NEWS October Molina Healthcare Secures New Transportation Vendor

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1 NEWS October 2015 Molina Healthcare Secures New Transportation Vendor On December 1, 2015 Molina Healthcare (Molina) will transition its transportation vendor from LogistiCare to Secure Transportation, for all regions in Illinois. Secure also will provide transportation for Molina s additional service area of Cook County, effective Jan. 1. Secure Transportation has been in business since 1980, originally serving Members in Southern California, with Non-Emergency Medical Transportation. Routine medical transportation is a benefit for Molina Members. It is designed to help get Members to their Provider visits, including: Medical or dental appointments Pharmacy locations to pick up medication Ongoing care, such as physical therapy Scheduling Transportation Members in need of transportation may call Secure Transportation at least three days in advance, but no more than 30 days before the appointment, to make a reservation. Please have the following information when making a reservation: Member ID Name and address of Provider Appointment date and time Pick-up time and location Find a Provider For a complete list of Providers in the Molina Healthcare network, visit and click on the I m a Professional option. Search under the Find a Provider section. You may also follow this link for access: https:// providersearch.molinahealthcare.com/ Provider/ProviderSearch? RedirectFrom=MolinaStaticWeb HCC Pearls Molina s HCC Pearls program focuses on the coding and documentation rules (Hierarchical Condition Category HCC) applied by the Centers for Medicare and Medicaid Services (CMS). HCC Pearls are concise tips for effectively and easily identifying, coding, and documenting the health status of your patients. Included in this month s packet are: Long-Term Use of Insulin Diabetes with Vascular Manifestations Diabetes with Eye Manifestations Additional HCC Pearls can be found at providers/il/duals/comm/pages/hccpearls.aspx ILPS1510.1

2 Molina Healthcare Supports the Patient Centered Medical Home Model Molina Healthcare of Illinois is working to support the transformation of primary care to the Patient-Centered Medical Home (PCMH) model. PCMH is a concept of care that began in the mid- 1960s and originally referred to a primary care environment that would provide care coordination to children with special health care needs. Recognizing that healthcare has become increasingly complex for everyone, ten years ago, several primary care societies developed set joint principles, outlining a model of care that is comprehensive, continuous, coordinated, culturally-competent, safe, accessible and effective. Since then, multiple studies have documented that the model provides better outcomes at lower costs, as well as improving consumer satisfaction. Achieving the goals of the PCMH model takes considerable investment. Molina supports the PCMH in three ways. 1. Molina provides educational support to Primary Care Providers (PCPs) to develop new systems of care and obtain PCMH certification. 2. The Molina Quality team provides tools such as reports that show which Members have missed needed services, which enhance the ability of PCPs to manage the healthcare of their entire patient population a critical feature of the medical home. 3. Molina supplements care coordination services provided at PCP offices with a team of nurses, pharmacists, and community health workers. The Molina care coordination team arranges appointments with various specialists, visits patients in their homes to educate them on self-management, and provides additional services such as medical therapy management to help patients understand and adhere to their medication regimens. PCMH is the foundation to high-quality healthcare and Molina is working to ensure that every Molina Member has a home sweet medical-home. For more information on the PCMH model, visit the Patient-Centered Primary Care Collaborative at Member Care Plans Now Available Via the Molina Healthcare Web Portal Providers are now able to access Molina Healthcare s High Risk MMP Care Plans by visiting the Molina Website. Care plans may only be accessed when Members agree to share this information with their Providers. Please follow the steps listed below to access care plans. Contact Provider Services at (855) from 8 a.m. to 5p.m. (CST), Monday through Friday if you have any questions. Visit and select the Health Care Professional option. Click on the Sign In icon and enter your User ID and Password. Select Member Eligibility at the top of the screen. Enter the Member ID or Member First Name, Last Name, and Date of Birth then click Search for Member to proceed. Click on the Member Health Record tab to locate the care plan available within this tab. Providers may request high risk member care plans for other Molina Healthcare programs via their Provider Services Representative. 2

3 Durable Medical Equipment (DME) - Guidelines for Claims Submission and Billing Billing Guide: DME Providers must bill on a 837P/CMS 1500 Providers must be registered with the Illinois Medicaid Assistance Program (MAP). The following is a link to register with MAP: a. Categories of service for which a Provider may be enrolled for: a. Category 41, Medical Equipment/Prosthetic Devices b. Category 48, Medical Supplies The Handbook for Providers of Medical Equipment and Supplies, Chapter M-200 Policy and Procedures for Medical Equipment and Supplies, in section M-204, identifies non-covered services HFS publishes maximum quantity limits, provided at this link: SiteCollectionDocuments/DMEFeeSchedule.pdf Specific DME requests require prior authorization, per the Molina Provider Handbook and guidelines. a. Verify code specific DME by contacting Molina Prior Authorization Department at (855) or via fax at (866) b. Review Molina s codification list located on the Molina Website: Upcoming Provider Education Webinars Illinois Department of Healthcare and Family Services (HFS) requires all contracted health plans to provide Covered Services in a culturally competent manner by ensuring the cultural competence of the Provider Network. Molina makes it easy for Providers to meet the requirement by offering trainings via webinar. Molina will host the following monthly webinars from October through December: Cultural Competency and Compliance Training and a special orientation for long-term care facilities. The online presentations are open to all Molina Providers and Providers not contracted with Molina, office staff, and clinical staff. To register, Providers should select Communications, and then Webinars and Events, on Details for the sessions are as follows: Cultural Competency and Compliance Training Tuesday, October 13, 2015 at 10 a.m. CST Tuesday, November 17, 2015 at 10 a.m. CST Tuesday, December 15, 2015 at 10 a.m. CST Long-Term Care Provider Orientation Tuesday, October 13, 2015 at 1 p.m. CST Tuesday, November 17, 2015 at 1 p.m. CST Tuesday, December 15, 2015 at 1 p.m. CST 3

4 Medical Records Molina Healthcare conducts regular medical record reviews for all Molina- contracted Providers. The process involves a review of the following components: Medical record confidentiality and release of medical records including behavioral health care records Medical record content and documentation standards, including preventive healthcare Storage maintenance and disposal Questions? Process for archiving medical records and implementing improvement activities Providers have a contractual arrangement to provide both Molina and Members access to the Members health information including, but not limited to, medical records and billing records, in accordance with applicable law, applicable government programs, and Molina s policies and procedures. Molina uses these medical records, to be available upon request, for purposes of quality improvement and utilization management. More information can be found within the Molina Provider Manual under the Contractual Obligations Section. Medical Records, Section 9.2 of the manual also provides more information. For additional information, please contact your Provider Services Representative or call (855) Provider Services Representative Territories A Provider Services Representative Territories Map, which includes contact information for each representative and the counties they cover, is included in this month s packet. Annual Comprehensive Exam Molina conducts a yearly Risk Adjustment Program for our Medicare-Medicaid Plan (MMP) Members using an Annual Comprehensive Exam (ACE) process. This process allows Molina to correctly identify the current health status of Members. During the first quarter 2016, Molina will deliver packets containing ACE forms and instructions for each identified Molina Member assigned to your practice. You may use your own progress note or Electronic Medical Records (EMR) to document the comprehensive examination. A sample copy of your EMR must be sent to the for prior approval. Contract Manager Territories To locate the Molina Contract Manager assigned to your county, please reference the Contract Manager Territories Map document included in this packet. Further information will be available in future Provider communications. Please reach out to your Provider Service Representative or your Quality Improvement Specialist or call (855) if you have any questions. 44

5 Molina Healthcare Coding Tips Diabetes with Vascular Manifestations EMR Documentation Examples: A/P: 72 year old male with DM w/ vascular manifestations, controlled ICD9 Code: ICD-10 Code: E11.51 Welcome to the Molina Healthcare Coding Institute Molina Healthcare is committed to supporting your clinical practice. Please take a moment to review this HCC Pearl. Assessment: well controlled Plan: Continue ASA, ACE Inhibitor and statin daily 72 year old male with Peripheral Angiopathy in other Disease ICD-9 Code: Molina Healthcare is committed to supporting your clinical practice. Please take a moment to review this HCC Pearl on DM with vascular manifestations. The role of glycemic control on microvascular disease in type 2 diabetes was documented in the United Kingdom Prospective Diabetes Study (UKPDS). Many studies suggest a correlation between higher rates of cardiovascular disease (CVD) and chronic hyperglycemia, thus it is our responsibility to screen, prevent and treat these complications in our patients. The clinical evidence supports initiating intensive therapy to target Hgba1c goals as early as possible in the course of Diabetes. Aggressive cardiac risk reduction (smoking cessation, aspirin, blood pressure control, reduction in serum lipids, preferably using a statin, diet, exercise, and, in high-risk patients, an angiotensin-converting enzyme inhibitor) should be the goal for Type 2 Diabetics. ICD-10 Code: E11.51 Assessment: well controlled Plan: Continue current therapy Paper Charting Documentation A/P: 64 year old female with Diabetic Vascular Disease, uncontrolled and atherosclerosis of left leg ICD-9 Code: , ICD-10 Code: E11.59, E11.65, I Assessment: Progressive disease based on clinical findings Plan: Recommend tighter glucose control, smoking cessation and compliance with medications to reduce risk of further CVD disease Have Questions? Contact: The information presented herein is for informational purposes only. It is not intended, nor is it to be used, to define a standard of care or otherwise substitute for informed medical evaluation, diagnosis and treatment which can be performed by a qualified medical professional. Molina Healthcare Inc. does not warrant or represent that the information contained herein is accurate or free from defects.

6 Molina Healthcare Coding Tips When Do I Use the Code For Long-Term Use of Insulin? Documentation Examples: Managing Existing Long-Term Insulin 65 year old man with diabetes using insulin daily Assessment: Poorly controlled HgbA1c of 9.4 Welcome to the Molina Healthcare Coding Institute Molina Healthcare is committed to supporting your clinical practice. Please take a moment to review this HCC Pearl. Plan: Extensive counseling provided, answered patient questions and increase dose of Lantus by 2 units ICD-9 Code : V58.67 ICD-10 Code : Z79.4 Starting Long-Term Insulin The use of Insulin in the diabetic population is quite prevalent, and we hope that all providers are aware of the various means to help patient s achieve HgbA1c goals and control this challenging and usually progressive disorder. There are numerous forms of insulin being used in the healthcare community, it is important that we consider that managing patients who use insulin requires significant training for clinicians, patients and their families to ensure patient safety is not compromised. CMS recognizes that when introducing, managing or adjusting insulin believed to be needed for the chronic management of Diabetes additional time and care must be attributed to this patient. Documentation of this code helps illustrate the increased complexity of patients who require this treatment. 58 year old woman newly diagnosed with diabetes starting insulin after labs revealed DM Assessment: Uncontrolled fasting blood glucose (FBG) of 480 with Hgba1c of 11.1 suggestive of need for insulin therapy Plan: Extensive education provided. Refer to Certified Diabetic Educator. Start Glucophage XR 500 mg daily. Start 2 units of Regular insulin with each meal. Follow up in 5 days. ICD-9 Code: V58.67 ICD-10 Code: Z79.4 Have Questions? Contact: The information presented herein is for informational purposes only. It is not intended, nor is it to be used, to define a standard of care or otherwise substitute for informed medical evaluation, diagnosis and treatment which can be performed by a qualified medical professional. Molina Healthcare Inc. does not warrant or represent that the information contained herein is accurate or free from defects.

7 Molina Healthcare Coding Tips Diabetes with Eye Manifestations Documentation Examples: A/P: Welcome to the Molina Healthcare Coding Institute Molina Healthcare is committed to supporting your clinical practice. Please take a moment to review this HCC Pearl. Diabetic patients are at high risk of developing eye manifestations. The ADA recommends annual screening for all diabetics with a dilated retinal examination. The practice of identifying and treating eye disorders is in order to prevent noncongenital blindness. Diabetes is the most common cause of non-congenital vision lost in the United States. It is also quite important to remember that cataracts in the setting of Diabetes are commonly seen. It is important to document accurately this condition which is a very common eye manifestation known as a Diabetic cataract. ICD-10 Note: DM with the following statuses should be coded by type, with hyperglycemia: Poorly controlled, out of control, uncontrolled A/P: 52 year old Asian male with Diabetic Macular Edema, uncontrolled ICD , , ICD-10: E11.311, E11.65 Assessment: worsening vision loss Plan: recommend tighter glycemic control, refer to Ophthalmologist 62 year old Black male with Diabetic Proliferative Retinopathy ICD-9: , ICD-10: E Assessment: noncompliant with recommendations Plan: recommend close follow up with CDE and Eye care specialist 61 year old Russian female with Type 1 Diabetic Retinopathy, controlled ICD , ICD-10: E Assessment: Stable Plan: Will monitor 58 year old White female with Diabetic Cataract ICD-9: ICD-10: E11.36 Assessment: Snelling testing without change Plan: Continue care with Ophthalmology and repeat labs as discussed Have Questions? Contact: The information presented herein is for informational purposes only. It is not intended, nor is it to be used, to define a standard of care or otherwise substitute for informed medical evaluation, diagnosis and treatment which can be performed by a qualified medical professional. Molina Healthcare Inc. does not warrant or represent that the information contained herein is accurate or free from defects.

8 September 9, 2015 Provider Memorandum Easier-to-Read Explanation of Payment Statements As part of Molina Healthcare of Illinois (Molina) ongoing efforts to incorporate feedback and continuously improve the service we offer Providers, Molina is making its Explanation of Payment (EOP) statements easier to read. What Providers can expect? Effective September 9, 2015, amounts previously listed under the Coordination of Benefits (COB) field for the Program: MMP Medicare will now be listed under the co-pay, coinsurance and deductible fields. The change aims to improve the clarity of the information presented and applies to both the electronic and paper versions of Molina Healthcare s Medicare Medicaid Plan (MMP) EOPs. A special reminder: MMP Members are not liable for Medicare Part A and B cost sharing, including deductibles, coinsurance and copayments. Questions? Please call Provider Services at , Monday through Friday between 8:00 a.m. and 5:00 p.m. Thank you for your continued service to Molina Healthcare Members. Sample Explanation of Payment Statement - Electronic Remittance Advice (835) PS

9 Sample MMP Explanation of Payment Statement (Paper Remittance Advice) with co-insurance and deductible

10 Sample MMP Explanation of Payment Statement (Paper Remittance Advice) with co-payment ample MMP Explanation of Payment Statement (Paper Remittance Advice

11 Sample MMP Explanation of Payment Statement (Paper Remittance Advice) with co-payment

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13 Provider Services Representative Territories Jared Fritz - Manager, Provider Services (217) Manages and oversees Provider Service Representatives Ensures State-escalated Provider complaints are timely addressed and resolved JO DAVIESS STEPHENSON CARROLL WHITESIDE LEE WINNEBAGO OGLE BOONE DE KALB MCHENRY KANE LAKE DU PAGE COOK Evanston Chicago Maywood Orland Park KENDALL Provider Service Representatives ROCK ISLAND MERCER WARREN HENDERSON HENRY KNOX BUREAU LA SALLE PUTNAM GRUNDY STARK MARSHALL PEORIA WOODFORD LIVINGSTON WILL KANKAKEE IROQUOIS Service Area Counties Non Service Area Counties Jonathan Jackson (312) Candace Peters - Excl. Memorial (217) Erin Wilson (815) MCDONOUGH FORD TAZEWELL MCLEAN HANCOCK FULTON SCHUYLER MASON DE WITT VERMILION LOGAN CHAMPAIGN ADAMS BROWN MENARD CASS PIATT MACON SANGAMON DOUGLAS MORGAN MOULTRIE EDGAR PIKE SCOTT CHRISTIAN COLES GREENE SHELBY MONTGOMERY CUMBERLAND CLARK MACOUPIN CALHOUN JERSEY EFFINGHAM JASPER FAYETTE CRAWFORD BOND MADISON RICHLAND CLAY CLINTON MARION LAWRENCE Ethan Muench (224) Michelle Atkins - BJC, WashU, Missouri (618) Christina Dorsett (217) ST. CLAIR WABASH WAYNE WASHINGTON EDWARDS MONROE JEFFERSON PERRY WHITE FRANKLIN HAMILTON RANDOLPH JACKSON SALINE GALLATIN WILLIAMSON HARDIN UNION POPE JOHNSON PULASKI ALEXANDER MASSAC Marietta Miner - Tenet, SSM, SluCare (618) Nancy Roots - Memorial (309)

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15 Contract Manager Territories Kim Gallaher - Manager, Provider Contracts (331) Manages and oversees all provider contracting Creates and implements Provider contracting strategies Responsible for single case agreement negotiation Handles out-of-state and national provider requests JO DAVIESS STEPHENSON CARROLL WHITESIDE WINNEBAGO OGLE LEE BOONE DE KALB MCHENRY KANE LAKE DU PAGE COOK Evanston Chicago Maywood Orland Park KENDALL ROCK ISLAND MERCER HENRY BUREAU PUTNAM LA SALLE GRUNDY WILL Contract Managers WARREN HENDERSON KNOX STARK PEORIA MARSHALL WOODFORD LIVINGSTON KANKAKEE IROQUOIS Service Area Counties Non Service Area Counties Sharon Moloney (309) HANCOCK ADAMS Diane Michael - BJC, WashU, SIHF, SSM, SIU (217) MCDONOUGH BROWN Sharetta Thomas - St. Louis Area & Southern Illinois (excl. BJC, WashU, SIHF, SSM, SIU) (618) PIKE SCHUYLER CALHOUN SCOTT GREENE FULTON CASS JERSEY MORGAN MONROE MASON MACOUPIN MADISON ST. CLAIR MENARD SANGAMON TAZEWELL BOND LOGAN CLINTON CHRISTIAN MONTGOMERY WASHINGTON FAYETTE MCLEAN DE WITT MACON MARION SHELBY JEFFERSON PIATT MOULTRIE EFFINGHAM CLAY FORD CHAMPAIGN DOUGLAS COLES CUMBERLAND WAYNE JASPER RICHLAND EDWARDS VERMILION CLARK EDGAR CRAWFORD LAWRENCE WABASH Sara Degrofft (217) RANDOLPH PERRY JACKSON FRANKLIN WILLIAMSON WHITE HAMILTON SALINE GALLATIN Michael Manade (630) UNION POPE JOHNSON PULASKI ALEXANDER MASSAC HARDIN Heather Wantland-Welch heather.wantland Caitlin Callahan

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