Eligibility
The effective dates are located here.
2 accepted answers:
What is the details tab or what is the enrollment tab?
Providers can review a list of the covered services here.
What is the Provider manuals?
This a list of services that require an authorization.
What is the PA matrix?
This is a listing of covered medication under the members plan.
What is the formulary?
Common reasons a provider may not be in Molina systems:
Provider is in a different state than the member
Provider doesn't bill with us often
Provider hasn't billed with us before
Provider recently attested and hasn't been added to the system yet
When we should document under "Temporary provider"?
The patient needs to reach out to the state.
What happens when the member enrollment has termed?
This code is used to search the covered services.
What is the Current Procedural Terminology Code?
These medical services are exceeding the limitation.
When a a Prior authorization is required?
This is the primary resource for specific pharmacy-related inquiries .
What is CVS/Caremark?
Providers not on file can still be HIPAA verified though this system.
What is NPPES / NPI Registry ?
This can only be sent to Providers
What is proof of eligibility?
Arch supports would be considered this type of coverage.
What are prosthetics?
This is when the authorization number can be provided to the caller .
What is the approved authorization?
They will handle any overrides for refills too soon for:
Who is the CVS Helpdesk?
These 2 forms are required to begin credentialing and contracting process.
What is the Provider request form and W( form?
The information in SF does not match what the state enrollment shows.
What is an eligibility discrepancy ?
An alphanumeric code beginning with the letter “D”
What are dental codes?
Current patient history
Relevant physical examination
Relevant lab or radiology results
Relevant specialty consultation notes
What is considered supportive documentation?
When provider says, the medication is rejecting or we’re having difficulty filling this medication. (Case Type)
What is
Case Type: MEDICAL CARE
Case Reason: Prescription Fulfillment
?
Providers can be participating and not participating at the same time depending in this.
Who is the affiliated group or plan?
This can be verified by the Segment type.
Is the primary coverage internal with Molina or external?
There is only a specific amount of services that will be allowed.
What is a benefit limitation?
Federal guidelines requires at least 30 days have passed between the date of the individual’s signature for this service to be performed.
What is the sterilization consent form?
Member has a specific pharmacy to fill the medications.
What is the lock in program?
Any questions regarding Contract terms would be referred to them.
Who is the provider services department?