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 a member is treated by a non-participating provider!
You must receive covered services from participating (in-network) providers in order for those service 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 covered services 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.
- In this case, these non-participating hospital based providers, must accept payment of the covered expense provided by
Molina and are prohibited from balance billing you beyond the applicable cost share under your plan.
Urgent Care Services:
Within 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.
How are claims for covered medical services submitted for payment under my plan?
While most claims for payment of Covered Services will be submitted directly by Your Participating Providers,
You may incur charges for Covered Services can be submitted by You as a claim to Molina Healthcare.
For example, you may have received Emergency Services from a non-Participating Provider.
With the exception of any required Cost Sharing amounts (such as a Copayment or Percentage Cost Sharing),
if You have paid for a Covered Service or prescription that was approved or does not require approval, Molina
Healthcare will pay You back. You will need to mail or fax us 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 Healthcare’s Customer Support Center: PO Box 22719, Long Beach, CA 90801,
or you call Member Services with any questions: (888) 560-2025 (TTY/TTD: 711).
You must provide us with notice of a claim within 20 days following the date of service, unless it is not reasonably possible to do so.
Failure to give notice within this time will not invalidate or reduce any claim if You show that it was not reasonably possible to give the notice,
and that the notice was given as soon as it was reasonably possible. Within 15 days following Our receipt of the notice of claim,
We will acknowledge the receipt of the claim, begin Our investigation of the claim, and request any additional items, statements,
and forms that We reasonably believe will be required from You. All claims must be properly submitted within 90 days of the date
that You receive the services or supplies. Claims not submitted and received by Molina Healthcare within twelve (12) months after
that date will not be considered for payment of benefits except in the absence of legal capacity.
What is my grace period?
- 30-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?
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 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, or disease.
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 by phone.
What is Prior Authorization, and how does it impact services under my plan?
A Prior Authorization is an approval by Molina that 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. A
prior authorization is not a guarantee of claim payment. 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.
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 Healthcare has a list of drugs that it will cover. The list is called the Drug Formulary.
The drugs on the list are chosen by a group of doctors and pharmacists from Molina Healthcare
and the medical communMolina Healthcare has a list of drugs that We will cover. The list is known as the Drug Formulary.
The drugs on the list are chosen by a group of doctors and pharmacists from Molina Healthcare and the medical community.
The group meets every 3 months to talk about the drugs that are in the Drug Formulary. They review new drugs and changes in health care,
in order to find the most effective drugs for different conditions. Drugs are added to or removed from the Drug Formulary based on changes
in medical practice and medical technology. They may also be added to the Drug Formulary when new drugs come on the market.
You can look at Our Drug Formulary on Our Molina Healthcare website.
The address is www.MolinaMarketplace.com. You may call Molina Healthcare and ask about a drug.
Call toll free 1 (888) 560-2025. We are here Monday through Friday, 8:00 a.m. through 6:00 p.m. CT. If You are deaf or hard of hearing, call Our TTY line.
You may dial 711 for the Telecommunications Service.
Access to Drugs Which Are Not Covered
Molina has a process to allow You to request clinically appropriate drugs that are
not covered under Your product. 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:
There are two types of requests for clinically appropriate drugs that are not covered under Your product:
- When Your doctor documents in Your medical record and certifies that the Drug Formulary
alternative has been ineffective in the treatment of the Member’s disease; or
- When the Drug Formulary alternative causes or is reasonably expected by the prescriber
to cause a harmful or adverse reaction in the Member. When the Drug Formulary alternative causes or is reasonably expected by the prescriber
to cause a harmful or adverse reaction in the Member.
You and/or Your Participating Provider will be notified of Our decision no later
- 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.
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:
- 24 hours following receipt of request for Expedited Exception Request
- 72 hours following receipt of request for Standard Exception Request
- 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)?
The Coordination of Benefits (COB) provision applies when a person has health care
coverage under more than one plan. 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 accord with its EOC 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 equal 100 percent of the total allowable
expense. 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 equal 100 percent
of the total allowable expense.