Systems
The state system that allows agents to check member eligibility.
What is ProviderOne?
The two types of hard edits used when claims are flagged for FWA or high dollar amounts.
IHT and CES edits
The team that assists with contracts and rate questions.
Who are provider service representatives (PSR).
The amount of time a provider has to submit a claim for payment.
What is Timely filing?
This team helps understand over payments and advance requests.
What is the claims recovery department/ cost recovery department?
This is where we go to see if checks have been cashed.
What is US Bank
Codes billed on a claim in addition to a primary code.
What are add on codes?
The form used to update provider information.
What is the Provider Information Update Request Form?
General timely filing for PAR Providers
What is 180 days from discharge or DOS?
The term for Molina holding funds paid on a claim because we have over paid a provider on previous claims.
What is an advance or takeback?
This is where agents go to view CPT benefits.
What is the WA reference database?
These codes indicate if a member arrived at a hospital wit a predetermined illness or condition.
What are POA indicators.
Tribal Providers with questions about denied claims reach out to this department and contact.
What is claims department representative Shawnna Neuser?
General timely filing for non-par providers
What is 365 days from discharge or DOS?
When Molina identifies that we are not responsible for a claim we've already paid, this process is called:
What is a reversal?
This system provides additional information about all types of provider codes from diagnosis to CPT and Modifiers.
What is EncoderPro?
A flat rate payment made based on predetermined factors like:
Age
Gender
Presence of complications.
DRG payment/ DRG codes
A group of providers that manage, organizes and pays for the member's care.
What are PCP Capitated Groups?
Timely filing for a member with primary insurance starts here.
What is the primary payment/ EOB date?
Reversals happen for a variety of reasons, some of these include:
What are
• COB – we originally paid the claim as primary but discover a member has another primary insurance carrier
• Corrected Claims – the provider submits a corrected claim to Molina. The corrected claim is processed and paid, and original claim is reversed.
• Audits - an audit is done on an HCI edit and a claim was corrected
This third party vendor check claims and applies edits for fraud, waste, and abuse . It has a separate tool to review these edits.
What is I Health Technologies /(IHT tool)
Per DHS instructions, lines 1 and 2 of a claim will always pay when using these two modifiers.
What is U1 and U2?
Reasons providers might request member guidance.
What are:
• The member wants to self refer to various Specialists without allowing the provider to run the appropriate and necessary tests
• The member wants a specific brand prescription and the provider has tried to explain step therapy which the member refuses to follow
• The member is always late to their appointments and the provider has explained they will be dropped if this behavior persists
• The member’s health is not improving because they don’t follow the provider’s treatment and/or care plan(s)
• The member acts inappropriately at the providers office impacting the providers office setting.
The timeframe for claims processed incorrectly by Molina.
What is 24 months from the original denial date?
The following are circumstances when claims process appropriately as paid and the paid amount is zero.
What are:
APC/OPPS Contract pricing
Benefit Exceptions
PCP Capitated Groups
DRG Claims
and ASC Claims