|Will I be responsible for any out of pocket costs billed by a Non-Participating (Out of Network) Provider?
In general, you must receive covered services from participating providers; otherwise, the services are not covered, you will be 100% responsible for payment to the non-participating provider and the payments will not apply to your deductible or annual out-of-pocket maximum. However, you may receive services from a non-participating provider:
- For emergency services in accordance with the section of the Agreement titled “Emergency Services and Urgent Care Services,”
- For out-of-area urgent care services in accordance with the section of the Agreement titled “Emergency Services and Urgent Care Services,”
- For exceptions described in the section of the Agreement titled “What if There Is No Participating Provider to Provide a Covered Service?,” and
- For exceptions described in the section of the Agreement titled “Non-Participating Provider at a Participating Provider Facility.
|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 California
200 Oceangate, Suite 100
Long Beach, CA 90802
1 (888) 858-2150
|What is my grace period?
- If You do not receive advance payment of the premium tax credit, Molina Healthcare will give You a thirty (30) calendar-day “grace period” Before cancelling or not renewing your coverage due to failure to pay Your Premium. Molina Healthcare will continue to provide coverage pursuant to the terms of this Agreement, including paying for Covered Services received during the thirty (30) calendar-day grace period. During the grace period, You can avoid cancellation or nonrenewal by paying the Premium You owe to [Covered California] [or] [Molina Healthcare] If You do not pay the Premium by the end of the grace period, this Agreement will be cancelled at the end of the grace period. You will still be responsible for any unpaid Premiums You owe Molina Healthcare for the grace period.
- If You receive advance payment of the premium tax credit, Molina Healthcare will give You a three (3) month “grace period” before cancelling or not renewing Your coverage due to failure to pay Your Premium. Molina Healthcare will pay for Covered Services received during the first month of the three-month grace period. If you do not pay the Premium by the end of the first month of the three-month grace period, Your coverage under this plan will be suspended and Molina Healthcare will not pay for Covered Services after the first month of the grace period until We receive the delinquent Premiums. If all Premiums due and owing are not received by the end of the three-month grace period, this Agreement will be cancelled effective the last day of the first month of the grace period You will still be responsible for any unpaid Premiums You owe Molina Healthcare for the grace period
|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?
||“Medically Necessary” or “Medical Necessity” means health care services that a provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms. Those services must be in accordance with generally accepted standards of practice; clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and not primarily for the convenience of the patient or provider. For these purposes, “generally accepted standards” means standards that are based on credible scientific evidence published in peer-reviewed literature generally recognized by the relevant provider community, physician specialty society recommendations, the views of providers practicing in relevant clinical areas, and any other relevant factors. For these purposes, “provider” means a licensed medical, mental health, substance use disorder, or dental provider competent to evaluate the relevant specific clinical issues, or a qualified autism service provider that is licensed, certified, or otherwise authorized under California law.
|What is Prior Authorization, and how does it impact services under my plan?
||A prior authorization is an approval from Molina for a requested health care service, treatment plan, prescription drug or durable medical equipment. A prior authorization confirms that the requested service or item is medically necessary and is covered under Your plan. Molina’s Medical Director and your doctor work together to determine the medical necessity of covered services before the care or service is given. This is sometimes also called prior approval. |
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?
Molina has a list of drugs that We will cover. The list is known as the Drug Formulary. You can determine if your prescription drug is on the Drug Formulary, by visiting www.molinamarketplace.com. You can also call Member Services and ask about whether a specific drug is covered.|
If your prescription drug is not listed on our Drug 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 initial request is denied, you may seek additional review, as described in the Agreement section on "Prescription Drug Coverage."
- 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.