|Will I be responsible for any out of pocket costs billed by a Non-Participating (Out of Network) Provider?
||You must receive covered services from participating (in-network) providers, in order for those services to be a covered service under your plan. |
Services provided by non-participating (out of network) providers without being prior authorized by Molina, are not covered services, and you will be 100% responsible for payment to non-participating providers, and the payments will not apply to any applicable deductible or annual out-of-pocket maximum under your plan.
- Emergency services obtained for treatment of an emergency medical condition within or outside of the service area of your plan, are considered a covered service without prior authorization, subject to payment of the applicable cost share under your plan.
- Some hospital based providers who may be involved in your emergency care (such as emergency room, radiology, anesthesiology, or pathology providers), may not contract as participating providers.
- For emergency services received by non-participating providers such as these, Molina will calculate the allowed amount of covered expense as the greatest of the following:
- Molina’s usual and customary rate for such services,
- Molina’s median contracted rate for such services, or
- 100% of the Medicare rate for such services.
Because non-participating providers are not in Molina’s contracted provider network, they may balance-bill you for the difference between our allowed amount, described above, and the rate that they charge. You will be responsible for charges that exceed the allowed amount covered under this benefit.
Urgent Care Services:
Within the service area of your plan –
Outside the service area of your plan –
- Participating providers – urgent care services do not require prior authorization. However within the service area, you must access participating urgent care providers in order for those services to be a covered service under your plan. You will only be liable for the urgent care cost share under your plan
- Non-participating providers – services provided by non-participating urgent care providers, are not covered services and you will be 100% responsible for payment to non-participating urgent care providers, and the payments will not apply to any applicable deductible or annual out-of-pocket maximum under your plan.
- Urgent care services, received outside the service area of your plan, do not require prior authorization, and you will only be responsible for the urgent care cost share under your plan.
|How are claims for covered medical services submitted for payment under my plan?
Once you have obtained covered services from a participating provider, the provider is responsible for submission of claims to Molina for determination of payment under your plan. You are not responsible for submitting claims to Molina for payment of benefits under your plan. |
However, if a participating provider fails to submit a claim, you may wish to send receipts for covered services to Molina. With the exception of any required cost sharing amounts (such as a deductible, copayment or
Coinsurance), if you have paid for a covered service or prescription that was approved or does not require approval, Molina will pay you back. You must submit your claim for reimbursement within 12 months from the date you made the payment.
Please refer to your evidence of coverage, policy or certificate. You will need to mail or fax Molina, a copy of the bill from the doctor, hospital or pharmacy and a copy of your receipt. If the bill is for a prescription, you will need to include a copy of the prescription label. Mail this information to Molina’s customer support center.
Molina Healthcare of Wisconsin, Inc.
Customer Support Center
11200 W. Parkland Ave
Milwaukee, WI 53224-3127
1 (888) 560-2043
Fax: 1 (414) 214-2489
|What is my grace period?
||If you receive advance payments of the premium tax credit, also called, federal subsidies, you are entitled to a three month grace period, if you have paid at least one month of premium for the benefit year. A grace period is the period that starts when you are late paying your premium, and ends when you are terminated. |
So if you receive help paying your premium from the federal government, you have a three month grace period, before your policy will be terminated for nonpayment.
During the first month of the grace period, Molina will pay the appropriate claims for services rendered to you during that time. However, during the second and third month of the grace period, Molina will not pay claims for services received, and will pend them. Pending claims means Molina will not pay the claim unless and until you pay the full outstanding balance of your premium. You will be responsible for any services received during the second and third months of the grace period if you do not pay the balance of your premium.
|What is a retroactive denial and when am I responsible?
||A retroactive denial is the reversal of a previously paid claim. This retroactive denial may occur even after you obtain services from the provider (doctor). If we retroactively deny the claim, you may become responsible for payment. The ways to prevent retroactive denials are paying your premiums on time, and making sure you doctor is a Participating (In-Network) Provider.
|How do I recover an overpayment to Molina?
||You may recover an over payment to Molina as a refund if you find that you paid too much. You may also seek a credit toward your next month’s premium, which might be easier.|
If you would like to recover an over payment to Molina, simply call the Member Services number located on your ID card, and explain the amount you are seeking and why you think you over paid Molina. We will be happy to help.
|What is Medical Necessity?
||Medical Necessity means that participating providers, who in the course of delivering covered services provided under your plan, use prudent clinical judgment, for the purposes of preventing, evaluating, diagnosing, or treating an illness, injury, disease or its symptoms.|
That your care is provided using generally accepted standards of medical practice, and be clinically appropriate in terms of the type, amount, frequency, level, site and duration of care needed. That the services are not primarily for convenience, but provided for the best diagnosis and potential outcomes.
|What is Prior Authorization, and how does it impact services under my plan?
||Your plan requires that you obtain a medical necessity review of certain services, prior to obtaining those services to be covered under your plan. Prior authorization is a process for Molina and your doctor, to review the medical necessity of your care before the care or service is given. This is to ensure that the proposed services are appropriate for your specific condition and that appropriate utilization review can occur.|
You should consult your evidence of coverage, policy or certificate, to determine what services require prior authorization under your plan. If you do not obtain prior authorization for the specified services, claims for benefit payment may be denied, impacting your out of pocket costs.
Routine prior authorization requests will be processed within 5 business days of receiving complete information from your doctor, and Molina will respond to prior authorization requests within 14 calendar days.
Medical conditions that may cause a serious threat to your health are processed within 72 hours from receipt of all information, or shorter as required by law.
|How can I determine if my prescription drug is covered?
What do I do if my prescription drug is not listed in my Plan’s formulary?
You can determine if your prescription drug is on our formulary, by visiting www.molinamarketplace.com. You can also call member services and ask about whether a specific drug is covered.|
How to complete an application of coverage appeal for non-formulary drugs:
If your prescription drug is not listed on our formulary, you or your participating provider may a request prior authorization review by contacting Molina Customer Support phone number identified on your ID Card and within the Provider Manual, to determine any access to clinically appropriate drugs that your doctor feels is best for you. The doctor will send to Molina a specially completed request form to let Molina know how the drug is medically necessary for your condition. If the request is approved, we will notify your doctor. If it is not approved, we will notify you and your doctor, including the reason why.
There are two types of prior authorization requests for clinically appropriate drugs not covered under plan:
Expedited exception request – this is for urgent circumstances that may seriously jeopardize your life, health, or ability to regain maximum function, or for undergoing current treatment using non-formulary prescription drugs
Standard exception request – this is for non-urgent circumstances
Notification - following your request, you and/or your doctor will be notified of our decision no later than:
If your request is denied, you may still seek review through independent review organization (IRO) review. Consult your evidence of coverage, policy or certificate for more information.
- 24 hours following receipt of request for expedited exception request
- 72 hours following receipt of request for standard exception request
|What is an Explanation of Benefits (EOB)?
||An explanation of benefits (EOB) is a statement Molina sends to you to explain what medical treatments and / or services Molina paid for on your behalf, the amount of the payment, and your financial responsibility pursuant to the terms of your policy. Molina will send you an EOB after you receive services from your doctor or a hospital. |
In some instances there may be one or more reasons why payment or partial payment cannot be made. If your claim has been denied and you believe that additional information will affect the processing of the claim, or you have a question about a covered service, a provider, your benefits or how to use your plan, you can contact member services to answer any questions you may have.
Here are some of the definitions of the terms used in the EOB:
- Procedure code - code number of the service that was performed.
- billed amount - the amount of billed charges received from your provider for services rendered
- Allowed amount - the amount the health plan pays for services rendered
- Copay amount - the amount of your copay for certain benefits (i.e. office visit, ER, etc.). This is a fixed dollar amount.
- Co-insurance amount – the amount owed by you after your deductible is applied. This is based on a percentage dictated by your benefit coverage.
- Deductible amount - the amount applied toward your annual deductible, based on benefit coverage and claim.
- Plan payment - the amount the health plan paid to the provider.
- Remark code – additional messages that may explain how your claim was processed under "explanations of claims handling"
- Total patient responsibility for this claim - the amount you owe the provider.
- Description of remark code - explanation of the claim payment or denial.
- Family out of pocket & deductible totals - a summation of your family's total yearly deductible amount and out of pocket amount based on your benefits, the year to date total that has been applied, and the remaining balances.
|What is Coordination of Benefits (COB)?
||Coordination of benefits (COB) is the process for the order of payment when you may have health insurance under more than one insurer.|
COB governs the order in which each plan will pay a claim for benefits. The plan that pays first is called the “primary plan”. The primary plan must pay benefits in accordance with its policy terms without regard to the possibility that another plan may cover some expenses. The plan that pays after the primary plan is the “secondary plan”. The secondary plan may reduce the benefits it pays so that payments from all plans do not exceed 100% of the total allowable expense.
For a complete description of how cob works with your plan, consult your evidence of coverage, policy or certificate.