Will I be responsible for any out of pocket costs billed by a Non-Participating (Out
of Network) Provider?
PLEASE NOTE: Urgent Care is not covered if member see's a non-participating provider!
Molina Healthcare of New Mexico may not restrict You or Your eligible Dependents
who are enrolled in this Policy from seeking medical treatment with a non-participating
provider. However, should You or Your eligible Dependents who are enrolled in this
Policy obtain medical treatment with a nonparticipating provider You will be 100%
responsible for payment and the payments will not apply to Your Deductible or Annual
Out-of-Pocket Maximum for any of these services.
For exceptions please review the following sections of the Agreement titled “Emergency Services and Urgent Care Services”,
and “What if There Is No Participating Provider to Provide a Covered Service?.”
EMERGENCY AND URGENT CARE SERVICES (pg 36,37 EOC)
What is an Emergency?
Emergency care means health care procedures, treatments, or services delivered to
a covered person after the sudden onset of what reasonably appears to be a medical
condition that manifests itself by symptoms of sufficient severity, including severe
pain, that the absence of immediate medical attention could reasonably be expected
by a reasonable layperson to result in:
- Placing the patient’s health in serious danger.
- Serious damage to bodily functions.
- Serious dysfunction of any bodily organ or part.
- Disfigurement to the person;
- Or a condition in which a reasonable person believes that immediate medical attention
If You are within Molina’s Service Area You can ask Your PCP what Participating
Provider urgent care center to use. It is best to find out the name of the Participating
Provider urgent care center ahead of time. Ask Your doctor for the name of the Participating
Provider urgent care center and the name of the hospital that You are to use.
If You are outside of Molina’s Service Area, and You need urgent care You may go to
the nearest emergency room.
You have the right to interpreter services at no cost. To help in getting after hours care call toll-free at 1 (888) 665-4621.
Urgent Care Services are subject to the Cost Sharing. Please be aware that if You go to a Non-Participating
Provider, You will be 100% responsible for payment and the payments will not apply
to Your Deductible or Annual Out-of-Pocket Maximum for any of these services.
How are claims for covered medical services submitted for payment under my plan?
Notice of Claim
Written notice of a Member’s claim relating to Covered Services under this EOC,
when applicable (a “Claim”) must be given to Molina Healthcare within 20 days after
the Claim for reimbursement or payment of Covered Services under this EOC becomes
owing, or as soon thereafter as is reasonably possible. Notice of the Claim given
by or on behalf of the Member to Molina Healthcare at the following address, with
information sufficient to identify the Member and the nature of the Claim, shall
be deemed notice to Molina Healthcare:
Molina Healthcare P.O. Box 22801 Long Beach,CA 90802
Upon Your submission of a Claim to Molina Healthcare, Molina will calculate the
amount of the Claim that may be due to You in accordance with this Agreement and
applicable state and federal laws. If amounts subject to the Claim are owing to
You, such amounts may be reduced by applicable Cost Sharing.
Molina Healthcare, upon receipt of a notice of Claim from a Member as provided above,
will furnish to the Member such forms as are usually furnished by Molina Healthcare
for filing proofs of loss (if such additional forms are appropriate and required
by Molina) with respect to such Claims. If Molina Healthcare does not furnish such
required forms to the Member within 15 days after the notice of Claim has been given
to Molina, the Member shall be deemed to have complied with the requirements of
this EOC as to proof of loss upon submitting, within the time fixed by this EOC
for filing proofs of loss, written proof covering the occurrence, the character
and the extent of the loss for which Claim is being made.
Proof of Loss
If required or appropriate as determined by Molina Healthcare, written proof of
loss relating to a Claim must be furnished to Molina at its office (identified in
the “Notice of Claim” section above) within 365 days after the occurrence or start
of the loss on which the Claim is based to validate and preserve the Claim. If written
proof of loss is not given within that time, the Claim will not be invalidated,
denied or reduced if it is shown that written proof of loss relating to a Claim
was given as soon as was reasonably possible or legal incapacity of the Member extended
the time period for providing such proof of loss. Foreign Claims and proof of loss
relating to such Claims must be translated in U.S. currency prior to being submitted
to Molina Healthcare.
Time of Payment of Claims
Upon the timely receipt of the proof of loss (if required by Molina Healthcare)
and all other information necessary to evaluate, process and pay a Claim under this
EOC, Molina Healthcare will pay the Claim within 60 days after receipt of such proof
of loss and other information. Payment of Claims by Molina requires that documentation,
however submitted to Molina, be in form and content reasonably acceptable to Molina
and contain all required information for processing without the need for additional
information from outside of Molina Healthcare. Interest penalties will not be applied
to Claims not paid within the timeframes stated.
What is my grace period?
31-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 grace period. You will be responsible for any unpaid Premiums
You owe Molina Healthcare 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 hold payment for Covered Services
received after the first month of the grace period until We receive the delinquent
Premiums. If Premiums are not received 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.
|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?
If You believe that we have not paid a claim properly, You should first attempt
to resolve the problem by contacting Us. Follow the steps described in the "Complaints"
section, below. If You are still not satisfied, You may call The New Mexico Office
of Superintendent of Insurance for instructions on filing a consumer complaint.
Call 1-855-4ASK-OSI (1-855-427-5674), or visit The New Mexico Office of Superintendent
of Insurance website at www.osi.state.nm.Us.
What is Medical Necessity?
“Medically Necessary” or “Medical Necessity” means health care services determined
by a provider, in consultation with Molina Healthcare, to be clinically appropriate
or clinically significant, in terms of type, frequency, event, site, according to
any applicable generally accepted principles and practices of good medical care
or practice guidelines developed by the federal government, national or professional
medical societies, boards and associations, or any applicable clinical protocols
or practice guidelines developed by Molina Healthcare consistent with such federal,
national, and professional practice guidelines, for the diagnosis or direct care
and treatment of a physical, behavioral, or mental health condition, illness, injury,
What is Prior Authorization, and how does it impact services under my plan?
What is a Prior Authorization?
A Prior Authorization is an approval from Molina which confirms that a requested
health care service, treatment plan, prescription drug or item of durable medical
equipment has been determined to be Medically Necessary and is covered under Your
plan Molina’s Medical Directors 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 a prior approval.
Routine Prior Authorization requests will be processed within five business days.
This is five days from when we get the information we need and ask for. We need
this information to make the decision. It may take up to 14 calendar days from the
receipt of the request. We will deny Prior Authorization requests if You do not
provide the information We requested.
We process Prior Authorizations for medical conditions that may cause a serious
threat to Your health within 24 hours.
This is 24 hours from when we get the information we need and ask for. We need this
information to make the decision. We will deny a Prior Authorization if information
We request is not provided to Us. The time required may be shorter under Section
2719 of the federal Public Health Services Act and subsequent rules and regulations.
Molina processes requests for urgent specialty services right away. This is done
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 look at Our Drug Formulary on Our Molina Healthcare website. The address
is MolinaMarketplace.com. You may call Molina Healthcare and ask about a drug. Call
toll free 1 (888) 295-7651. We are here Monday through Friday, 8:00 a.m. through
5:00 p.m. MT. If You are deaf or hard of hearing, call Our TTY line. You may dial 711 for the Telecommunications Service.
You can also ask Us to mail You a copy of the Drug Formulary. A drug listed on the
Drug Formulary does not guarantee that Your doctor will prescribe it for You.
Access to Drugs Which are Not Covered
Molina has a process to allow You to request clinically appropriate drugs that are
not covered under this Agreement. Your doctor may order a drug that is not in the
Drug Formulary that he or she believes is best for You. Your doctor may contact
Molina’s Pharmacy Department to request that Molina cover the drug for You. If the
request is approved, Molina will contact Your doctor. If the request is denied,
Molina Healthcare will send a letter to You and Your doctor. The letter will explain
why the drug was denied.
You may be taking a drug that is no longer on Our Drug Formulary. Your doctor can
ask Us to keep covering it by sending Us a Prior Authorization request for the drug.
The drug must be safe and effective for Your medical condition. Your doctor must
write Your prescription for the usual amount of the drug for You. Molina may cover
specific non-Drug Formulary drugs under the following conditions:
- Document in Your medical record;
- Certify that the Drug Formulary alternative has not been effective in Your treatment;
- The Drug Formulary alternative causes or is reasonably expected by the prescriber
to cause a harmful or adverse reaction in the Member.
There are two types of requests for clinically appropriate drugs that are not covered under this Agreement:
- Expedited Exception Request for urgent circumstances that may seriously jeopardize
life, health, or ability to regain maximum function, or for undergoing current treatment
using non-Drug Formulary drugs.
- Standard Exception Request.
You and/or Your Participating Provider will be notified of Our decision no later than:
- 24 hours following receipt of request for Expedited Exception Request
- 5 working days following receipt of request for Standard Exception Request.
Molina Healthcare may extend the review period for a maximum of 10 working days if it:
- can demonstrate reasonable cause beyond its control for the delay;
- can demonstrate that the delay will not result in increased medical risk to You; and
- provides a written progress report and explanation for the delay to You and Your
provider within the original five working day review period.
If a request for services is denied, the requesting provider and the member will receive a letter explaining
the reason for the denial and additional information regarding the grievance and appeals process. Denials
also are communicated to the provider by telephone/fax or electronic notification. Verbal and fax denials
are given within one business day of making the denial decision, or sooner if required by the member’s condition.
If initial request is denied, You and/or Your Participating Provider may request an IRO review. You and or Your
Participating Provider will be notified of the IRO’s decision no later than:
- No later than 72 hours following receipt of request for Expedited Exception Request
- 10 working days 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
- Description of remark code - explanation of the claim payment or
- 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
This Coordination of Benefits (“COB”) provision applies when a person has health
care coverage under more than one Plan. For purposes of this COB provision, Plan
is defined below.
The order of benefit determination rules govern 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
Definitions (applicable to this COB provision)
A “Plan” is any of the following
that provides benefits or services for medical or dental care or treatment. If separate
contracts are used to provide coordinated coverage for members of a group, the separate
contracts are considered parts of the same plan and there is no COB among those
1. Plan includes: group and non-group insurance contracts, health maintenance organization
(HMO) contracts, Closed Panel Plans or other forms of group or group-type coverage
(whether insured or uninsured) ; medical care components of long-term care contracts,
such as skilled nursing care; medical benefits under group or individual automobile
contracts; and Medicare or any other federal governmental plan, as permitted by
2. Plan does not include: hospital indemnity coverage or other fixed indemnity coverage;
accident only coverage; specified disease or specified accident coverage; limited
benefit health coverage, as defined by state; school accident type coverage; benefits
for non-medical components of long-term care policies; Medicare supplement policies;
Medicaid policies; or coverage under other federal governmental plans, unless permitted
Each contract for coverage under (1) or (2) is a separate Plan. If a Plan has two
parts and COB rules apply only to one of the two, each of the parts is treated as
a separate Plan:
• “This Plan” means, in a COB provision, the part of the contract providing the
health care benefits to which the COB provision applies and which may be reduced
because of the benefits of other Plans. Any other part of the contract providing
health care benefits is separate from This Plan. A contract may apply one COB provision
to certain benefits, such as dental benefits, coordinating only with similar benefits,
and may apply another COB provision to coordinate other benefits.
The order of benefit determination rules determine whether This Plan is a Primary
Plan or Secondary Plan when the person has health care coverage under more than
one Plan. When This Plan is primary, it determines payment for its benefits first
before those of any other Plan without considering any other Plan’s benefits. When
This Plan is secondary, it determines its benefits after those of another Plan and
may reduce the benefits it pays so that all Plan benefits do not exceed 100% of
the total Allowable Expense. When there are more than two Plans covering the person,
This Plan may be a Primary Plan as to one or more other Plans and may be a Secondary
Plan as to a different Plan or Plans.
“Allowable Expense” is a health care expense, including Deductibles, Coinsurance,
and Copayments, that is covered at least in part by any Plan covering the person.
When a Plan provides benefits in the form of services, the reasonable cash value
of each service will be considered an Allowable Expense and a benefit paid. An expense
that is not covered by any Plan covering the person is not an Allowable Expense.
In addition, any expense that a provider by law or in accordance with a contractual
agreement is prohibited from charging a Member is not an Allowable Expense.
The following are examples of expenses that are not Allowable Expenses:
The difference between the cost of a semi-private hospital room and a private hospital
room is not an Allowable Expense, unless one of the Plans provides coverage for
private hospital room expenses.
1. If a person is covered by 2 or more Plans that compute their benefit payments
based on usual and customary fees, relative value schedule reimbursement methodology,
or other similar reimbursement methodology, any amount in excess of the highest
reimbursement amount for a specific benefit is not an Allowable Expense.
2. If a person is covered by 2 or more Plans that provide benefits or services based
on negotiated fees, an amount in excess of the highest of the negotiated fees is
not an Allowable Expense.
3. If a person is covered by one Plan that calculates its benefits or services on
the basis of usual and customary fees or relative value schedule reimbursement methodology
or other similar reimbursement methodology and another Plan that provides its benefits
or services on the basis of negotiated fees, the Primary Plan’s payment arrangement
shall be the Allowable Expense for all Plans.
However, if the provider has contracted
with the Secondary Plan to provide the benefit or service for a specific negotiated
fee or payment amount that is different from the Primary Plan’s payment arrangement
and if the provider’s contract permits, the negotiated fee or payment shall be the
Allowable Expense used by the Secondary Plan to determine its benefits.
4. The amount of any benefit reduction by the Primary Plan because a Member has
failed to comply with the Plan provisions is not an Allowable Expense. Examples
of these types of plan provisions include second surgical opinions, precertification
of admissions, and preferred provider arrangements.
“Closed Panel Plan” is a Plan
that provides health care benefits to Members primarily in the form of services
through a panel of providers which have contracted with or are employed by the Plan,
and that excludes coverage for services provided by other providers, except in cases
of emergency or referral by a panel member.