CONTRACTING What if our facility is auto-assigned a member, but is not contracted with Molina? If you are not contracted with Molina, we will sign a single case agreement, or Letter of Agreement, while we move toward a full agreement and credentialing. Prior Authorization of services is required. What if our facility is not contracted yet? If you are in the process of the contracting/credentialing process, a Letter of Agreement (LOA) is not required for any auto-assigned members. Once a contract/complete credentialing information is received, Molina updates the facility status to provisional for authorization and claims payment purposes. If you have not started this process, please contact Diane Carr at 248.925.1790, ext. 156235 or diane.carr@molinahealthcare.com. Can our pharmacy participate with CVS Caremark? Yes, your pharmacy may contract with MHM s Pharmacy Benefit Manager (PBM), CVS Caremark. Please call 866.693.4620. HEALTH SERVICES How will Molina Care Coordinators be assigned, by facility or by patient? Molina s goal is to assign by facility. How long will it take for a Molina Care Coordinator to be assigned new members within their aligned facility? The assignment of the Care Coordinator happens upon notification of member enrollment. How big will the caseloads be for the Case Managers? Care Managers have a targeted case load of 300 members and care coordinators have a targeted case load of 50 members. 1
If a member comes from the hospital, or from home, how long before the Care Coordinator performs the assessment? Molina s Care Coordinators will do the assessment within 48 hours. When the member is in the hospital, does the hospital obtain the prior authorization for the transfer to the nursing home? Yes, the hospital would obtain the prior authorization for the transfer to the nursing facility. If a member has a stage four wound and needs an air mattress, who will order it? The nursing facility will complete the form as usual and send it in to Molina for authorization. The timeframe for Level of Care Determinations (LOCDs) is 90 days if a member is a current resident in a nursing facility. If the member is a new resident, when will the LOCD be completed? Molina s timeframe to complete a LOCD is no longer than 90 days; however, we will make every effort to complete prior to the 90 th day. Each nursing facility should complete the LOCD per its current process. Beginning in the Fall of 2015, the state will assign a vendor to perform the LOCDs, but that does not change the process the nursing facility currently has in place. How often is a prior authorization required for custodial care? Prior Authorizations are required every six months for custodial care. If you have a member in the MI Health Link plan, you must request a continued stay authorization every six months. 2
Will the nursing facilities be notified when the six-month time period for authorization is coming close? No, Molina will not notify the nursing facility of pending continued stay authorizations. Molina is not always informed when members enter custodial care. Please notify Molina directly by calling the Utilization Management Department at 888.898.7969 or fax a request to 888.295.7665 when you admit a new MI Health Link member. What is the process when a member is custodial and develops a need for PT/OT/ST? This is covered under Medicare Part B. Providers will submit an authorization request for the necessary services based on the Molina Prior Authorization guide. What are the approval times for the Pre-Paid Inpatient Health Plans (PIHPs) for behavioral health services? Molina does not approve behavioral health services. Please contact the PIHP in the appropriate county. Normal NCQA and state requirements apply for 72 hours for urgent cases and 14 days for non-urgent cases. PIHP contact information is: Detroit Wayne Mental Health Authority 800.241.4949 Macomb County Community Mental Health 855.996.2264 Who is responsible for ordering DME? DME is covered under the per diem. The nursing facility is responsible for ordering, paying and obtaining the authorization for their vendors, since they are paid at a per diem. Will Molina notify nursing facilities of new members? We request that you please contact Molina s call center at 888.898.7969 to let us know if you have a custodial care member. 3
How long does the process take if home care is required when leaving the facility to go home? The initial three home care visits do not require preauthorization; then the home care agency will request further visits. What if a durable medical equipment transitions from the hospital to the nursing facility under rehabilitation; how long will it take for the prior authorization? The hospital will notify Molina and Molina strives to complete the authorization within 72 hours. Where will the required 30 day meeting for members take place if they are in the nursing facility? The Molina Care Coordinator will stay in touch and make the visit with the member at the nursing facility. There will be one or two Care Coordinators per facility who will work with the facility to figure out the best process when conducting meetings. There is no hospice care in the MI Health Link program. So, if a member moves from MI Health Link to hospice, how is the transition period handled? When the member elects hospice, Molina is responsible for covering services until the first of the next month. The member will be disenrolled from MI Health Link as of the first day of the month following the month the member elects to receive hospice care. Is authorization for short-term rehab required upon patient discharge from the hospital? Authorization is required. Under regulatory and NCQA guidelines, Molina has up to 72 hours to respond, but our goal is to respond within 24 hours. Molina works with the hospital throughout the inpatient stay to plan for anticipated needs upon discharge. 4
Does the care coordinator follow the patient into multiple settings such as rehab? Yes, Care Coordinators are available to assist in multiple settings. Does Molina have a process in place to work with hospitals to ensure all applicable services are coordinated upon transfer to a nursing facility? Molina has a hospital transition team that works with the discharge planners at the hospital during the inpatient stay to ensure that all equipment and other services are coordinated at the point of discharge. Working in conjunction with the hospital, we will make our best effort to ensure sure the nursing facility is notified of the discharge and the member s special needs (order of equipment, infusion, etc.). QUALITY MANAGEMENT Does Molina following the guidelines utilized by the State of Michigan for incident reporting? Yes, Molina utilizes the same algorithm as the state for Critical Incident Reporting. What are the notification requirements for Critical Incident Reporting? Follow the state process and notify Molina as well. Does Molina process incident reports via the state? Molina will report what the state mandates. Our Care Coordinators will work with the nursing facility Director of Nursing on all incidents and will report within 48 hours. The nursing facility must inform Molina of any incidents that require mandatory reporting. 5
BLLING/OTHER What is the turnaround time for claims going through two cycles? Molina processes claims for Medicare benefits first, then Medicaid. All claims are processed within 30 days. Both segments of the payment will appear on the same remittance advice. How should the nursing facility bill for therapy services billed on a UB04 for Part B services only, with no room and board? Please bill Molina in the same way you would bill Medicare or Medicaid. What is covered under the per diem? Same as it is for you today, for all services you are billing. What is covered under Medicaid? Services not covered or benefits that have been exceeded under Medicare. How is it different now that Molina is the insurance provider? You only have to bill one entity. When patients come to the nursing facility under Medicare and convert to MI Health Link, when do they begin billing Molina? They begin billing on the first of the month following their effective date. What is the best method to validate eligibility? The state s CHAMPS system and then Molina s WebPortal to verify MI Health Link coverage. What if a member if retroactively enrolled? Please notify Molina as soon as you know the patient is Molina. Authorizations, as appropriate, will be given back to the first of the month of eligibility. 6
What are the member s rights to opt in or opt out of MI Health Link? Members can choose to dis-enroll and opt out of the MI Health Link program or choose a different MI Health Link health plan to coordinate their care. Members are sent at least two letters about being enrolled in a new MI Health Link health plan. The letter includes details regarding the plan, effective date of enrollment, and instructions on choice or opt out. Can you hold a follow-up session for nursing facilities? Yes, one will be held in the fall. Molina will notify nursing facilities of the date. 7