthChoice Medicaid product, and the populations for each measure are those who meet the NCQA criteria. In order to assist providers with determining eligible Members, Molina will make reasonable efforts to ensure accurate member rosters and provide regular Missing Services Reports. For more information on the Quality Incentive Program s measures, parameters and payment schedule, please visit MolinaHealthcare.com 46
Quality Improvement Quality is a Molina Healthcare core value and ensuring Members receive the right care in the right place at right time is everyone s responsibility. Molina Healthcare s Quality improvement department maintains key processes and continuing initiatives to ensure measurable improvements are made in the care and service provided to our Members. Clinical and service quality are measured, evaluated and monitored through the following programs: Healthcare Effectiveness Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS) Provider Satisfaction Surveys Health Management Programs: o o o o o Molina Breathe with Ease (asthma) Molina Healthy Living with Diabetes Chronic Obstructive Pulmonary Disease Heart-Healthy Living Motherhood Matters (support and education for Members and to provide special care to those with high risk pregnancy) Preventive Care and Clinical Practice Guidelines Additional information about Molina Healthcare s Quality Improvement initiatives is available at www.molinahealthcare.com 47
Access Standards Molina Healthcare monitors compliance and conducts ongoing evaluations regarding the availability and accessibility of services to Members. Please ensure adherence to these regulatory standards. Appointment Type Wait Time Standards Urgent Care Within 24 hours of the request Office Wait Time Should not exceed 30 minutes from appointment time Primary Care Provider (PCP) or Prenatal C are Emergency Care Immediately Routine Care (non-urgent) Within three weeks of the request Preventive Care Within five weeks of the request Prenatal First Trimester Within two weeks of request Second Trimester Third Trimester Follow up Discharge Specialty Care Provider Routine Care (non-urgent) Within one week of request Within three days of request Within seven days of discharge Within 10 working days of the request Behavioral Health Non-Life Threatening Emergency Care Within six hours of request Urgent Care Routine Care Within 24 hours of request Within 10 working days of request 48
After Hours Access All physicians must have back-up coverage after hours or during absence/ unavailability. Molina Healthcare requires Providers to maintain a 24-hour telephone service, seven days a week. Access may be via an answering service and voicemail alone is not acceptable. The after-hours answering service must instruct the Member as follows: If this is a life-threatening emergency, hang up and call 911. 49
Disability Sensitivity Chronic Conditions and Access to Services Molina Healthcare Members have numerous chronic health conditions requiring the coordination and provision of a wide array of health care services. Chronic conditions within the population include, but are not limited to: Cardiovascular disease Diabetes Congestive heart failure Osteoarthritis Mental health disorders These Members can benefit from Molina Healthcare s integrated care management approach which will improve the quality of their health. If you identify a Member in need of such services, please make the appropriate/timely referral to our case management team. Molina can then continue to expand access for the Member to not only Primary Care Providers but also Long Term Support Services, mental health providers, community supports and medical specialists. Access must be easy to understand and easy to navigate. 50
Disability Sensitivity Americans with Disabilities Act (ADA) The ADA prohibits discrimination against people with disabilities, including discrimination that may affect: Employment Public accommodations (including health care) Activities of state and local government Transportation Telecommunications The ADA is based on three underlying values: Equal opportunity Integration Full participation Compliance with the ADA extends, expands, and enhances the experience for all Americans accessing health care and ensures that people with disabilities will receive the same, full, equal health and preventive care that is provided to others. 51
Disability Sensitivity Barriers By reducing or eliminating barriers to health care access, we can improve the health and quality of life for people with disabilities. Some of the most prevalent barriers for seniors and people with disabilities are: Physical access: ability to get to, into and through buildings Communication access: ensuring that a sign language or language interpreter is present Medical equipment access: ability to safely transfer onto tables or access equipment Attitudinal: opinions and/or prejudices about a person s quality of life; embracing the idea that disability, chronic conditions and wellness exist simultaneously Another barrier to accessing health care may be related to out-of-pocket expenses, utilization management and care coordination. These barriers affect our Members more often than others because of limited incomes, high utilization of health care services, limited education and complexities of the system. Disability Sensitivity Training Molina Healthcare requires its network Providers to participate in health education programs. Disability Sensitivity Training is offered as a quarterly webinar. The online presentation is open to all network Providers, office staff and clinical staff. Ask your Provider Services Representative for more information. 52
Interpretive Services Molina Healthcare has interpreter services available on a 24-hour basis. Please contact Member Services for more information. The Nurse Advice Line provides access to 24-hour interpretive services. Members may call Molina Healthcare s 24-Hour Nurse Advice Line directly at (888) 275-8750. Providers are required to participate in and cooperate with Molina Healthcare s Provider education and training efforts as well as Member education efforts. Providers are also to comply with all health education, cultural and linguistic, and disability standards, policies and procedures. Molina Healthcare makes every effort to ensure that our Providers are accessible and make accommodations for people with disabilities. 53
Cultural and Linguistic Expertise Cultural Competency Training Molina Healthcare requires network Providers to participate in our health education programs. Our Cultural Competency training is offered as a quarterly online webinar and is open to all network Providers, office staff and clinical staff. Ask your Provider Network Manager for more information. Cultural and Linguistic Resources: Low-literacy materials Translated documents Accessible formats (e.g. Braille, audio or large print) Linguistic consultations 54
Fraud, Waste & Abuse Molina Healthcare 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. More information on Molina Healthcare policies on fraud, abuse and compliance is available online at www.molinahealthcare.com. Reporting an Issue Online: https://molinahealthcare.alertline.com Email: MHILCompliance@MolinaHealthcare.com Compliance Hotline: (866) 606-3889 Fax: (630) 571-1220 Mail: Molina Healthcare of Illinois Attn: Compliance Officer 1520 Kensington road, Suite 212 Oak Brook, Illinois 60523 55
Contact Molina Important Numbers / Contact Information Member Eligibility Verification (855) 866-5462 Non Emergent Transportation (844) 644-6354 Provider Services (855) 866-5462 Member Services (855) 687-7861 Main Fax (630) 571-1220 Prior Authorization Fax (866) 617-4971 Pharmacy Prior Authorization Fax (855) 365-8112 Molina Healthcare of Illinois 1520 Kensington Rd., Suite 212 Oak Brook, IL 60523 Business Hours: 8 a.m. to 5 p.m. Monday -- Friday 56