Molina Healthcare of Michigan
MI Health Link Presentation – June 3, 2015
Nursing Facility – FAQs
CONTRACTING
What if our facility is auto-assigned a member, but is not contracted with
Molina?
If you are not contracted with Molina, we will sign a single case agreement, or
Letter of Agreement, while we move toward a full agreement and credentialing.
Prior Authorization of services is required.
What if our facility is not contracted yet?
If you are in the process of the contracting/credentialing process, a Letter of
Agreement (LOA) is not required for any auto-assigned members. Once a
contract/complete credentialing information is received, Molina updates the
facility status to provisional for authorization and claims payment purposes.
If you have not started this process, please contact Diane Carr at 248.925.1790,
ext. 156235 or [email protected].
Can our pharmacy participate with CVS Caremark?
Yes, your pharmacy may contract with MHM’s Pharmacy Benefit Manager (PBM),
CVS Caremark. Please call 866.693.4620.
HEALTH SERVICES
How will Molina Care Coordinators be assigned, by facility or by patient?
Molina’s goal is to assign by facility.
How long will it take for a Molina Care Coordinator to be assigned new
members within their aligned facility?
The assignment of the Care Coordinator happens upon notification of member
enrollment.
How big will the caseloads be for the Case Managers?
Care Managers have a targeted case load of 300 members and care coordinators
have a targeted case load of 50 members.
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Molina Healthcare of Michigan
MI Health Link Presentation – June 3, 2015
Nursing Facility – FAQs
If a member comes from the hospital, or from home, how long before the Care
Coordinator performs the assessment?
Molina’s Care Coordinators will do the assessment within 48 hours.
When the member is in the hospital, does the hospital obtain the prior
authorization for the transfer to the nursing home?
Yes, the hospital would obtain the prior authorization for the transfer to the
nursing facility.
If a member has a stage four wound and needs an air mattress, who will
order it?
The nursing facility will complete the form as usual and send it in to Molina for
authorization.
The timeframe for Level of Care Determinations (LOCDs) is 90 days if a member
is a current resident in a nursing facility. If the member is a new resident, when
will the LOCD be completed?
Molina’s timeframe to complete a LOCD is no longer than 90 days; however, we
will make every effort to complete prior to the 90th day. Each nursing facility
should complete the LOCD per its current process. Beginning in the Fall of 2015,
the state will assign a vendor to perform the LOCDs, but that does not change the
process the nursing facility currently has in place.
How often is a prior authorization required for custodial care?
Prior Authorizations are required every six months for custodial care. If you have
a member in the MI Health Link plan, you must request a continued stay
authorization every six months.
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Molina Healthcare of Michigan
MI Health Link Presentation – June 3, 2015
Nursing Facility – FAQs
Will the nursing facilities be notified when the six-month time period for
authorization is coming close?
No, Molina will not notify the nursing facility of pending continued stay
authorizations. Molina is not always informed when members enter custodial
care. Please notify Molina directly by calling the Utilization Management
Department at 888.898.7969 or fax a request to 888.295.7665 when you admit a
new MI Health Link member.
What is the process when a member is custodial and develops a need for
PT/OT/ST?
This is covered under Medicare Part B. Providers will submit an authorization
request for the necessary services based on the Molina Prior Authorization guide.
What are the approval times for the Pre-Paid Inpatient Health Plans (PIHPs) for
behavioral health services?
Molina does not approve behavioral health services. Please contact the PIHP in
the appropriate county. Normal NCQA and state requirements apply for 72 hours
for urgent cases and 14 days for non-urgent cases.
PIHP contact information is:
 Detroit Wayne Mental Health Authority 800.241.4949
 Macomb County Community Mental Health 855.996.2264
Who is responsible for ordering DME?
DME is covered under the per diem. The nursing facility is responsible for
ordering, paying and obtaining the authorization for their vendors, since they are
paid at a per diem.
Will
Molina
notify
nursing
facilities
of
new
members?
We request that you please contact Molina’s call center at 888.898.7969 to let us
know if you have a custodial care member.
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Molina Healthcare of Michigan
MI Health Link Presentation – June 3, 2015
Nursing Facility – FAQs
How long does the process take if home care is required when leaving the
facility to go home?
The initial three home care visits do not require preauthorization; then the home
care agency will request further visits.
What if a durable medical equipment transitions from the hospital to the
nursing facility under rehabilitation; how long will it take for the prior
authorization?
The hospital will notify Molina and Molina strives to complete the authorization
within 72 hours.
Where will the required 30 day meeting for members take place if they are in
the nursing facility?
The Molina Care Coordinator will stay in touch and make the visit with the
member at the nursing facility. There will be one or two Care Coordinators per
facility who will work with the facility to figure out the best process when
conducting meetings.
There is no hospice care in the MI Health Link program. So, if a member moves
from MI Health Link to hospice, how is the transition period handled?
When the member elects hospice, Molina is responsible for covering services until
the first of the next month. The member will be disenrolled from MI Health Link
as of the first day of the month following the month the member elects to receive
hospice care.
Is authorization for short-term rehab required upon patient discharge from the
hospital?
Authorization is required. Under regulatory and NCQA guidelines, Molina has up
to 72 hours to respond, but our goal is to respond within 24 hours. Molina works
with the hospital throughout the inpatient stay to plan for anticipated needs upon
discharge.
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Molina Healthcare of Michigan
MI Health Link Presentation – June 3, 2015
Nursing Facility – FAQs
Does the care coordinator follow the patient into multiple settings such as
rehab?
Yes, Care Coordinators are available to assist in multiple settings.
Does Molina have a process in place to work with hospitals to ensure all
applicable services are coordinated upon transfer to a nursing facility?
Molina has a hospital transition team that works with the discharge planners at
the hospital during the inpatient stay to ensure that all equipment and other
services are coordinated at the point of discharge. Working in conjunction with
the hospital, we will make our best effort to ensure sure the nursing facility is
notified of the discharge and the member’s special needs (order of equipment,
infusion, etc.).
QUALITY MANAGEMENT
Does Molina following the guidelines utilized by the State of Michigan for
incident reporting?
Yes, Molina utilizes the same algorithm as the state for Critical Incident Reporting.
What are the notification requirements for Critical Incident Reporting?
Follow the state process and notify Molina as well.
Does Molina process incident reports via the state?
Molina will report what the state mandates. Our Care Coordinators will work
with the nursing facility Director of Nursing on all incidents and will report within
48 hours. The nursing facility must inform Molina of any incidents that require
mandatory reporting.
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Molina Healthcare of Michigan
MI Health Link Presentation – June 3, 2015
Nursing Facility – FAQs
BLLING/OTHER
What is the turnaround time for claims going through two cycles?
Molina processes claims for Medicare benefits first, then Medicaid. All claims are
processed within 30 days. Both segments of the payment will appear on the
same remittance advice.
How should the nursing facility bill for therapy services billed on a UB04 for Part
B services only, with no room and board?
Please bill Molina in the same way you would bill Medicare or Medicaid.
What is covered under the per diem?
Same as it is for you today, for all services you are billing.
What is covered under Medicaid?
Services not covered or benefits that have been exceeded under Medicare.
How is it different now that Molina is the insurance provider?
You only have to bill one entity.
When patients come to the nursing facility under Medicare and convert to
MI Health Link, when do they begin billing Molina?
They begin billing on the first of the month following their effective date.
What is the best method to validate eligibility?
The state’s CHAMPS system and then Molina’s WebPortal to verify MI Health Link
coverage.
What if a member if retroactively enrolled?
Please notify Molina as soon as you know the patient is Molina. Authorizations,
as appropriate, will be given back to the first of the month of eligibility.
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Molina Healthcare of Michigan
MI Health Link Presentation – June 3, 2015
Nursing Facility – FAQs
What are the member’s rights to opt in or opt out of MI Health Link?
Members can choose to dis-enroll and opt out of the MI Health Link program or
choose a different MI Health Link health plan to coordinate their care. Members
are sent at least two letters about being enrolled in a new MI Health Link health
plan. The letter includes details regarding the plan, effective date of enrollment,
and instructions on choice or opt out.
Can you hold a follow-up session for nursing facilities?
Yes, one will be held in the fall. Molina will notify nursing facilities of the date.
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