Claims Submission
As a participating provider with Molina, you have established a contractual agreement to provide physical, behavioral and/or other long-term support services to our members. The arrangement is fee-for-service for the provision of covered healthcare services unless otherwise specified under your Participating Agreement. The rates established in your Participating Agreement are considered full payment for covered services provided. Accordingly, Molina members may not be balance billed for any remaining amounts and/or difference between what is billed, and your negotiated reimbursement rates defined in the rate exhibit of your Participating Provider Agreement.
- Reimbursement of Covered Services
As a participating Molina provider, you agree to bill all covered services provided to Molina members on the required forms and/or electronic claims file format. All claims should be billed on a fully completed CMS 1500, UB04 and/or CMS 1450 to be considered for adjudication and/or payment. You may visit the Centers for Medicare and Medicaid Services (CMS) website at www.cms.hhs.gov to obtain more information about these forms and/or for more instruction and/or information on the proper use of claims forms for services.
Any claims requiring authorization should include the authorization number in the appropriate field of the CMS 1500, UB04 or CMS 1450 to assist with appropriate claims processing and timely claims payment. Download this list of services requiring prior authorization (coming soon). A reference to the listing is also located in Section 10: Medical Management of the Molina provider manual.
- How do I submit my claims to Molina?
You can submit your claims to Molina by paper or electronically. You are strongly encouraged to submit your claims electronically. Electronically transmitted claims result in faster claims payment turnaround times and higher acceptance rates. However, if you choose not to bill electronically, we can accept paper claims.
Submitting Electronic Claims
Molina uses Change Healthcare as its gateway clearinghouse. Change Healthcare has relationships with hundreds of other clearinghouses. There are several other claims clearinghouses that we work with. Please call Customer Care to check if Molina has a relationship with your clearinghouse. Molina's clearinghouse payer ID for both Medicare and Medicaid claims is MCC02. The MCCVA Payer ID will no longer be accepted effective 7/1/2022.
Molina also offers a direct submit/web-based claims option through Availity Essentials Provider Portal to Molina for both Medicaid and Medicare claims. As of November 19, 2022 you will need to have a premium subscription with Availity to submit EDI batch claims. There is no charge to participating providers for submitting direct data entry claims through the Availity tools.
You must register with Availity to use the service and add Molina Healthcare Virginia as one of your payers. If you are not currently registered with Availity please visit Availity.com to get connected.
Submitting Paper Claims
Participating Providers should submit Claims electronically. If electronic Claim submission is not possible, please submit paper Claims to the following address:
Molina Healthcare of Virginia, LLC
PO Box 22656
Long Beach, CA 90801Please keep the following in mind when submitting paper Claims:
- - Paper Claims should be submitted on original red colored CMS 1500 Claims forms.
- - Paper Claims must be printed, using black ink.
- Timely Filing of Claims
Claims for services provided to Molina members should be submitting within six months (180 days) of the date of service unless otherwise agreed upon in the Participating Provider Agreement. If not otherwise defined in the Participating Agreement, and/or in the case of a non-participating provider who provides covered service to Molina members, claims must be received within twelve months (180 calendar days) to be considered for processing and payment.
There are three timely filing exceptions that Molina takes under consideration:- Coordination of benefits—When an Molina member has a primary insurance, the primary insurance Explanation of Payment (EOP) or Medicare Summary Notice (MSN) is used to determine the timely filing deadline. For these claims, the time frame begins with the print date on the primary insurance EOP or MSN.
- Members with retroactive eligibility—When a member becomes eligible for a DMAS Medicaid program after the date of service, but their coverage is backdated to include the date of service, the time frame for timely filing begins on the date Molina receives notification from the enrollment broker of the member’s enrollment.
- Other (good cause)—Molina will consider exceptions on a case by case basis for other causes of filing delays, such as incorrect information provided by official sources.
Corrected claims, adjustments, or reconsiderations should be submitted within 180 days of the original claim paid date in order to be considered for reprocessing.
Processing and payment of claims for covered services are generally made within 30 calendar days of receipt of a clean claim. For more information on claims submission and payment, please refer to the Molina provider manual.
- Coordination of benefits—When an Molina member has a primary insurance, the primary insurance Explanation of Payment (EOP) or Medicare Summary Notice (MSN) is used to determine the timely filing deadline. For these claims, the time frame begins with the print date on the primary insurance EOP or MSN.