For Molina Members About Molina
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Provider Responsibilities


Molina Healthcare expects that its contracted Providers/Practitioners will respect the privacy of Molina Healthcare members and comply with all applicable laws and regulations regarding the privacy of patient and member PHI.

In applying the standards listed below, participating Providers have agreed they will not discriminate against any Member on the basis of:
  • Age
  • Race
  • Creed
  • Color
  • Religion
  • Sex
  • National origin
  • Sexual orientation
  • Marital status
  • Physical
  • Mental or sensory handicap
  • Place of residence
  • Socioeconomic status
  • Status as a recipient of Medicaid benefits

Additionally, participating Providers or contracted medical groups/IPAs may not limit their practices because of a Member’s medical (physical or mental) condition or the expectation for the need of frequent or high cost care. If PCPs choose to close their panel to new Members, Molina Healthcare must receive (30) days advance notice from the Provider.

Access to Care Standards


Molina Healthcare is committed to providing timely access to care for all Members in a safe and healthy environment. Molina Healthcare will ensure Providers offer hours of operation no less than offered to commercial members. Access standards have been developed to ensure that all health care services are provided in a timely manner. The PCP or designee must be available (24) hours a day, seven days a week to Members for emergency services. This access may be by telephone. Appointment and waiting time standards are shown below. Any Member assigned to a PCP is considered his or her patient.

Type of Care Appointment Wait Time
Preventive Care Appointment Within (30) days of request
Routine Care Within seven days of request
Urgent Care Within (24) hours
Emergency Care Available by phone (24) hours/seven days
After-Hours Care Available by phone (24) hours/seven days
Office Waiting Time Should not exceed (30) minutes

Site and Medical Record-Keeping Practice Reviews


Molina Healthcare has a process to ensure the offices of all PCPs, OB/Gyns and high volume behavioral health Providers meets Molina Healthcare office-site standards. Molina Healthcare assesses the quality, safety and accessibility of office sites where care is given. Standards and thresholds for office site criteria, medical treatment and record-keeping practices have been approved by Molina Healthcare’s Professional Review Committee (PRC). The site and medical record-keeping review is conducted prior to the initial credentialing decision. The PRC considers site and medical record-keeping review reports with other criteria and information about the Provider when making initial credentialing determinations.

New Providers joining a contracted medical group reviewed and found to be 80% or more in compliance with Molina Healthcare site review guidelines will not require another site review. A copy of the medical group’s site and medical record-keeping practices review report will be filed in the Provider’s credentials file and reviewed by the PRC as part of the initial credentialing process.

A standard site-visit survey form is completed at the time of each visit. This form includes the Site and Medical Record Keeping Practice Guidelines outlined below and the thresholds for acceptable performance against the criteria.

This includes an assessment of:
  • Physical accessibility
  • Physical appearance
  • Adequacy of waiting-room and examining-room space
  • Availability of appointments
  • Adequacy of medical/treatment record keeping

Adequacy of medical record-keeping practices


During the site visit, Molina Healthcare discusses office documentation practices with the Provider or Provider’s staff. This discussion includes a review of the forms and a method used to keep the information in a consistent manner and includes how the practice ensures confidentiality of records.

Molina Healthcare assesses medical/treatment records for orderliness of record and documentation practices. To ensure Member confidentiality, Molina Healthcare reviews a blinded medical/treatment record or a model record instead of an actual record.

Newborn Notification Process


PCPs must notify Molina Healthcare within (2) working days of the first prenatal visit and/or positive pregnancy test of any member presenting themselves for healthcare services.

The PCP shall submit to Molina Healthcare the Pregnancy Notification Report Form (included in Appendix B) within (2) working days of the first prenatal visit and/or positive pregnancy test of any member presenting themselves for healthcare services. Providers shall enter all applicable information in sections (3) and (2) of the form. The form should be faxed to Molina Healthcare Member Services.

Relocations and Additional Sites


Providers should notify Molina Healthcare (60) days in advance when they relocate or open an additional office. When this notification is received, a site review of the new office will be conducted before the Provider’s recredentialing date.

Compliance Standards


Provider sites must demonstrate an overall 80% compliance with the site and medical record-keeping practice guidelines listed below. If a serious deficiency is noted during the review but the office demonstrates overall compliance, a follow-up review may be required at the discretion of the Site Review Nurse to ensure correction of the deficiency.

Site and Medical Record-keeping Practice Guidelines


Facility
  • Office appearance demonstrates that housekeeping and maintenance are performed appropriately on a regular basis and parking area and walkways demonstrate appropriate maintenance.
  • Handicapped parking is available, the building and exam rooms are accessible with an incline ramp or flat entryway, and the restroom is handicapped accessible with a bathroom grab bar.
  • Adequate seating includes space for an average number of patients in an hour and there is a minimum of two office exam rooms per physician.

Access


Standards for appointment scheduling include:
  • Next available date for preventive care appointment is less than or equal to (30) calendar days.
  • Next available date for routine primary care appointment is less than or equal to (7) calendar days.
  • Next available time for urgent appointment is within (24) hours.
  • Standard wait time to be seen for a scheduled appointment is less than (30) minutes.

Safety


  • Basic emergency equipment is located in an easily accessible area. This includes a pocket mask and Epinephrine, plus any other medications appropriate to the practice.
  • At least one Cardio Pulmonary Resuscitation (CPR) certified employee is available.
  • Yearly Occupational Safety and Health Administration (OSHA) training (Fire, Safety, Blood-Borne Pathogens, etc.) is documented for offices with ten or more employees.
  • A container for sharps is located in each room where injections are given.
  • Labeled containers, policies, and contracts evidence hazardous waste management.

Administration & Confidentiality


  • Patient check-in systems are confidential. Signatures on fee slips, separate forms, stickers or labels are possible alternative methods.
  • Confidential information is discussed away from patients. When reception areas are unprotected by sound barriers, scheduling and triage phones are best placed at another location.
  • Medical records are stored away from patient areas. Record rooms and/or file cabinets are preferably locked.
  • A Clinical Laboratory Improvement Amendments waiver is displayed when the appropriate lab work is run in the office.
  • Prescription pads are not kept in exam rooms.
  • Narcotics are locked, preferably double locked. Medication and sample access is restricted.
  • System in place to ensure expired sample medications are not dispensed and injectibles and emergency medication are checked monthly for outdates.
  • Drug refrigerator temperatures are documented daily.

Medical Record-keeping Practices


  • Each patient has a separate medical record. Records are stored away from patient areas and preferably locked. Records are available at each patient visit. Archived records are available within (24) hours.
  • Pages are securely attached in the medical record. Computer users have individual passwords.
  • Medical records are organized by dividers or color-coding when the thickness of the record dictates.
  • A chronic problem list is included in the record for all adults and children.
  • Allergies (and the lack of allergies) are prominently displayed at the front of the record.
  • A complete health history questionnaire or History & Physical is part of the record.
  • Health Maintenance forms includes dates of preventive services.
  • A medication sheet is included for chronic medications.
  • Advance Directives discussions are documented for those (18) years and older.
  • Record-keeping is monitored for Quality Improvement and Health Insurance Portability and Accountability Act (HIPAA) compliance.

Improvement Plans/Corrective Action Plans


Within (30) calendar days of the review, a copy of the site review report and a letter will be sent to the medical group notifying them of their results. If the medical group does not achieve the required compliance with the site review standards, the Site Review Nurse (SRN) will do all of the following:
  • Send a letter to the Provider that identifies the compliance issues.
  • Send the Provider helpful information such as forms on which to document problems or medication allergies in the medical record.
  • Request the provider to submit a written corrective action plan to Molina within (30) calendar days.
  • Send notification that another review will be conducted of the office in six months.

When compliance is not achieved, the provider will be required to submit a written Corrective Action Plan (CAP) to Molina Healthcare within (30) calendar days of notification by Molina Healthcare. The request for a CAP will be sent certified mail, return receipt requested. This improvement plan should be submitted by the office manager or provider and must include the expected time frame for completion of activities. The SRN conducts additional site reviews of the office at six-month intervals until compliance is achieved. The information and any response made by the provider is included in the providers permanent credentials file and reported to the PRC on the watch status report. If compliance is not attained at follow-up visits, an updated CAP will be required.

Providers who do not submit a CAP may be terminated from network participation. Any further action is conducted in accordance with Molina Healthcare’s policy.

PCP Responsibilities in Case Management Referrals:

The Member’s PCP is the primary leader of the health team involved in the coordination and direction of services for the Member. The case manager provides the PCP with reports, updates, and information regarding the Member’s progress through the case management plan. The PCP is responsible for the provision of preventive services and for the primary medical care of Members.

 

Office of Civil Rights
United States Department of Health and Human Services
105 W. Adams, 16th Floor
Chicago, Illinois 60603
(312) 886-2359 (312) 353-5693 TTY

Bureau of Civil Rights
Florida Agency of Health Care Administration
2727 Mahan Drive
Tallahassee, FL 32308
(888) 419-3456

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