Molina Healthcare Prior Authorization Prior Authorization is a - - PowerPoint PPT Presentation

Molina Healthcare

Prior Authorization

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

Molina requires prior authorization for specified services as long as the requirement complies with Federal or State Molina requires prior authorization for specified services as long as the requirement complies with Federal or State regulations and the Molina Hospital or Provider Network Management Agreement. 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 available in narrative form, along with a more detailed list by CPT and HCPCS codes. Services performed without authorization may not be eligible for payment.

Prior Authorization Request

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. Services provided emergently (as defined by Federal and State law) are excluded from the prior authorization requirements. Molina does not “retroactively” authorize services that require prior authorization. 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

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
• 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

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. services. The Prior Authorization (PA) form is available to providers at: http://www.molinahealthcare.com/providers/il/medicaid/forms/Pages/fuf.aspx

Billing Members

Providers contracted with Molina cannot bill the Member for any covered benefits. The provider is responsible for verifying eligibility and obtaining approval for those services that require prior authorization.

• Providers agree that under no circumstance shall a Member be liable to the provider for any sums owed by Molina

to the provider

• Provider agrees to accept payment from Molina as payment in full, or bill the appropriate responsible party
• Provider may not bill a Molina Member for any unpaid portion of the bill or for a claim that is not paid with the

following exceptions: following exceptions:

• The Member has been advised by the provider that the service is not a covered benefit and the provider has

documentation.

• The Member has been advised by the provider that he/she is not contracted with Molina and has

documentation.

• The Member agrees in writing to have the service provided with full knowledge that they are financially

responsible for payment.

Claim Standards

Molina Healthcare processes more than 90% of claims received within 30 calendar days, and 99% of claims are processed within 90 days following receipt. These standards must be met in order for Molina Healthcare to remain compliant with State requirements and ensure Providers are paid in a timely manner.

The following information must be included on every claim:

• Place and type of service code.
• Days or units as applicable.
• Provider tax identification.
• National Provider Identifier (NPI).
• Member name, date of birth and Molina Member ID

number.

• Member’s gender.
• Member’s address.
• National Provider Identifier (NPI).
• Rendering provider as applicable.
• Provider name and billing address.
• Place of service and type (for facilities).
• Disclosure of any other health benefit plans.
• E-signature.
• Service Facility Location.
• Member’s address.
• Date(s) of service.
• Valid International Classification of Diseases diagnosis

and procedure codes.

• Valid revenue, CPT or HCPCS for services or items

provided.

• Valid Diagnosis Pointers.
• Total billed charges for service provided.

Claim Submission

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
• ffers 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)

Participating providers are required to enroll for Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA). Providers who enroll in EFT payments will automatically receive ERAs as well. EFT/ERA services allow providers to reduce paperwork, provides searchable ERAs, and providers receive payment and ERA access faster than the paper check and RA processes. There is no cost to the provider for EFT enrollment, and providers are not required to be in-network to enroll.

Timely Claim Filing

Providers shall promptly submit to Molina Claims for Covered Services rendered to Members. All Claims shall be submitted in a form acceptable to and approved by Molina, and shall include any and all medical records pertaining to the Claim if requested by Molina or otherwise required by Molina’s policies and procedures. Claims must be submitted by provider to Molina within 180 calendar days after the discharge for inpatient services or the Date of Service for outpatient services. If Molina is not the primary payer under coordination of benefits or third party liability, provider must submit Claims to Molina within 90 calendar days after final determination by the primary payer.

Coding Requirements

Correct coding is required to properly process claims. Molina requires that all claims be coded in accordance with the HIPAA transaction code set guidelines and follow the guidelines within each code set.

CPT and HCPCS Codes

Codes must be submitted in accordance with the chapter and code-specific guidelines set forth in the current/applicable version of the AMA CPT and HCPCS codebooks. In order to ensure proper and timely reimbursement, codes must be effective on the date of service (DOS) for which the procedure or service was rendered and not the date of submission.

ICD-10-CM/PCS Codes

Molina utilizes ICD-10-CM and PCS billing rules, and will deny claims that do not meet the Plan’s ICD-10 Claim Submission Guidelines. In order to ensure proper and timely reimbursement, codes must be effective on the dates of service (DOS) for which the procedure or service was rendered and not the date of submission.

Coding Requirements

Modifiers

Modifiers consist of two alphanumeric characters and are appended to HCPCS/CPT codes to provide additional information about the services rendered. Modifiers may be appended only if the clinical circumstances justify the use of the modifier(s).

Place of Service Codes

Place of Service Codes are two-digit codes placed on health care professional claims (CMS 1500) to indicate the setting in which a service was provided.

Type of Bill Codes Type of Bill Codes

Type of bill is a four-digit alphanumeric code that gives three specific pieces of information after the first digit, a leading zero. The second digit identifies the type of facility. The third classifies the type of care. The fourth indicates the sequence of the bill in this particular episode of care, also referred to as a “frequency” code.

Revenue Codes

Revenue codes are four-digit codes used to identify specific accommodation and/or ancillary charges. There are certain revenue codes that require CPT/HCPCS codes to be billed.

Diagnosis Related Group (DRG)

Facilities contracted to use DRG payment methodology submit claims with DRG coding. Claims submitted for payment by DRG must contain the minimum requirements to ensure accurate claim payment. The Plan processes DRG claims through DRG software. If the submitted DRG and system-assigned DRG differ, the Plan-assigned DRG will take precedence. Providers may appeal with medical record documentation to support the ICD- 10-CM principal and secondary diagnoses (if applicable) and/or the ICD-10-PCS procedure codes (if applicable). If the claim cannot be grouped due to insufficient information, it will be denied and returned for lack of sufficient information.

National Drug Code Number

Coding Requirements

National Drug Code Number

The 11 digit National Drug Code Number (NDC) must be reported on all professional and outpatient claims when submitted on the CMS-1500 claim form, UB-04 or its electronic equivalent. Providers will need to submit claims with both HCPCS and NDC codes with the exact NDC that appears on the medication packaging in the 5-4-2 digit format (i.e. xxxxx-xxxx-xx) as well as the NDC units and descriptors. Claims submitted without the NDC number will be denied.

Claim Editing Process

Molina has a claims pre-payment auditing process that identifies frequent billing errors such as:

• Bundling and unbundling coding errors
• Duplicate claims
• Services included in global care
• Incorrect coding of services rendered

Coding edits are generally based on state fee-for-service Medicaid edits, AMA, Current Procedural Coding edits are generally based on state fee-for-service Medicaid edits, AMA, Current Procedural Terminology (CPT), HRSA and National Correct Code Initiative (NCCI) guidelines.

Claim Rejections

Claims are rejected for two reasons:

• Non-compliant claim rejections – These are claims that do not meet the HIPAA standards and do not pass

the minimum Strategic National Implementation Process (SNIP) claim edits. These claims are not considered clean claims and therefore are ineligible to be processed through the Molina’s claims system for determination of

• payment. These claims do not even enter the claims system.
• Compliant claim rejections – These are claims that meet the HIPAA standards and also pass the Strategic

National Implementation Process (SNIP) claim edits. These claims are considered clean claims. These claims may National Implementation Process (SNIP) claim edits. These claims are considered clean claims. These claims may enter the payer claims system but do not pass further into adjudication and payment processing due to missing administrative elements on the claim. Examples of missing administrative elements include taxonomy code, value codes, occurrence codes, modifier codes, billed units, covered days, notes, and NDC codes. In most cases, once the administrative element is added and the claim is resubmitted by the provider to the MCO, the claim may be accepted.

Corrected Claims

Corrected Claims are considered new Claims for processing purposes. Corrected Claims must be submitted electronically with the appropriate fields on the 837I or 837P completed. Molina’s Provider Portal includes functionality to submit corrected Institutional and Professional claims. Corrected claims must include the correct coding to denote if the claim is Replacement of Prior Claim or Corrected Claim for an 837I or the correct Resubmission Code for an 837P.

Claim 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:

• 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
• The claim number clearly marked on all supporting documents

These requests shall be classified as a Claims Disputes/Adjustment and be sent to the following address: Molina Healthcare of Illinois Attention: Claims Disputes / Adjustments 1520 Kensington Rd., Suite 212 Oak Brook, IL 60523 Fax: (855) 502-4962

Claim Auditing

Provider acknowledges Molina’s right to conduct post-payment billing audits. Provider shall cooperate with Molina’s audits of Claims and payments by providing access at reasonable times to requested Claims information, all supporting medical records, provider’s charging policies, and other related data. Molina shall use established industry Claims adjudication and/or clinical practices, State, and Federal guidelines, and/or Molina’s policies and data to determine the appropriateness of the billing, coding, and payment.