Molina Healthcare. Commitment to Provider Satisfaction
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1 2016 Molina Healthcare Updates 2016 Molina Healthcare Commitment to Provider Satisfaction Molina Healthcare of Ohio is committed to increasing our Provider Partners satisfaction by obtaining your feedback. Some of the ways we do this include: Dedicated Provider Services Representatives in each region of the state for training and on site visits Annual Provider Satisfaction Survey It Matters to Molina Online Survey It Matters to Molina Post Cards Online and Onsite Orientations Provider Forums Please share your feedback through one of our It Matters to Molina postcards or us at so we can continue to provide you with excellent customer service! 1
2 New Vendors New transportation vendor Secure Transportation New dental vendor Scion Dental Recent Changes Reduced Prior Authorization list by 2,500 codes New Medicaid & MyCare combined provider manual 2
3 Provider Online Resources Provider Manuals Provider Online Directories Web Portal Preventive & Clinical Care Guidelines Prior Authorization Information Advanced Directives Claims Information Pharmacy Information Health Insurance Portability and Accountability Act (HIPAA) Fraud, Waste and Abuse Information Communications & Newsletters Member Rights & Responsibilities Contact Information Register for Web Portal Register at You will need the TIN and your Provider Identification number or three of the following: NPI, State License Number, Medicaid Number, or DEA Number. 3
4 Provider Manual Highlights Benefits and Covered Services Interpreter Services Claims, Encounter Data and Compensation Compliance and Fraud, Waste, and Abuse Credentialing and Re credentialing Delegation Oversight Eligibility and Enrollment Health Care Services Health Insurance Portability and Accountability Act (HIPAA) Member Grievances and Appeals Member Rights and Responsibilities Preventive Health Guidelines Provider Responsibilities Quality Improvement Transportation Services Utilization Management, Referral and Authorization The Benefits of Clear Coverage Automatic Authorization Immediate proof ofauthorization Flexibility to submit requests 24/7 Minimal need for phone calls or faxes Ability to attach Medical Records Printable confirmation with authorization number Track status of your requests 4
5 Access to Care Standards Providers will not discriminate against any member on the basis of age, race, creed, color, religion, sex, national origin, sexual orientation, marital status, physical, mental or sensory handicap, place of residence, socioeconomic status, or status as a recipient of Medicaid benefits. Members medical (physical or mental) condition or the expectation of frequent or high cost care may not negatively affect the care received. Providers must give Molina Healthcare 30 days written notice if closing a panel to new members. Office Wait Times Not to exceed 30 minutes All providers are required to monitor waiting times and adhere to the outlined standards After Hours Care Providers must have backup (on call) coverage 24/7 It may be an answering service or recorded message It must instruct members with an emergency to hang up and call 911 or go to the nearest emergency room Access to Care Standards Category Type of Care Access Standard Primary Care Provider Preventive/routine care Within six weeks (general practitioners, internist, family Urgent care By the end of the following work day practitioners, Emergent care Triaged and treated immediately pediatricians) After hours Available by phone 24 hours a day, seven days a week OB/GYN Pregnancy (initial visit) Within two weeks Routine visit Within six weeks Orthopedist Routine visit Within eight weeks Otolaryngologist Routine visit Within six weeks Dermatologist Routine visit Within eight weeks Dental Routine visit Within six weeks Endocrinologist Routine visit Within eight weeks Neurologist Routine visit Within eight weeks Behavioral health Routine care Within 10 business days Urgent care Within 48 hours Non life threatening Within six hours Other non primary care Routine care Within eight weeks All Office wait time Maximum of 30 minutes 5
6 EPSDT Billing Healthchek (EPSDT) Billing Guideline To receive payment for the EPSDT services, bill the appropriate preventive medicine CPT codes, diagnosis codes and EPSDT referral indicators. The referral field indicator (field 24h) must be populated on EPSDT claims. Claims missing this information will be rejected. 11 State Innovation Model (SIM) Focus on paying for value instead of volume. Partnership and standardization to include ODM and MCPs. Adopt episode and patient centered medical home (PCMH) models. Align 50% of Molina s Medicaid claims payment to value oriented programs by
7 Wave 1 W SIM Episodes of Care EPISODES: Asthma*, COPD*, Perinatal*, Acute Percutaneous Coronary Intervention (PCI), Non acute PCI, Joint Replacement LAUNCH: Episode reports released by individual MCPs and ODM. Report release began to Principal Accountable Providers in early * MCP built/released episodes. REPORTING Established Threshold Reporting Performance period: 2016, with tie to incentive (positive and negative) payments to providers which meet defined thresholds SIM Episodes of Care W Wave 2 Wave 3 EPISODES: URI, UTI, cholecystectomy, appendectomy, GI Hemorrhage, Upper GI endoscopy and colonoscopy LAUNCH: Episode reports will be centralized for MCPs and ODM. Reporting Period to began in 2016 for Accountable Providers. Episode design and number will be accelerated during LAUNCH: Early
8 SIM PCMH MODEL DESIGN: In final stages of completion, includes phases along a continuum to a mature/transformed PCMH. Currently evaluating inclusion of Medicare CPC+ (Comprehensive Primary Care) Model. TWO PAYMENT STREAMS: 1. PCMH Operational Activity Payments (PMPM) 2. Quality and Financial Outcomes Based Payments (Total Cost of Care) LAUNCH: 2016, 2 nd Half Communication and engagement with providers 2017, January Implement program with initial provider groups Quality Related Performance Each year, health plan members are chosen randomly and are asked to take a blind survey about how they feel about their doctor, their overall health and their health plan. This survey is conducted by a third party vendor and is known as the Consumer Assessment of Healthcare Providers and Systems (CAHPS). 8
9 Quality Related Performance ODM rated the MCPs on several areas of quality related performance. These are measured through the annual CAHPS Survey: Getting Care Based on member survey responses Does the MCP provide adequate access to care? Can members get care they need, when they need it? Doctors Communication and Service Based on member survey responses Are members happy with their doctors? Do doctors communicate well? Do doctors involve members in decision making about care? Quality Related Performance Areas of quality related performance Keeping Kids Healthy Based on related HEDIS rate results on timeliness of receiving immunizations, recommended well visits and dental visits? Living with Illness Based on related HEDIS rate results related to how well the MCP manages chronic illnesses, e.g. diabetes, hypertension, asthma, depression? Women s Health Based on related HEDIS rate results related to: Do women receive preventive screenings for female cancers and diseases? Do women receive recommended prenatal and postpartum care? 9
10 Quality Related Performance Molina scored above targets for calendar year 2014 on: Keeping Kids Healthy: Well Child Visits 0 15 months old Appropriate Treatment of Children with Upper Respiratory Infection Living with Illness Comprehensive Diabetes Care HbA1c < 8.0% Comprehensive Diabetes Care Annual Eye Exam Comprehensive Diabetes Care Blood Pressure Control Controlling High Blood Pressure 2016 Area s of Opportunity Results for this year (service dates in 2015) are not finalized, but so far indicate that particular attention needs to be focused on: Controlling High Blood Pressure All Well Child and Adolescent Visits and Children s Access to Primary Care Adults Access to Preventive/Ambulatory Health Services Timeliness of Prenatal Care 10
11 Partnership can make a difference We understand the tremendous increase in your office s workload each year due to numerous requests for medical records to support our medical records review projects. To alleviate some of this burden, we would like to partner with you to gain access to Electronic Medical Records (EMR) systems. This should make the collection of medical records less demanding. Molina offers many educational programs to both members and providers focused on improving results on target measures. For EMR access, please contact your Provider Services Representative. ICD 10 Ongoing Communications Health Care Coding Tips We have developed coding tips, called HCC Pearls, to provide better clarity on some of the coding and documentation rules that are applied by the Centers for Medicare and Medicaid Services (CMS). The coding rules can sometimes be confusing and not make sense to the way a clinician is trained. We are utilizing our best information to give providers concise tips on how best to identify, code and document a patient s health status. 11
12 Health Care Coding Tips Our Health Care Coding Tips can be found on our website at under the Health Resources tab. We have already posted many key topics and are adding more all the time, some of the topics listed include: Amending Progress Notes Coding for Acute Conditions after Hospitalization COPD vs Emphysema Diabetes Fractures Primary Cancer Major Depressive Episodes and many more! Provider Online Directory Molina Healthcare providers are encouraged to use the Online Provider Directory on our website to find a network provider or specialist. To find a Molina Healthcare provider, visit /Providers/OH and click Find a Doctor or Pharmacy. 12
13 Provider Bulletin A monthly Provider Bulletin is sent to Molina Healthcare s provider network to report system updates. The Provider Bulletin includes: Prior authorization changes Provider training opportunities Updates to the Molina Healthcare Formulary Changes in policies that could effect claim submission, billing procedures, or appeals Updates to the Molina Provider Web Portal Visit our website at to join our distribution list. Contacting Provider Services Provider Services is available 8 a.m. to 6 p.m. for MyCare Ohio or 8 a.m. to 5 p.m. Monday through Friday for all other lines of business. Call (855) and follow the prompts for services. Care Management Claims/Claims Inquiry Pharmacy Prior Authorizations Web Portal Help Desk Eligibility Utilization Management Behavioral Health Contracting/ Credentialing 13
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