|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 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 “Second Opinions From Non-Participating Providers."
|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 Florida, Inc.
8300 NW 33 St., Suite 400,
Doral, FL 33122
1 (888) 560-5716
|What is my grace period?
If You have received a Late Notice that Your coverage is being terminated or not renewed due to failure to pay Your Premium, Molina will give a:
- 10-day grace period to pay the full Premium payment due if You do not receive advance payment of the premium tax credit.
Molina will process payment for Covered Services received during the 10-day grace period.
You will be responsible for any unpaid Premiums You owe Molina for the grace period; or
- Three month grace period to pay the full Premium payment due if You receive advance payment of the premium tax credit.
Molina will process payment for Covered Services received after the first month of the grace period so long as Your Premiums
are paid in full before the end of the grace period. If We do not receive Premiums by the end of the three-month grace period,
You will be responsible for payment of the Covered Services received during the second and third months.
During the grace period applicable to You, You can avoid termination or nonrenewal of this Agreement by paying the full
Premium payment You owe to Molina.
If You do not pay the full Premium payment by the end of the grace period, this Agreement will terminate.
You will still be responsible for any unpaid Premiums You owe Molina for the grace period if You receive
advance payment of the premium tax credit.
|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 physician exercising prudent clinical judgment would provide to a patient.
This is for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms.
Those services must also be deemed by Molina to be:
- In accordance with generally accepted standards of medical practice;
- Clinically appropriate and clinically significant, in terms of type, frequency, extent, site and duration;
- Effective for the patient’s illness, injury or disease; and,
- Not primarily for the convenience of the patient, physician, or other health care provider.
The services must not be more costly than an alternative service or sequence of services
at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or
treatment of that patient’s illness, injury or disease.
For these purposes, “generally accepted standards of medical practice” means standards based on
credible scientific evidence published in peer-reviewed medical literature. This literature is generally
recognized by the relevant medical community, physician specialty society recommendations, the views
of physicians practicing in relevant clinical areas and any other relevant factors.
|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 Agreement 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.
For routine prior authorization requests, Molina will provide a decision within 15 days of receipt of the request.
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:
- 24 hours following receipt of request for expedited exception request
- 72 hours following receipt of request for standard exception request
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.
|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.