Molina HealthCare Transition Plan - Asespr
Molina HealthCare Transition Plan 5 de Agosto de 2020
Cronograma del Proceso de Transición Entrega Final de Datos (NPL, PCP Updates) Entrega de beneficiarios a MCOs Go – Live 8/13/2020 9/20/2020 11/1/2020 Aug Sep Oct Nov Today Ejecución de Auto asignación 8/14/2020 8/17/2020 8/17/2020 Seguimiento a los No asignados 9/28/2020 9/29/2020 10/31/2020 Entrega de Datos de Transición (Semanal) Seguimiento de Transición 11/02/2020 11/02/2020 2020
TRANSITION WORKPLAN FOR MOLINA HEALTHCARE BENEFICIARIES Milagros Soto, Interim Director Clinical Affairs and Planning Department
Important Facts and Time Frame Milestones Other Normative letters will be issue by ASES in order to: Extend special coverage for those who ended between November 1st to November 30,2020 Admitted Patients before November 1st and remain in hospital after November 30, 2020 Guarantee 90 days for continuous of care in services for non contracted providers (DME) Guarantee any Referrals or Preauthorization issue before October 31, 2020 Molina s last day of operation in Puerto Rico will be October 31, 2020. Total of Molina's beneficiaries as of June 30, 2020: 161,370.
Important Facts and Time Frame Milestones Molina's’ beneficiaries were notified by Molina on July 15, 2020. Remaining Vital MCOs were notified on transition phase out process on July 17,2020. Molina's’ beneficiaries auto-assigment to new MCO will be from on August 15th, 2020 to September 14th, 2020. Molina’s beneficiaries can make MCO voluntary changes up to September 14th, 2020. Voluntary changes will prevail from auto assignment. Patient/PCP, relation will be sustained during the assignment process. Annual open enrollment period will be from November 1rst to December 15th, 2020.
Auto-assigment Process Rafael Vázquez, Chief Information Officer Information Systems Depatment
CRITERIOS QUE ASES UTILIZARA PARA LA ASIGNACION DE BENEFICIARIOS A LOS MCOS SERAN EXCLUIDOS LOS BENEFICIARIOS QUE HAYAN REALIZADO CAMBIOS A OTRO MCO HASTA EL 14 DE SEPTIEMBRE DE 2020 SIN JUSTA CAUSA Relación Médico-Paciente Mantener relación médico-paciente (PCP, PMG, Especialistas). Distribución Equitativa Distribución equitativa de miembros entre “MCO's” contratados. Cónsono a las capacidades de Risk Based Capital Relación Grupal Mantener Relación Grupal / Familiar a través de asignación.
RELACION MEDICO PACIENTE Beneficiario – PMG – PCP (No Registrado en Cubierta Especial) PMG – Federal Tax ID PCP – NPI Beneficiario – PMG- PCP-Especialista (Registrado en Cubierta Especial) ESPECIALISTA - NPI Beneficiario-PMG-PCP- Obstetricia (Embarazada) NPI DEL OBSTETRA
PROCESO PARA LA ASIGNACION DE BENEFICIARIOS A LOS MCOS Comenzará el 14 de agosto de 2020. En o antes de septiembre 21 de 2020 las aseguradoras recibirán la población autoasignada. Se excluirá cualquier beneficiario que haya realizado un cambio de MCO. Debe cumplir con los criterios de asignación definidos. Cualquier remanente se identificarán los elementos por los cuales no coincide la información. Ejemplo de estos y no se limita a: Validación con la fuente primaria: Molina Healthcare Validación con Grupo Médico Primario Validación con Medico Primario y/o Especialista Comunicación al beneficiario
FUENTE DE INFORMACION (Datos) MOLINA HEALTHCARE RELACION DEL Beneficiarios PMG, PCP, Especialistas OFICINA DE MEDICAID Relación Grupal Familias, Contactos, Representantes MCO's Redes de Proveedores contratadas NPL Capacidades – “RBC” Limites de población establecidos para cada aseguradora contratada. ANALISIS DE LA FIRMA ACTUARIOS DE MILLIMAN, DE COMISIONADO DE SEGUROS CERTIFICACION DE LOS MCO's
ORDEN DE ASIGNACION ” Población Dual - EXCLUYO PLATINOS IDENTIFICADOS EN EL TBQ-ARCHIVO DE CMS 01 Población “High Cost High Need” Población de Cubierta Especial / Embarazadas Población General 02 03 04
Transition of Care Milagros Soto, Interim Director Clinical Affairs and Planning Department
Layouts for Transition of Care / Molina Phase Out
Recommended Layouts for Transition of Care 1. Case Management & HCHN 2. Serious Mental Illness Layout (New) 3. Pre-Authorization Layout (Open PA) 4. PA Denied 4. OBGYN Layout 5. Special Coverage Layout 6. Life Support Program Layout 7. Hospital Layout For the purpose of this transition a weekly submission of this file will be require to MHPR from September 28, 2020, and every Monday up to October 31, 2020.
Transition of Care File Case Management / HCHN This file is received by ASES from the insurance companies and on a monthly basis. It contains data pertinent to the transition of care of the patient Case Management / HCHN Layout Item num 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Record Fields Carrier Source MPI Last Name1 Last Name2 First Name Initial DOB Gender Addr1 Addr2 City State Zip Phone PCP Name PCP NPI Servicing NPI Description Source Carrier Code Member MPI Member Last Name Member Last Name 2 Member First Name Initial Enrollee DOB Member Gender Member Address1 Member Address2 Member City Member State Member Zip Member Phone PCP Name PCP NPI Servicing Provider NPI Position 1 3 16 46 76 106 107 115 116 161 206 251 253 262 272 302 312 Size Data Type 2 Numeric 13 Numeric 30 Varchar 30 Varchar 30 Varchar 1 Varchar 8 Numeric 1 Numeric 45 Varchar 45 Varchar 45 Varchar 2 Varchar 9 Numeric 10 Numeric 30 Varchar 10 Numeric 10 Numeric Required/ Optional R R R O R O R R R O R R R R R R R Notes Carrier Code Given by ASES YYYYMMDD 1 Masculibo, 2 Femenino 999999999 9999999999 18 Servicing Specialty 19 Servicing Name Servicing Provider Specialty type Servicing provider Name 322 324 2 30 Varchar Varchar R R 20 Servicing Phone 21 Care Ma Prog 22 Prog Start Date Servicing provider phone number Care Management Program Program Start Date 354 364 864 10 500 8 Numeric Varchar Numeric R R R 9999999999 23 24 25 26 27 28 Program End Date Primary Diagnostic Code Diagnosis Code Diagnosis Code Diagnosis Code Diagnosis Code 872 880 888 896 904 912 8 8 8 8 8 8 Numeric Varchar Varchar Varchar Varchar Varchar R R R R R R YYYYMMDD (for open period use 20990101) 29 Problem Problems/Situations 920 500 Varchar R Care Plan Problems. One or more situations 30 Intervention Interventions (ongoing and Pending ) 1420 1920 500 Varchar R Include one or more inverventions Prog End Date Diag Code1 Diag Code2 Diag Code3 Diag Code4 Diag Code5 YYYYMMDD
Transition of Care File Serious Mental Illness Patients (SMI) This file is received by ASES from the insurance companies and on a weekly basis. It contains data pertinent to the transition of care of the patient Serious Mental Illness (SMI) Layout SMI: Is Define by NIMH as a mental, behavioral, or emotional disorder resulting in serious functional impairment, which substancially interferes with or limits one or more mayor life activities. Item num 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Position 1 3 16 46 76 106 107 115 116 161 206 251 253 262 272 302 312 322 324 354 364 864 872 880 888 896 904 912 Size 2 13 30 30 30 1 8 1 45 45 45 2 9 10 30 10 10 2 30 10 500 8 8 8 8 8 8 8 Data Type Numeric Numeric Varchar Varchar Varchar Varchar Numeric Numeric Varchar Varchar Varchar Varchar Numeric Numeric Varchar Numeric Numeric Varchar Varchar Numeric Varchar Numeric Numeric Varchar Varchar Varchar Varchar Varchar Required/Optio nal R R R O R O R R R O R R R R R R R R R R R R R R R R R R Problems/Situations 920 500 Varchar R Care Plan Problems. One or more situations Interventions (ongoing and Pending ) 1420 1920 500 Varchar R Include one or more inverventions Record Fields Carrier Source MPI Last Name1 Last Name2 First Name Initial DOB Gender Addr1 Addr2 City State Zip Phone PCP Name PCP NPI Servicing NPI Servicing Specialty Servicing Name Servicing Phone Care Ma Prog Prog Start Date Prog End Date Diag Code1 Diag Code2 Diag Code3 Diag Code4 Diag Code5 Description Source Carrier Code Member MPI Member Last Name Member Last Name 2 Member First Name Initial Enrollee DOB Member Gender Member Address1 Member Address2 Member City Member State Member Zip Member Phone PCP Name PCP NPI Servicing Provider NPI Servicing Provider Specialty type Servicing provider Name Servicing provider phone number Care Management Program Program Start Date Program End Date Primary Diagnostic Code Diagnosis Code Diagnosis Code Diagnosis Code Diagnosis Code 29 Problem 30 Intervention Notes Carrier Code Given by ASES YYYYMMDD 1 Masculibo, 2 Femenino 999999999 9999999999 9999999999 YYYYMMDD YYYYMMDD
Pre Authorization Layout (Open PA) Transition of Care File Pre Authorization Layout This file is received by ASES from the insurance companies and on a monthly basis. It contains data pertinent to the transition of care of the patient Item Required/O Num Record Fields Description Position Size Data Type ptional Notes 1 Carrier Source Source Carrier Code 1 2 Numeric R Carrier Code Given by ASES 2 MPI Member MPI 3 13 Numeric R 3 Last Name1 Member Last Name 16 30 Varchar R 4 Last Name2 Member Last Name 2 46 30 Varchar O 5 First Name Member First Name 76 30 Varchar R 6 Initial Initial 106 1 Varchar O 7 DOB Enrollee DOB 107 8 Numeric R YYYYMMDD 8 Gender Member Gender 115 1 Numeric R 1 Masculino, 2 Femenino 9 Addr1 Member Address1 116 45 Varchar R 10 Addr2 Member Address2 161 45 Varchar O 11 City Member City 206 45 Varchar R 12 State Member State 251 2 Varchar R 13 Zip Member Zip 253 9 Numeric R 999999999 14 Phone Member Phone 262 10 Numeric R 9999999999 15 PCP Name PCP Name 272 30 Varchar R 16 PCP NPI PCP NPI 302 10 Numeric R 17 Servicing NPI Servicing Provider NPI 312 10 Numeric R 18 Servicing Specialty Servicing Provider Specialty type 322 2 varchar R 19 Servicing Name Servicing provider Name 324 30 Varchar R 20 Servicing Phone Servicing provider phone number 354 10 Numeric R 9999999999 21 Req Prov NPI Requesting provider NPI 364 10 Numeric R 22 Req Prov Specialty Requesting provider Speciallty Type 374 2 Varchar R 23 Req Prov Name Requesting provider Name 376 30 Varchar R 24 Req Prov Phone Requesting provider Phone Number 406 10 Numeric R 9999999999 25 Diag code1 Primary Diagnostic Code 416 8 Varchar R 26 Diag code2 Diagnostic Code 424 8 Varchar R 27 Diag code3 Diagnostic Code 432 8 Varchar R Include all related diagnoses 28 Diag code4 Diagnostic Code 440 8 Varchar R 29 Diag code5 Diagnostic Code 448 8 Varchar R 30 Service units Units or quantity services 456 4 Numeric R 31 Authorization date Service Authorization date 460 8 Numeric R YYYYMMDD 32 Service code1 Service code/Procedure (S) 468 6 Varchar R CPT, No decimal period 33 Service code2 Service code/Procedure (S) 474 6 Varchar R CPT, No decimal period 34 Service code3 Service code/Procedure (S) 480 6 Varchar R CPT, No decimal period 35 Service code4 Service code/Procedure (S) 486 6 Varchar R CPT, No decimal period 36 Service code5 Service code/Procedure (S) 492 6 Varchar R CPT, No decimal period 37 Hospice Hospice 498 1 Varchar R Y Yes, N No 38 Authorization number For references only 499 15 Varchar R 39 Serv Start Date Service start date 514 8 Numeric R YYYYMMDD 40 Serv End Date Service end date 522 8 Numeric R YYYYMMDD (for open period use 20990101) 530
PA Denied Layout Transition of Care File PA Denied Layout This file is received by ASES from the insurance companies and on a monthly basis. It contains data pertinent to the transition of care of the patient Required/O Item Num Record Fields Description Position Size Data Type ptional Notes 1 Carrier Source Source Carrier Code 1 2 Numeric R Carrier Code Given by ASES 2 MPI Member MPI 3 13 Numeric R 3 Last Name1 Member Last Name 16 30 Varchar R 4 Last Name2 Member Last Name 2 46 30 Varchar O 5 First Name Member First Name 76 30 Varchar R 6 Initial Initial 106 1 Varchar O 7 DOB Enrollee DOB 107 8 Numeric R YYYYMMDD 8 Gender Member Gender 115 1 Numeric R 1 Masculino, 2 Femenino 9 Addr1 Member Address1 116 45 Varchar R 10 Addr2 Member Address2 161 45 Varchar O 11 City Member City 206 45 Varchar R 12 State Member State 251 2 Varchar R 13 Zip Member Zip 253 9 Numeric R 999999999 14 Phone Member Phone 262 10 Numeric O 9999999999 15 Req NPI Requesting Provider NPI 272 10 Numeric R 16 Req Specialty code Requesting Provider Specialty type 282 2 Numeric R 17 Req Name Requesting provider Name 284 30 Varchar R 18 Req Phone Requesting provider phone number 314 10 Numeric R 9999999999 19 Service Denied1 Procedure code denied 324 6 Numeric R CPT, No decimal period 20 Service Denied2 Procedure code denied 330 6 Numeric R CPT, No decimal period 21 Service Denied3 Procedure code denied 336 6 Numeric R CPT, No decimal period 22 Service Denied4 Procedure code denied 342 6 Numeric R CPT, No decimal period 23 Service Denied5 Procedure code denied 348 6 Numeric R CPT, No decimal period 24 Request date Authorization request date 354 8 Numeric R YYYYMMDD - Considered up to 60 25 PA Denial Determ Date PA Denial Determination Date 362 8 Numeric R days to summit the appeal 26 Total Units Denied Total Units Denied 370 3 Numeric R 27 Diag Code1 Primary Diagnostic Code 373 8 Numeric R ICD 10 28 Diag Code2 Diagnosis Code 381 8 Numeric R ICD 10 29 Diag Code3 Diagnosis Code 389 8 Numeric R ICD 10 30 Diag Code4 Diagnosis Code 397 8 Numeric R ICD 10 31 Diag Code5 Diagnosis Code 405 8 Numeric R ICD 10 413
OB-GYN Layout Transition of Care File OBGYN Layout This file is received by ASES from the insurance companies and on a monthly basis. It contains data pertinent to the transition of care of the patient Item Required/Opt num Record Fields Description Position Size Data Type ional Notes 1 Carrier Source Source Carrier Code 1 2 Numeric R Carrier Code Given by ASES 2 MPI Member MPI 3 13 Numeric R 3 Last Name1 Member Last Name 16 30 Varchar R 4 Last Name2 Member Last Name 2 46 30 Varchar O 5 First Name Member First Name 76 30 Varchar R 6 Initial Initial 106 1 Varchar O 7 DOB Enrollee DOB 107 8 Numeric R YYYYMMDD 8 Gender Member Gender 115 1 Numeric R 2 Femenino 9 Addr1 Member Address1 116 45 Varchar R 10 Addr2 Member Address2 161 45 Varchar O 11 City Member City 206 45 Varchar R 12 State Member State 251 2 Varchar R 13 Zip Member Zip 253 9 Numeric R 999999999 14 Phone Member Phone 262 10 Numeric R 9999999999 15 PCP Name PCP Name 272 30 Varchar R 16 PCP NPI PCP NPI 302 10 Numeric R 17 Req NPI Requesting Provider NPI 312 10 Numeric R 18 Req Specialty Requesting Provider Specialty type 322 10 Numeric R 19 Req Name Requesting provider Name 332 30 Varchar R 20 Req Phone Requesting provider phone number 362 10 Numeric R 21 OB NPI OBGYN NPI 372 10 Numeric R 22 OB Group OBGYN -PMG 382 20 Varchar R If apply 23 OB Name OBGYN Physician Name 402 30 Varchar R 24 OB Phone OBGYN phone number 432 10 Numeric R 9999999999 25 Program Program 442 20 Varchar R 26 Preg Trim Reg Pregnant Woman Trimester at Registry 462 1 Numeric R 27 Est Date Deli Estmated Date of Delivery 463 8 Numeric R YYYYMMDD 28 Preg High Risk Pregnant Woman is a High Risk YES/NO? 471 1 Varchar R Y/N 29 Prog Start Date Registry Program Start Date 472 8 Numeric R YYYYMMDD 30 Prog End Date Registry Program End Date 480 8 Numeric R YYYYMMDD (for open period use 20990101) 31 Diag Code Primary Diagnostic Code 488 8 Numeric R ICD 10 32 Diag Code Diagnosis Code 496 8 Numeric R ICD 10 33 Diag Code Diagnosis Code 504 8 Numeric R ICD 10 34 Diag Code Diagnosis Code 512 8 Numeric R ICD 10 35 Diag Code Diagnosis Code 520 8 Numeric R ICD 10 36 Last men date last menstruation date 528 8 Numeric R YYYYMMDD 37 Problems Problems 536 500 Varchar R Care Plan Problems. One or more situations 38 Intervention Interventions (ongoing and Pending ) 1036 500 Varchar R Include one or more inverventions 1536
Transition of Care File Special Coverage Layout This file is received by ASES from the insurance companies and monthly basis. It contains data pertinent to the transition of care of the patient Special Coverage Layout Item Num 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Record Fields Carrier source MPI Last Name1 Last Name2 First Name Initial DOB Gender Addr1 Adrr2 City State Zip Phone Servicing NPI Description Source Carrier code Member MPI Member Last Name Member Last Name 2 Member First Name Initial Enrollee DOB Member Gender Member Address1 Member Address2 Member City Member State Member Zip Member Phone Servicing Provider NPI 16 17 Servicing Specialty Servicing Name 18 19 20 21 Required/Opti onal Notes R R R O R O R YYYYMMDD R 1 Masculino, 2 Femenino R O R R R 999999999 R 9999999999 R Position 1 3 16 46 76 106 107 115 116 161 206 251 253 262 272 Size 2 13 30 30 30 1 8 1 45 45 45 2 9 10 10 Data Type Numeric Numeric Varchar Varchar Varchar Varchar Numeric Numeric Varchar Varchar Varchar Varchar Numeric Numeric Numeric Servicing Provider Specialty type Servicing provider Name 282 284 2 30 Numeric Varchar R R Servicing Phone Program Prog Start Date Prog End Date Requesting provider phone number Program Registry Program Start Date Registry Program End Date 314 324 330 338 10 6 8 8 Numeric Varchar Numeric Numeric R R R R 9999999999 22 23 24 25 26 27 28 Condition Diag Code1 Diag Code2 Diag Code3 Diag Code4 Diag Code5 Problems Condition Primary Diagnostic Code Diagnostic Code Diagnostic Code Diagnostic Code Diagnostic Code Problem 346 354 362 370 378 386 394 8 8 8 8 8 8 500 Varchar Varchar Varchar Varchar Varchar Varchar Varchar R R R R R R R See Condition Table TAG ICD 10 ICD 10 ICD 10 ICD 10 ICD 10 Care Plan Problems. One or more situations 29 Intervention Interventions (ongoing and Pending ) 894 1394 500 Varchar R Include one or more inverventions YYYYMMDD YYYYMMDD (for open period use 20990101)
Life Support Program Layout Item Num 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 Transition of Care File Life Support Case Layout This file is received by ASES from the insurance companies and on a monthly basis. It contains data pertinent to the transition of care of the patient Required/Opti Record Fields Description Position Size Data Type onal Notes Carrier Source Source Carrier Code 1 2 Numeric R Carrier Code Given by ASES MPI Member MPI 3 13 Numeric R Last Name1 Member Last Name 16 30 Varchar R Last Name2 Member Last Name 2 46 30 Varchar O First Name Member First Name 76 30 Varchar R Initial Initial 106 1 Varchar O DOB Enrollee DOB 107 8 Numeric R YYYYMMDD Gender Member Gender 115 1 Numeric R 1 Masculino, 2 Femenino Addr1 Member Address1 116 45 Varchar R Addr2 Member Address2 161 45 Varchar O City Member City 206 45 Varchar R State Member State 251 2 Varchar R Zip Member Zip 253 9 Numeric R 999999999 Phone Member Phone 262 10 Numeric R 9999999999 Servicing NPI Servicing Provider NPI 272 10 Numeric R Servicing Specialty Servicing Provider Specialty type 282 2 Numeric R Servicing Name Servicing provider Name 284 30 Varchar R Servicing Phone Servicing provider phone number 314 10 Numeric R 9999999999 Req NPI Requesting Provider NPI 324 10 Numeric R Req Specialty Requesting Provider Specialty type 334 10 Numeric R Req Name Requesting provider Name 344 30 Varchar R Req Phone Requesting provider phone number 374 10 Numeric R 9999999999 Service Pla Trans Services In place to be transitioned 384 10 Varchar R Service Code1 Service codes 394 10 Varchar R CPT, No decimal period Service Code2 Service codes 404 10 Varchar R CPT, No decimal period Service Code3 Service codes 414 10 Varchar R CPT, No decimal period Service Code4 Service codes 424 10 Varchar R CPT, No decimal period Service Code5 Service codes 434 10 Varchar R CPT, No decimal period Resquest date Authorization request date 444 8 R YYYYMMDD Approved date Approved date 452 8 Numeric R YYYYMMDD Place of Service Place of Services 460 10 Numeric R See Place of Service TAG (Source Milliman Layout) Service Start Period Period Start Date 470 8 Numeric R YYYYMMDD Service Expected End Expected Period End Date 478 8 Numeric R YYYYMMDD Diag code1 Diagnosis Code 486 6 Varchar R ICD 10 Diag code2 Diagnosis Code 492 6 Varchar R ICD 10 Diag code3 Diagnosis Code 498 6 Varchar R ICD 10 Diag code4 Diagnosis Code 504 6 Varchar R ICD 10 Diag code5 Diagnosis Code 510 6 Varchar R ICD 10 516
Transition of Care File Hospital Layout Hospital Layout Item Num 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 This file is received by ASES from the insurance companies and on a monthly basis. It contains data pertinent to the transition of care of the patient Required/Optio Record Fields Description Position Size Data Type Notes nal R Carrier source Source Carrier Code 1 2 Numeric Carrier Code Given by ASES R MPI Member MPI 3 13 Numeric Last Name1 Member Last Name 16 30 Varchar R Last Name2 Member Last Name 2 46 30 Varchar O First Name Member First Name 76 30 Varchar R Initial Initial 106 1 Varchar O DOB Enrollee DOB 107 8 Numeric R YYYYMMDD Gender Member Gender 115 1 Numeric R 1 Masculino, 2 Femenino Addr1 Member Address1 116 45 Varchar R Addr2 Member Address2 161 45 Varchar O City Member City 206 45 Varchar R State Member State 251 2 Varchar R Zip Member Zip 253 9 Numeric R 999999999 Phone Member Phone 262 10 Numeric R 9999999999 R Adm date Admision Date 272 8 Numeric YYYYMMDD R Dis date Actual Discharge Date 280 8 Numeric YYYYMMDD R Hosp NPI Hospital NPI 288 10 Numeric R Hosp Name Hospital Name 298 30 Varchar R Adm Diag1 Admission Diagnosis 328 8 Varchar ICD 10 R Adm Diag2 Admission Diagnosis 336 8 Varchar ICD 10 R Adm Diag3 Admission Diagnosis 344 8 Varchar ICD 10 R Adm Diag4 Admission Diagnosis 352 8 Varchar ICD 10 R Adm Diag5 Admission Diagnosis 360 8 Varchar ICD 10 Adm type Admission type 24 25 26 27 28 29 Dis diag1 Dis diag2 Dis diag3 Dis diag4 Dis diag5 Discharge Diagnostic Discharge Diagnostic Discharge Diagnostic Discharge Diagnostic Discharge Diagnostic 30 Authorization number For references 368 370 377 384 391 398 405 420 2 Varchar R 7 7 7 7 7 Varchar Varchar Varchar Varchar Varchar R R R R R 15 Varchar R PH Physical, ME Mental, MP Mental Partial, SN skill nursing facility ICD 10 ICD 10 ICD 10 ICD 10 ICD 10
Naming Convention -Transition of Care - File layouts FLAT FILE NAMING CONVENTION File are always dated by the month being reported. Flat files names are composed in the following manner: New carrier 09 10 12 13 From 11 To NewCarrier TypeOfFile yyyymm S.TRN Where: Carrier 11 NewCarrier Carrier Code TypeOfFile ---------------------- YYYY Year MM Month S Sequence number of file submission. Layout File Type Case Management CM Serious Mental Ilness SMI Pre Authorizations PA Pre Authorizations Denied PD OBGYN OB Special Coverage AC Life Support LS Hospitalizations HP Disease DS Note: All submissions start with S 0 and continue increasing in numerical order as files are re-submitted up to a maximum of 9. If files must be re-submitted beyond 9 times then alphabetic characters will be used (a, b, c ) in order. The file extension must be .TRN for ALL files. Ex. 1 FROM 11 TO 09 CM 202010 0.TRN Files must be named using all UPPERCASE characters. FREQUENCY (for the purpose of this transitions process) Transition files will be submitted weekly based on the information received in the export files. MHPR will submit it weekly from September 28, 2020 to October 31, 2020 . The other carriers will continue to submit files on a monthly basis. If files are re-submitted subsequent files completely replace the old ones. Carriers may upload their reports to the ASES FTP.
Other Required Complementary Information
High Cost High Needs (HCHN) Register ASES You will be sending each insurer the HCHN Registry file of MHPR's self-assigned beneficiaries. This will take place on October 21, 2020. The current Layout will be used. This will help the MCO to have visibility of the expiration dates of the registration and the preregistration. Historical Claims Files ASES Will be sending each insurer one year of claims for each beneficiary on October 23, 2020 to allow each insurer to be sufficiently supported to provide continuity of services to transferred members. Data to MC-21 Each insurer is responsible for coordinating all the data that will be provided to it in such a way that the services to each beneficiary have continuity, including pharmacy services. All insurers will provide to MC-21 the corresponding diagnoses (flag) of each beneficiary to avoid interruptions of drug treatments.
MCO’s Readiness Review Madeline Figueroa , ASES Chief Compliance Officer Compliance Department
Transition and Uploading Molina’s Layouts and Files (First Step) MCO’s NPL layouts and PCP update files starts on July 23,2020. Subsequent updates will be received from MCOs’ every Thursday. Submission of layouts files templates to MCOs from ASES: Case Management, Special Coverage, HCHN, Pregnant women, Mental Illness, DME, Pre-authorization for surgeries and interventions, ventilators, ambulance , Hi-tech files, were sent on July 31,2020. Molina will send information for these files every week. ASES will resend it to MCOs weekly. General oversight of the file's submission will be under ASES –IT area and process completeness will be coordinated with Compliance area.
MCO’s Readiness Oversight (Second Step) AREA I Review completion of the uploaded information. (Starts August 1rst 2020) Molina's Beneficiaries files completion with templates submitted for those purposes. Special coverage, HCHN and chronic disease; Mental patients files, Pregnant Women files. Care Management files, etc. as uploaded in Step 1. AREA II MCO’s Providers Network Oversight (Starts September 1rst, 2020) Network adequacy (patient ratios) Accessibility Contracting Full Credentialing
Readiness oversight( cont.) Area III Testing Interphases with PBM, MCO and ASES (September 15, 2020) Beneficiaries Pharmacy Files oversight to guarantee prescriptions continuity and coverage. Area IV Communication of MCOs to new enrolled beneficiaries (September 21, 2020) Beneficiaries IDs Welcome letters and Kits Provider Directory Enrollee Manual Special Coverage letters Disease Management letters
Readiness oversight( cont.) Beneficiaries Call Center Orientation (October 15,2020. Special orientations to new enrollees Access of information(web site, phone lines, dedicated service) On site audits for any of the reviewed areas might take place. MCO Readiness Certification( October 26-30, 2020)
QUESTIONS?
Recommended Layouts for Transition of Care 1. Case Management & HCHN 2. Serious Mental Illness Layout (New) 3. Pre-Authorization Layout (Open PA) 4. PA Denied 4. OBGYN Layout 5. Special Coverage Layout 6. Life Support Program Layout 7. Hospital Layout For the purpose of this transition a weekly submission of this file will be require to MHPR from
Molina Healthcare of South Carolina, Inc. Marketplace Provider Manual Any reference to Molina Healthcare members means Molina Healthcare Marketplace . member. s. Phone: (855) 237-6178 . Compliance and Fraud AlertLine . If you suspect cases of fraud, waste, or abuse, you must report it to Molina. You may do
Molina Healthcare of Illinois, Inc. (Molina Healthcare or Molina) Medicaid Program . . EDI Payer ID number 20934 To verify the status of your claims, please use the Provider Portal. For other claims . English Phone - (888) 275-8750; English TTY - (888) 735-2929; Spanish Phone - (866) 648-3537 ; Spanish TTY
1National Imaging Associates, Inc. is an affiliate of Magellan Healthcare, Inc. 1—Molina Complete Radiation Oncology QRG Molina Complete Care (Molina) . radiation therapy treatment plan procedures are authorized before services are rendered. Reimbursement is based on approved treatment plans and techniques. Please refer to the
Member Name and ID Number Molina members are issued a unique Molina ID Card in addition to the state issued Medicaid card. Molina members should present both cards when receiving services. The members Molina card lists the ID Number which you will use for billing. Because a member's eligibility can
provider.molinahealthcare.com. Molina Healthcare of Wisconsin, Inc. Medicaid Provider Manual 5 Any reference to Molina Members means Molina Healthcare Medicaid Members. Fax: (562) 901-1176 Health Management and Maternity Programs Phone: (866) 891-2320 Fax: (800) 642-3691 .
Molina Clinical Policy Enteral Nutrition Policy No. 406 Last Approval: 10/13/2021 Next Review Due By: October 2022 Molina Healthcare, Inc. 2021 - This document contains confidential and proprietary information of Molina Healthcareand cannot be
The Provider Newsletter is a newsletter available to all network providers serving Molina Healthcare Members. Second Quarter 2022 New Clinical Policy Website Available to Molina Providers In February 2022, Molina launched a new provider tool via our website - it is available at: MolinaClinicalPolicy.com. The site includes Molina
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