Molina Medicaid Program Provider Manual Molina Healthcare of Illinois 2020 Contents 1. Introduction............................................................................................................. 9 Medicaid Plan .............................................................................................................. 9 2. Contact Information for Providers ...................................................................... 10 Provider Services Department ................................................................................... 10 Member Services Department ................................................................................... 10 Claims Department .................................................................................................... 10 Claims Recovery Department .................................................................................... 10 Compliance/Anti-Fraud Hotline .................................................................................. 11 24-Hour Nurse Advice Line........................................................................................ 11 Healthcare Services Department ............................................................................... 11 Health Management Level 1 and Health Management Department .......................... 12 Behavioral Health....................................................................................................... 12 Pharmacy Department ............................................................................................... 12 Quality Improvement.................................................................................................. 12 Supplemental Services .............................................................................................. 12 3. Benefits and Covered Services ........................................................................... 13 HealthChoice Illinois Benefits and Covered Services ................................................ 13 Obtaining Access to Certain Covered Services ......................................................... 13 Preventive Care ......................................................................................................... 15 Emergency Services .................................................................................................. 16 Nurse Advice Line...................................................................................................... 16 Children’s Behavioral Health Services ....................................................................... 17 Health Management Programs .................................................................................. 19 Member Newsletters .................................................................................................. 20 Member Health Education Materials .......................................................................... 20 Program Eligibility Criteria and Referral Source......................................................... 20 Provider Participation................................................................................................. 20 4. Telehealth and Telemedicine Services ............................................................... 22 Definitions .................................................................................................................. 22 Requirements for Telehealth Services ....................................................................... 23 Benefits...................................................................................................................... 24 Member Eligibility and Consent for Telehealth Services ............................................ 24 Privacy and Security .................................................................................................. 26 2 Geography and Physical Environment for Telehealth Services ................................. 26 Contingency Support for Member .............................................................................. 27 Fraud and Abuse Protocols........................................................................................ 27 Provider Directory Listing........................................................................................... 27 Claims and Billing ...................................................................................................... 27 Subcontract Relationships for Telehealth Services.................................................... 27 Administrative Standards ........................................................................................... 28 Clinical Standards ...................................................................................................... 29 Emergent Encounters via Telehealth ......................................................................... 31 Technical Standards .................................................................................................. 31 Glossary..................................................................................................................... 32 Resources for Telehealth Policies, Best Practices and Regulations .......................... 32 5. Long Term Services and Support (LTSS)........................................................... 33 LTSS Overview .......................................................................................................... 33 LTSS Services and Molina Healthcare ...................................................................... 33 LTSS Benefits and Approved Services ...................................................................... 33 LTSS Services by Waiver Program............................................................................ 36 Getting Care, Getting Started..................................................................................... 37 Care Management Team or Integrated Care Team or Interdisciplinary Care Team (ICT)........................................................................................................................... 37 Individualized Care Plan Coordination ....................................................................... 38 Transition of Care Programs...................................................................................... 39 Continuity of Care (COC) Policy and Requirements .................................................. 39 Claims for LTSS Services .......................................................................................... 40 Billing Molina.............................................................................................................. 40 Billing Molina Members.............................................................................................. 41 Provider Complaints................................................................................................ 42 Appendix 1: Home and Community Based Services (HCBS) Codes ......................... 43 Appendix 2: Nursing Facility Billing Guidance............................................................ 44 6. Enrollment, Eligibility and Disenrollment........................................................... 47 Enrollment.................................................................................................................. 47 Illinois Client Enrollment Services and HFS Health Plan Assignment........................ 47 Eligibility Verification .................................................................................................. 49 Molina Member Eligibility Verification......................................................................... 49 Disenrollment ............................................................................................................. 50 3 PCP Dismissal ........................................................................................................... 51 Missed Appointments................................................................................................. 52 PCP Assignment........................................................................................................ 52 PCP Changes ............................................................................................................ 52 7. Member Rights and Responsibilities .................................................................. 53 Second Opinions........................................................................................................ 53 8. Healthcare Services (HCS)................................................................................... 54 Introduction ................................................................................................................ 54 Utilization Management (UM)..................................................................................... 54 Medical Necessity Review ......................................................................................... 57 Levels of Administrative and Clinical Review............................................................. 57 Clinical Information .................................................................................................... 57 Prior Authorization ..................................................................................................... 58 Inpatient Management ............................................................................................... 60 Exceptions ................................................................................................................