2019 PROVIDER MANUAL Molina Healthcare of Idaho, Inc ...

PROVIDER MANUAL

(Provider Handbook)

Molina Healthcare of Idaho, Inc.

(Molina Healthcare or Molina)

Medicare Plans 2023

Capitalized words or phrases used in this Provider Manual shall have the meaning set forth in your Agreement with Molina Healthcare. "Molina Healthcare" or "Molina" have the same meaning as "Health Plan" in your Agreement. The Provider Manual is customarily updated annually but may be updated more frequently as needed. Providers can access the most current Provider Manual at . Last Updated: 01/2023

Molina Healthcare of Idaho, Inc. Provider Manual Addendum ? January 2023

Section Title:

Provider Responsibilities

Subsection Title:

Ensuring Adequate COVID-19 Safety Protocols for Federal Contractors for Subcontracts Over the Simplified Acquisition Threshold of $250,000

The following language has been removed due to Executive Order 14042 remaining on hold and not being enforced:

Ensuring Adequate COVID-19 Safety Protocols for Federal Contractors for Subcontracts Over the Simplified Acquisition Threshold of $250,000

(a) Definition. As used in this clause "United States or its outlying areas" means: (1) The fifty States; (2) The District of Columbia; (3) The commonwealths of Puerto Rico and the Northern Mariana Islands; (4) The territories of American Samoa, Guam, and the United States Virgin Islands; and (5) The minor outlying islands of Baker Island, Howland Island, Jarvis Island, Johnston Atoll, Kingman Reef, Midway Islands, Navassa Island, Palmyra Atoll, and Wake Atoll.

(b) Authority. This clause implements Executive Order 14042, Ensuring Adequate COVID Safety Protocols for Federal Contractors, dated September 9, 2021 (published in the Federal Register on September 14, 2021, 86 FR 50985).

(c) Compliance. The Provider, a subcontractor, shall comply with all guidance, including guidance conveyed through Frequently Asked Questions, as amended during the performance of this Agreement, for contractor or subcontractor workplace locations published by the Safer Federal Workforce Task Force (Task Force Guidance) at contractors/.

(d) Subcontracts. The Provider shall include the substance of this clause, including this paragraph (d), in subcontracts at any tier that exceed the simplified acquisition threshold, as defined in Federal Acquisition Regulation 2.101 on the date of subcontract award, and are for services, including construction, performed in whole or in part within the United States or its outlying areas."

TABLE OF CONTENTS

1. MEDICARE ADVANTAGE PRODUCTS..................................................................................2 2. CONTACT INFORMATION .................................................................................................. 3 3. PROVIDER RESPONSIBILITIES.............................................................................................7 4. CULTURAL COMPETENCY AND LINGUISTIC SERVICES......................................................17 5. MEMBER RIGHTS AND RESPONSIBILITIES........................................................................22 6. ENROLLMENT IN MEDICARE ADVANTAGE PLANS ........................................................... 23 7. BENEFIT OVERVIEW.........................................................................................................25 8. HEALTH CARE SERVICES (HCS) ......................................................................................... 28 9. BEHAVIORAL HEALTH ...................................................................................................... 48 10. QUALITY .......................................................................................................................... 51 11. RISK ADJUSTMENT MANAGEMENT PROGRAM ............................................................... 66 12. COMPLIANCE...................................................................................................................68 13. CLAIMS AND COMPENSATION ........................................................................................ 86 14. MEDICARE MEMBER GRIEVANCES AND APPEALS ......................................................... 102 15. CREDENTIALING AND RECREDENTIALING......................................................................109 16. DELEGATION..................................................................................................................118 17. MEDICARE PART D.........................................................................................................119 18. MANAGED LONG-TERM SERVICES AND SUPPORT (MLTSS) ........................................... 126 19. APPENDIX 1: HOME AND COMMUNITY BASED SERVICES (HCBS) CODES ...................... 141 20. APPENDIX 2: NURSING FACILITY BILLING GUIDANCE .................................................... 143 21. FREQUENTLY ASKED QUESTIONS (FAQ) ........................................................................ 144

Molina Healthcare of Idaho, Inc. Medicare Advantage Provider Manual

1

Any reference to Molina Members means Molina Medicare Advantage Members.

1. MEDICARE ADVANTAGE PRODUCTS

Medicare Products Overview

Molina Medicare Complete Care (HMO D-SNP)

Molina Medicare Complete Care (HMO D-SNP) is Molina's Dual Eligible Special Needs Plan (DSNP) designed for beneficiaries who are eligible for both Medicare and Medicaid (dual eligible). This plan offers all services covered by Original Medicare Parts A and B, prescription drug coverage, and more. This plan coordinates benefits of Medicare and Medicaid in order to provide quality health care coverage and service with little out-of-pocket costs.

Molina Medicare Complete Care Select (HMO D-SNP)

Molina Medicare Complete Care Select (HMO D-SNP) is Molina's Dual Eligible Special Needs Plan (D-SNP) designed for beneficiaries who are eligible for both Medicare and Medicaid (dual eligible). This plan offers all services covered by Original Medicare Parts A and B, prescription drug coverage, and more. This plan coordinates benefits of Medicare and Medicaid in order to provide quality health care coverage and service with little out-of-pocket costs.

Molina Medicare Choice Care (HMO)

Molina Medicare Choice Care (HMO) is Molina's Medicare Advantage and Prescription Drug plan designed for beneficiaries who are eligible for Medicare Part A and B. This plan offers all services covered by Original Medicare Parts A and B, prescription drug coverage, and more.

Molina Healthcare of Idaho, Inc. Medicare Advantage Provider Manual

2

Any reference to Molina Members means Molina Medicare Advantage Members.

2. CONTACT INFORMATION

Molina Healthcare of Idaho, Inc. 7050 Union Park Center, Suite 200 Midvale, UT 84047

Provider Services Department

The Provider Services department handles telephone and written inquiries from Providers regarding address and Tax-ID changes, contracting, and training. The department has Provider Services representatives who serve all of Molina's Provider network. Eligibility verifications can be conducted at your convenience via the Availity Essentials portal.

Availity Essentials portal: provider. Email: MHIDProviderSvcReq@ Phone: (844) 239-4914

Member Services Department

The Member Services department handles all telephone and written inquiries regarding Member Claims, benefits, eligibility/identification, Pharmacy inquiries, selecting or changing Primary Care Providers (PCP), and Member complaints. Member Services representatives are available 8 a.m. to 8 p.m. MST. Monday through Friday, excluding State holidays. Eligibility verifications can be conducted at your convenience via the Availity Essentials portal.

Molina Medicare Complete Care (HMO SNP) ? (844) 239-4913 Molina Medicare Choice Care (HMO) ? (844) 560-9811 Hearing Impaired (TTY/TDD): 711 Relay

Claims Department

Molina strongly encourages Participating Providers to submit Claims electronically (via a clearinghouse or the Availity Essentials portal) whenever possible. ? Access the Availity Essentials portal at provider. ? EDI Payer ID number 61799 ? For Paper Claims submittal for Idaho:

Molina Healthcare of Idaho, Inc. PO Box 22617 Long Beach, CA 90801

To verify the status of your Claims, please use the Availity Essentials portal. Claims questions can be submitted through the chat feature on the Availity Essentials portal or contact Provider Services.

Molina Healthcare of Idaho, Inc. Medicare Advantage Provider Manual

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Any reference to Molina Members means Molina Medicare Advantage Members.

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