Molina Healthcare of Illinois Provider Summit 2019 October 10 th , - - PowerPoint PPT Presentation

Molina Healthcare of Illinois Provider Summit 2019

October 10th, 2019

Table of Contents

Molina Healthcare of Illinois, pages 3-5 Provider Resources, pages 6-15

• Provider Network Manager Assignments
• Provider Email Alerts and Memos
• Online Provider Resources
• Provider Web Portal
• Credentialing and Effective Date
• Provider Changes

Billing and Claims Support, pages 16-22

• Identification Card Examples
• IAMHP Billing Guide
• Provider Billing Webinars
• MLTSS Billing
• The Molina Approach to Identify Billing Errors
• Most Common Issues & Billing Mistakes

Claims Appeals and Disputes, pages 23-26

• Provider Disputes/Adjustments

Value Based Contracting, pages 27-28

• Overview of Offerings

Quality Improvement Programs, pages 29-43

• 2019 P4P Program
• Behavioral Health Excellence
• Achieving HEDIS Goals

Utilization Management, pages 44-59

• Process Overview
• Submissions
• Concurrent Reviews and Denied Authorizations

Care Coordination, pages 60-67

• Case Management
• Transition of Care

Community Engagement, pages 68-71

• Community Engagement Goals
• Outreach Events
• Helping Hands

Presence in Key Medicaid Markets

3

Molina Healthcare of Illinois

4 Molina Healthcare has been happily serving its Illinois members since 2013

Provider Network Medicaid MMP

Provider Type Count Count Hospitals 200 159 Primary Care Providers

21,815 16,484

Specialist Physicians

54,719 38,398

WHCP 3,100 2,233 Behavioral Health 7,581 6,731 FQHC 358 258

Molina Healthcare of Illinois

5

Kim Blackwell AVP, Compliance David Vinkler VP, Government Contracts Vijay Parthasarathy Regional Chief Financial Officer Kris Classen AVP, Healthcare Services Matt Wolf VP, Network and Operations Karen Babos, DO, MBA Chief Medical Officer Pam Sanborn Plan President

Provider Resources

6

Natalie Kasper, Director Network Mgt. Mike Manade, Mgr. Provider Network LaTasha Smith, Mgr. Provider Network

Provider Network Managers

In 2018 Molina changed our staffing model with a focus on creating end-to-end relationship management and accountability of provider relationships by eliminating handoffs that have been problematic. Staffing assignments are separated by provider types and regions. Benefits:

• End-to-end relationship management - eliminates confusion of roles and

responsibilities for provider changes

• Elimination of unnecessary handoffs
• Servicing is specialized with narrow focus on relationship building, education, billing

and configuration requirements

• Specialization will allow for increased provider satisfaction and understanding of

Molina processes

• Specialization will allow for better understanding of provider loading

requirements/configuration

• Dedicated 1 position to creating/reviewing provider communication

7

8

Our up to date territory maps can be found on our provider website. As staffing changes are made or territories are changed, we update our

• nline maps to align with the correct

managers and contact information

Provider Network Managers Hospitals/Healthcare Systems

9

Provider Network Managers Ancillary Providers

• Long Term Care
• Supportive Living Facilities
• Skilling Nursing Facilities
• Dialysis
• Emergent Transportation
• Waiver Services
• DME
• Lab
• Home Health
• SUPR & CMHC

10

Provider Network Managers FQHC/RHC/ERC

• Federally Qualified Health Centers
• Rural Health Clinic
• Encounter Rate Clinics

Provider Email Alerts and Memos New Feature!

To help keep providers informed of Molina updates we created a new feature in 2019 giving providers the ability to receive email alerts. Providers no longer have to check our website to see if we made an update, get the latest information delivered right to your inbox. To receive email alerts from Molina providers can sign up by visiting www.molinahealthcare.com/providers/il

11

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
• Webinar & Events
• Fraud, Waste & Abuse

information

• Communications & Newsletters
• Member Rights &

Responsibilities

• Contact information
• News & Updates
• Service area maps

12

Provider Web Portal

13

• Why register for Molina’s Provider Web Portal?

– Easy-to-use online tool designed to meet your needs

• Web Portal features

– Search for member details, including eligibility status and covered benefits – Create, submit, correct and void claims; submit attachments and receive notifications of status changes – Check current claim status and print claims – Submit disputes online – 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 – Update provider demographics

As of January 1, 2019 Molina contracted providers are required to submit provider information via the universal roster template issued by the Illinois Association of Medicaid Health Plans (IAMHP). Use the Universal IAMHP Roster Template to:

– Add – Terminate or – Update a provider

• This process applies to

– Pay To information – Servicing location – Rendering Provider

14

Provider Changes

Provider Effective Date

A provider’s effective date as a participating provider under the HealthChoice Illinois program is noted as the following:

Molina will load a provider’s effective date at the later of:

• The execution date of Molina and provider’s contract
• The date the provider submits to Molina a complete and accurate IAMHP roster form for the

provider in the format approved by HFS

• The provider’s effective date contained within HFS provider enrollment subsystem with the

IMPACT system

• Provider may submit to Molina the IAMHP roster at the same time that the provider

submits an enrollment application to HFS through IMPACT

15

Provider Billing Support

IAMHP Billing Guide

17

• The Illinois Medicaid Managed Care Organizations (MCOs), in

collaboration with the Illinois Association of Medicaid Health Plans (IAMHP), have developed a Comprehensive Billing Guide for Medical Assistance Program providers. This billing guide is designed to help providers who are contracted with the MCOs understand the general MCO billing requirements.

• MCOs have different policies and procedures related to billing. With this

manual, the MCOs have created a single source of information for all claims regardless of provider type.

• IAMHP Comprehensive Billing Guide

Provider Billing Webinars

Providers can sign up at any time by visiting www.molinahealthcare.com/providers/il

18

• Each month Molina reviews claims

denial trends and creates an educational billing webinar based on key findings from that review

• We’ve completed over 35 billing

webinars this year and had over 400 providers registered

• These webinars are recorded and

posted online so they can be available for 24/7 access

• All webinars are available to both

contracted and non-contracted providers

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 have opted out of Medicare-Medicaid Alignment Initiative

• MLTSS includes Long-Term Care (LTC) and Home and Community Based

Services (HCBS)

• Medicare remains the primary payer for the dual-eligible beneficiaries

enrolled in HealthChoice Illinois MLTSS

– LTC is for an individual living in a facility-based care setting (such as nursing home or intermediate care facility) – Home and community-based services provide supportive services in community so individuals can continue to live in their home and empower them to take active role in their health care

19

Managed Long Term Services and Supports (MLTSS)

Helpful tips when submitting claims:

• Medicare-covered services must be billed

to the patient’s Medicare carrier.

• Non-Medicare covered long-term-care

services, home and community-based waiver services, non-Medicare behavioral health services, and non-emergency transportation services must be billed to the Medicaid MLTSS MCO.

• All other non-Medicare covered services

covered by Medicaid (e.g., non-Medicare Durable Medical Equipment, prescription drugs, inpatient hospital, dental services, vision services, Medicare rollover services, etc.) should be billed to Medicaid FFS unless they are covered as part of a long- term-care facility per diem.

• Claims questions or appeals should be

sent to the entity responsible for covering the service (Medicare, HealthChoice Illinois MLTSS MCO or the Medicaid FFS).

20

The Molina Approach to Identify Billing Errors

21

• Each month the Molina Operations team meets to review denial

rates and trends by provider and by specialty

• Denial rates are split by UB and 1500 to help identify if one area

requires more attention

• Trends are spotted by comparing denial rates from previous years

and comparing providers against their peers with the same specialty

• Each month our Operations team identifies the top 5 areas of

concern to conduct a deep dive review

• Based on this review we determine if provider education is needed,

HFS guidance is needed, or if a configuration change is required

Most Common Issues & Billing Mistakes

22

• Not providing updated rosters
• Billing medical services for MLTSS members
• Billing with incorrect NPI that isn’t appropriately registered in

IMPACT

• Member Not Enrolled
• Not obtaining an authorization or failure to provide full medical

records to demonstrate medical necessity

• Service is not included in the fee schedule or contracted/legislated

fee arrangement

• Provider is not certified on the date of service
• Invalid Pay-to Provider Address

Claim Appeals & Disputes

23

Provider Claim Appeals and Disputes

24

• Effective July 1, 2019 providers appealing or disputing a previously

adjudicated claim must submit documentation electronically

• Providers are required to submit request within 90 days of Molina’s original

remittance advice date

• Appeals and Disputes being submitted should be clearly marked as a such

and include: – Payment adjustment requests must be fully explained – Previous claim and remittance advice, and other documentation to support adjustment and copy of referral/authorization form (if applicable) must accompany request – Claim number clearly marked on supporting documents

Provider Claim Appeals and Disputes

25

Claim Appeal & Dispute Request Submission Options

• Web Portal (Preferred): Providers are encouraged to use Molina Web

Portal to submit Claims Dispute Request

• Fax: Claims Dispute Request Form and supporting documentation can be

faxed to (855) 502-4962

• Providers should allow up to 60 days to process the request

Molina Claim-Issue Template

26

Less than 10 claims

• Submit your claims dispute and wait for the outcome
• If you disagree with the outcome of the dispute, enter the claims and

issues on the IAMHP Claim-Issue Template and coordinate with your dedicated Provider Network Manager (PNM) Greater than 10 claims

• Coordinate with your dedicated Provider Network Manager
• The 10 or more claims have to be for the same root cause
• Enter the issue on the IAMHP Claim-Issue Template and provide 3-5 claim

examples for research and resolution

Value Based Contracting

27

Value Based Contracting

28

Molina currently offers (P4P, Accountable Care/Shared Savings, Shared/ Partial and/or Full- Risk) the full spectrum of VBC arrangements in

• Illinois. These arrangements are specifically tailored

to support our providers’ varied states of readiness for VBC adoption, moving them along the VBC continuum to improved member outcomes, accountability, and potential for increased rewards based on increased levels of risk.

• P4P - Payout based on providers achieving certain benchmarks for the members assigned to them
• PCMH - Payout is based on tiered structure; tiers are calculated based on PCMH Level and % of

avoidable/preventable ED visit reduction (discontinued in 2018)

• Shared Savings - Payout based on achieved MLR/quality targets; we pay a monthly capitation

(optional) as well as an annual incentive based on demonstrated MLR performance metrics.

• Risk Sharing - This model is designed for our provider partners with at least two years of demonstrated

consistency in providing quality outcomes under the Shared Savings program by managing our members’ care effectively, and achieving cost savings.

Quality Improvement Programs

29

Judy Hutchinson, Sr. Specialist Quality

30

2019 P4P Program

31

Paying for Quality Performance

Partnering with Providers to Achieve Quality Access and Outcomes

32

Paying for Quality Performance

Partnering with Providers to Achieve Quality Access and Outcomes

Measuring P4P Performance

33

Scorecard Example

34

Behavioral Health Excellence Program

• Improve quality

– Increase collaboration between facility and Molina – Incentivize improvement

• Increase satisfaction

– Member/patient satisfaction – Facility satisfaction

35

Purpose of Behavioral Health Excellence Program

To guide and reward inpatient psychiatric care facilities for delivering services more efficiently and effectively

Measuring Success

36

Readmission rate 30 day 90 day

*Goal 10% 20%

Metrics Overview

Follow Up rate 7 day 30 day

*Goal 50% 70%

*Lower rate is better *Higher rate is better

Program Levels & Rewards

37

Reward Top-Tier High-Quality Satisfactory Not Meeting Expectations

Reduced behavioral health inpatient utilization

• versight

X Certificate/plaque X Local news recognition X Preferred facility listing (newsletter) X X Extra directory recognition X X X Benchmark scorecard X X X X

Meets all 4 readmit & follow- up metrics Meets 1 of 2 readmit & 1 of 2 follow-up metrics Meets 1 of 4 readmit or follow- up metrics Meets no readmit

• r follow-up

metrics

Measuring BHEP Performance

38

Scorecard Example

39

Achieving HEDIS Goals

40

What We Can Do

2019 Member Programs

$25Walmart Gift Card - Prenatal visit $50 Walmart Gift Card - Postpartum visit $50 Walmart Gift Card – W15 $25 Walmart Gift Card - HbA1C testing $25 Walmart Gift Card - Nephropathy Screen $50 Walmart Gift Card - Breast Cancer Screening Performance Reporting Monthly Scorecards HEDIS Gap Reports Educational Resources HEDIS Coding Booklets Preventive Care Guidelines Strategic Planning Molina Day Events Value Based Contracting Embedded Case Management

PROVIDER Engagement & Collaboration Performance Reporting Strategic Planning Educational Resources Access CM Resources Member Programs

• Plan the work

– Connect us with a Quality contact

• Review reporting and prioritize measures, members by area,

service location, etc.

• Delineate roles for outreach at service locations
• Each service location could have staff prepared to outreach

when PCP’s are out of the office – Use reporting to flag EMR regarding needed services – Leverage our Member Rewards Programs – Offer a “Molina Day” to close gaps for a selected measure

• Educate providers, billers/coders, and office staff
• Partner with us — let us know how we can help!

41

General Tips & Strategies

• Ensure engagement with your Quality team

– Have your Quality Coordinator or Quality “point person” provide feedback on monthly reporting

• What can we do to help?
• How do we best outreach members for specific measures?
• Is there a way to prioritize the measures?

– Structure communication with your service locations

• Monthly reporting
• HEDIS coding and tips
• Escalate to Molina Case Management on time-sensitive measures

– Prenatal Care – Follow-up After Hospitalization – Initiation and Engagement of Alcohol and Other Drug Dependence Treatment

42

Next Steps For You

• Providing quality care is our #1 priority

– We can only serve members when we see them

• Improved patient health outcomes & experience

– Getting the member in for the preventive visit can build trust, keep them out of the ED, and identify issues before they become chronic conditions

• Increased revenue potential

– Office visits for members who haven’t previously been seen – Office visits for members who should be seen regularly – Office visits that close gaps in care and achieve P4P goals

43

Why Quality is Important

Utilization Management

• Dr. Karen Babos

Chief Medical Officer

• Utilization Management (UM) consists of two main teams

– Non-clinical team

• Takes general UM phone calls, processes correspondences, intakes and

routes faxes, builds authorization requests in our documentation system. – Clinical team

• Nurses – review clinical documentation against evidence-based criteria

guidelines to assess for medical necessity, communicate request decisions to Providers.

• Medical Directors – physicians who review clinical documentation

against evidence-based criteria guidelines to assess for medical necessity and conduct peer to peer reviews with Providers

• Molina Healthcare has dedicated teams for Medicaid and MMP
• UM team is available 24 hours per day, 7 days per week, 365 days per

year via phone, fax, or portal.

45

Molina Utilization Management Department

• Providers can submit authorization request using the Molina Healthcare

Provider Portal (preferred option) – Features of the Provider Portal include the ability to submit authorization request and view current status – Medical records can be uploaded directly to the portal in PDF format, but must be limited to 10 pages or less – For instructions on how to utilize the Provider Portal you may view our Quick Reference Guide or attend one of our monthly webinars by registering at www.molinahealthcare.com

• Authorization request can also be submitted via fax by using the Molina

Healthcare of Illinois Prior Authorization Request form available at www.molinahealthcare.com

46

Prior Authorization Submission Options

• To determine which services require authorization you may view the

Molina Healthcare of Illinois codification list – Codification list updates quarterly so please use the version that is appropriate for the time of service – Molina Healthcare issues provider memos at least 30 days in advance

• utlining any new service that will require an authorization prior to

adding to the codification list

• Available at www.molinahealthcare.com under Frequently Used Forms is

the Prior Authorization Pre-Service Review Guide – Provides an outline of services that require authorization – Does not contain code level detail which is available in the codification list

47

Submission Requirements

48

Codification Table of Contents

• Displayed in categories
• Easy to search with Ctrl +F &

type in code The Prior Authorization Codification List is updated quarterly and provides code level detail on which services require an authorization

• Notification of IP admissions (emergent and planned IP admissions) must

be made within one (1) business day – Admissions after business hours Friday or over the weekend, notification of admission must be made next business day (Monday)

**Helpful Tip: If the member is admitted from ER on Friday and you don’t have clinical information ready, wait until Monday to submit your IP admission notification.

• All authorization requests should be submitted with the appropriate

request form (or face-sheet for emergent IP admissions) and supporting clinical information at the time of request – Non-Emergent Prior Authorization: Supporting clinical information must be submitted at the time of request – Urgent Prior Authorization: Strongly preferred to have clinical information supplied at the time of request, but should never be supplied later than 24 hours – Emergent Admission Notification: Strongly preferred to have clinical information supplied at the time of request, but an extension of 48 hours can be allowed if clinical information is not ready

49

Submission Requirements

• All requests require relevant and current medical information

– Information should be no older than 6 months – Includes relevant exam, lab, x-ray and/or consult results – Includes documentation of response(s) to any prior treatments/therapies tried and the outcome(s)

• Complete the appropriate PA request form in legible handwriting

– Include the treating physician/surgeon NPI # & fax # – Include treating facility NPI # & fax # – All procedure codes that will be billed with diagnoses

• Provider who is performing the service (i.e. should be paid for the service)

should complete the PA request form

• Limit use of Expedited/Urgent requests using the following definitions:

– Treatment required to prevent serious deterioration in member’s health – Could jeopardize member’s ability to regain maximum function – Scheduling services sooner than 4 days prior to obtaining the PA is not a reason to mark as Urgent

50

Submission Requirements – Prior Authorization

Molina is contractually obligated by HFS to make a determination on a Pre-service authorization request within the following timelines: – Elective/Routine Services (Standard Request)

• From the date we receive the request we have four (4) days to

approve, partially approve, or deny the request.

• If insufficient clinical information is submitted with original request, an

extension of four (4) days may be granted to allow time to submit additional information before we must render our decision. – Expedited/Urgent Requests

• From the date we receive the request we have 48 hours (2 days) to

approve, partially approve, or deny the request.

• No extensions may be granted for Urgent requests – no or insufficient

information submitted with Urgent requests may result in a denial of your request. Important Note: We will send the determination to the fax number provided on the

• riginal authorization request from the provider. If you need us to send the decision

to an alternate fax number, please clearly indicate that on your initial request.

51

Submission Requirements

Non Emergent PA Request Timeline Example:

Provider X is requesting to perform a non-emergent tonsillectomy. Request for prior authorization is sent to Molina on Monday February 18th to perform the surgery scheduled in March.

• Since the request is non-emergent, all supporting clinical information must be

submitted by the Provider at the time the request is made on Monday, February 18th

• Molina has four (4) days to approve, partially approve, or deny the request

– If it is determined more clinical information is needed we will inform you of the additional information needed. An extension of four (4) additional days may be granted to send in the additional information to support your request before we make our determination.

• A determination will be issued by Molina on Friday February 22nd if sufficient clinical

information was received with the request or by Tuesday February 26th if more clinical information was required to make a determination and you requested an extension to provide additional information.

52

Submission Requirements

Emergent Timeline Example

Hospital X has a Molina member come in through the emergency room on Monday, February 18th. The member remains in the ER until Tuesday, February 19th when the member is ordered to inpatient status at the Hospital.

• Hospital X has until the next business day (Wednesday February 20th) to submit the

admission notification/authorization request to Molina. – It is strongly preferred the supporting clinical information is provided at the time the authorization request is made to justify the inpatient status

• Molina must issue the decision to the Hospital within 1 day of the notification of

admission or Thursday, February 21 for this example.

• If clinical information is not ready on Wednesday February 20th the Hospital must

still notify Molina of the admission. – The Hospital must still supply the additional clinical information by noon on Thursday to allow time for Molina to review. – If clinical is not received by noon on Thursday, Molina will request clinical information from the Hospital and implement a 48 hours extension.

• If an extension is implemented, the Hospital must send Molina the clinical

information no later than noon from the 3rd day of notification of admission (Saturday, February 23nd for this example).

53

Submission Requirements

Concurrent Reviews & Options for Denied Authorizations

For members who remain IP after the approval timespan:

• Clinical progress update is required within 24 hours (1 day) of the last approved day

based on the information provided from the most recent authorization determination from Molina

• Concurrent review clinical information should be sent via the portal or faxed to the fax

number provided on the most recent determination – Faxed clinical information for concurrent review should contain the Molina authorization number provided with the initial approval, member name, date of birth, date of admit, and the rendering provider/facility.

• For concurrent review, the additional clinical information should only include the

information for clinical days not previously reviewed – not the entire admission (limit to 10 pages)

• If clinical information is not received within 24 hours (1 day) from the last approved

day, Molina will request the information from you and implement a 48 hours (2 day) extension to allow you time provide the clinical information. Molina will communicate to you the date by which clinical is needed. If no clinical information is received, additional IP days may be subject to a denial.

55

Concurrent Review

Options for Denied Authorization Request When an authorization request is denied, a provider has three options to reverse the original decision made by Molina: 1. Reconsideration 2. Peer to Peer (P2P) 3. Post-Service Appeals

56

Options for Denied Authorization Request

Reconsideration is a submission of additional clinical information after the authorization request has been denied. A reconsideration is not an appeal.

• Will be considered only if services have NOT been rendered for Pre-service
• authorizations. (Emergent, IP admissions may still be reconsidered after post-

stabilization services have been rendered or while treatment is ongoing.)

• Must be made within 5 business days of receipt of denial notification.
• Reconsiderations must be submitted to the same fax number (or portal) as the
• riginal request

– Must clearly indicate “Reconsideration” on the cover page – Include the original reference number of the denied authorization

• Submission of additional clinical information for reconsideration available one-time
• nly.
• If denial is upheld, must follow appeal process.

57

Options for Denied Authorization Request

*Reconsideration is not available for MMP members at this time. Providers must follow the post-service appeal process.

Peer-to-Peer (P2P) is when the treating provider requests to speak with a Molina Medical Director to discuss the determination of the request.

• To request a P2P, contact the Molina UM Department at: 1-855-866-5462, press 1, then opt.

4 and a representative will take your request. Our scheduler will call you back with the scheduled date and time of the P2P. Please be prepared to provide the following information when you call: – Patient name and DOB – Molina Authorization number on the denial – Caller name and phone number – Physician name and telephone number who will be conducting the P2P – 3 dates and times physician is available to speak with the Molina Medical Director

• P2P is not available for non-covered services (always check the HFS fee schedule to

determine if the service is covered) or when clinical information has not been submitted for review.

• Request for P2P must be made within 5 business days of receipt of the denial notification.

Requests made after 5 business days will be directed to follow the post-service appeal process.

• If the denial is upheld during the P2P, you must follow the post-service appeal process.

58

Options for Denied Authorization Request

Post Service Appeals are made when services are rendered even though the authorization request had been denied, which resulted in a claim denial for payment. These requests must be made within 90 days from the date or

• riginal payment remit issued by Molina.
• Can be submitted to Molina Healthcare using the Provider Portal

(preferred) or via Fax (855-502-4962) using the Claims Dispute Request Form found at www.molinahealthcare.com

• Post service appeals must include the following for reconsideration:

– Molina claim number from the remit – Medical records demonstrating medical necessity has been met

• Please limit to no more than 10 pages
• Post-service appeals will be reviewed within 60 days

59

Options for Denied Authorization Request

Care Coordination

Case Management Transition of Care

60

Kris Classen, AVP Healthcare Services Erin Willis, Program Coordinator

Statistics Case Management Goals

61

Case Management

• Link members to providers
• Encourage appropriate care
• Link members to community resources
• Outreach members with risk or gaps in

care

• Assessment
• Education
• Support
• 10,223 members in Case Management
• 7,928 with open care plans
• July 2019
• 28,689 Contacts Made
• 716 Care Plans Opened
• 589 Care Plans Closed

Value of Case Management

62

Case Management Success Stories

Case Study 1 Case Study 2

Problem: Level of Care Intervention: Peer to Peer between Medical Director and Primary Care Provider Problem: Engagement and Medical Literacy Intervention: Interdisciplinary Care Team meeting with members Urologist’s nurse

63

Case Management and Provider Collaboration

How can Case Managers help Providers?

Appointment Setting

Complete Prior Authorization Request Locating & Contacting Members

Locate Services Provide Health History

We’re here to help! Contact us at 1-855-687-7861

64

Transition of Care

Member

PCP/Specialist Molina Care Coordination Vendors Member Support

Inpatient Admission of Member Transition of Care Coach Assigned Contact Discharge Planner/Social Worker All discharge needs are provided prior to discharge

65

Transition of Care

Members

Preventative Visit % % of Preventable 30 Day ED Visit % w/ 7 Day Readmit % w/ 30 Day Readmit

With ToC 79% 22% 0% 12% Without ToC 59% 83% 6% 16% Embedded Hospitals

• Chicago Lakeshore Hospital
• Gateway Regional Medical Center
• Hartgrove
• Saint Francis Medical Center
• Riveredge Hospital
• St. Bernard Hospital
• St. Mary’s of Nazareth
• Touchette Regional Hospital

Transitions of Care Success Stories

Case Study 1 Problem: Unable to Contact Intervention: Collaboration of Transition of Care Coach and Therapist Case Study 2 Problem: Frequent Readmission Intervention: Collaboration of Transition of Care Coach and Hospital

Partnering with Providers

• Thresholds
• Lutheran Social Services of

Illinois (LSSI)

• Providers with Specialized

Programs Call to Collaborate: Erin Willis @ (217) 492-5452

Community Engagement

Laurinda Paschal Dodgen Director Community Engagement

Community Engagement Goals

The overarching goals of Community Engagement at Molina are:

• Grassroots execution of initiatives aligned with the company’s strategic & operational plans
• Foster a better understanding of the community’s role in achieving our mission
• Broaden and deepen connections with local communities
• Provide input to policy, corporate programs and practices
• Raise and enhance Molina’s brand awareness (through turnkey programs, Community

Champions and charitable giving)

Molina Community Outreach Events

Community events held/attended by the Community Outreach Team consist of:

• Health/resource fairs
• Education events (where general health/wellness educational information is

provided)

• Formal marketing presentations detailing the Medicaid-Medicare Alignment

program(MMP).

• Helping Hands events (local, hands-on volunteer opportunities for Molina

employees that align with the Molina’s mission to help the populations we serve).

• Community Champions event that recognizes “unsung heroes” in our local

community

Molina Helping Hands

• Molina’s Community Engagement staff
• rganize Helping Hands events (local,

hands-on volunteer opportunities for Molina employees that align with the Molina’s mission to help the populations we serve).

• Available to external partners as a

collaborative event in partnership with Molina staff.

• More information contact Tammy

Lackland: tammy.lackland@molinahealthcare.com

Thanks for Participating!

Appendix

74

Important Authorization Contacts

Authorization Request Type Fax Number Phone Medicaid Inpatient/Outpatient 1 (866) 617-4971 1 (855) 866-5462 press 1, then opt. 4 Medicaid Behavioral Health 1 (866) 617-4971 1 (855) 866-5462 press 1, then opt. 4 Medicaid Radiology Authorizations 1 (877) 731-7218 1 (855) 714-2415 Medicaid Transplant Authorizations 1 (877) 813-1206 1 (855) 714-2415 Medicaid NICU Authorizations 1 (877) 731-1220 1 (855) 714-2415 Medicaid Pharmacy 1 (855) 365-8112 1 (855) 866-5462 opt. 2 MMP Outpatient or Elective IP 1 (844) 251-1450 MMP Inpatient (ER Admits, SNF, LTAC, Rehab) 1 (844) 834-2152 MMP Pharmacy 1 (866) 290-1309 1 (877) 901-8181

*Molina MMP has a dedicated line as indicated in the chart above.

HealthChoice Illinois and HealthChoice Illinois MLTSS Sample Member Identification Card

75

Front

Back

HealthChoice Illinois HealthChoice Illinois MLTSS

Medicare-Medicaid Alignment Initiative (MMP) Sample Member Identification Card

76

77

Submission Requirements

• Complete the member information including phone number
• Select appropriate Elective/Routine or Expedited/Urgent status
• NOTE: Retroactive requests cannot be urgent; retroactive requests will not be

reviewed for medical necessity by Utilization Management and will instead need to be submitted with claim

78

Submission Requirements

• Select setting where service will be performed
• Provide ICD-10 diagnosis code(s), description(s), & CPT codes that will be included
• n bill (remember only covered services should be requested)
• To ensure smooth claims process, include all CPT codes that will be submitted

for payment

• Number of visits/units should reference how many of the actual services/visits being

requested, not the number of codes requested

79

Submission Requirements

• Requesting Physician Information is the provider performing or requesting the

services, including a contact name in the office

• Servicing Facility/Provider is where the services will be rendered & who is wanting

reimbursed for services – hospital, surgicenter, outpatient, etc.

Helpful Tips for Frequently Submitted Requests

Pregnancy and Delivery

• Notification of delivery is our only requirement
• Notify Molina after delivery to include type of delivery, sex of baby & the

nursery type and we will return to you an approval up to the Federal mandate

• If member stays past the Federal mandate, concurrent review with clinical

submission will be required

• Please send us the discharge date and disposition for all cases
• Notification of transfer is required within 24hrs if baby is admitted to NICU

Sleep Studies

• Strongly encourage home sleep studies as first level evaluation

Specialty Pharmacy Drugs

• Requests should be faxed to: 1-855-365-8112

81

Helpful Tips

Wound Therapy

• Must include beginning & ongoing measurements of each wound
• Include all CPT codes that will be submitted on claim
• Note if member being seen at wound clinic
• Start and end dates for wound vacs need to be clearly noted

Durable Medical Equipment (DME)

• Company supplying DME should submit PA request & include all CPT

codes that will be billed to ensure smooth claims processing

• Review quantity and service limits per state fee schedule before submitting

the request

• If requesting above state limits must supply clinical rationale regarding why

this is medically necessary for the member’s condition

82

Helpful Tips

Home Healthcare / Speech Therapy

• Review is required after evaluation, plus six (6) visits
• Please note on PA request form that the evaluation +6 has been completed

– Including date, physician order, evaluation & most recent therapy note with request Inpatient Admissions Discharge Planning

• Acute hospital, Skilled Nursing Facilities (SNF), Rehabilitation, Long Term

Acute Care (LTAC) Facility, Hospice – planning for transfer to SNF LTAC or Rehab should start upon admission or as soon as reasonably indicated by the member’s clinical progression. Transfer requests should not wait until the day the member is ready for discharge. We will gladly process the request even if the exact discharge date is pending.

• Molina has Care Management programs to help with member discharge needs

– please reach out to the nurse reviewer on the case and we will help to connect you with those resources. Non-PAR Providers

• Always require prior authorization with limited exceptions (e.g. Emergency

Room visits, Observation services, etc.)

83

Helpful Tips

Pain Management Procedures

• Always require evidence of conservative management tried first – PT, meds,

activity modification & response to treatment, as well as exams & any imaging results Partial Hospitalization Program (PHP) & Intensive Outpatient Program (IOP)

• Psychiatric partial hospitalization services require prior authorization when

using revenue code 912 or 913.

• Molina does not require prior authorization for intensive outpatient psychiatric

services when billing HCPCS code S9480 alone.

84

Helpful Tips

Successful PA Request Tips

• Check state website to ensure proposed services are covered before

submitting your request

• Check Molina PA Review Guide on our website to determine if PA is required
• Submit relevant clinical notes supporting requested services at the time the

request is made.

• Select Expedited/Urgent or Elective/Routine appropriately (scheduling is not

an appropriate use of an Expedited/Urgent request)

• Have a PA form filled out legibly by the provider who will be billing

for services rendered

• To ensure smooth claims processing submit all CPT codes that will

be submitted on claim

• Allow up to 8 calendar days to complete prior authorization for elective

procedures before scheduling the procedure (14 days for MMP)

• Utilize options available for denied services

85

Helpful Tips

• Frequently Used Forms,

www.molinahealthcare.com/providers/il/medicaid/forms/Pages/fuf.aspx

• 2019 Prior Authorization Codification List,

https://www.molinahealthcare.com/providers/il/medicaid/forms/pages/fuf.as px

• Pre-Service Review Guide
• News & Updates,

www.molinahealthcare.com/providers/il/medicaid/comm/Pages/newsupdates.aspx

• Webinars & Events,

www.molinahealthcare.com/providers/il/medicaid/comm/Pages/updatesevents.aspx

• Provider Portal, https://provider.molinahealthcare.com/provider/login
• Provider Portal Quick Reference Guide,

www.molinahealthcare.com/webportaldocs/Providers/UserManual/Quick%20Refere nce%20Guide.pdf.pdf

86

Available Online Resources