Provider Rights and Responsibilities
To receive information: The right to receive information about Molina Healthcare, its services, its policies and procedures, practitioners and providers and member rights and responsibilities.
To advocate: The right, when acting within the lawful scope of their license, to advise or advocate for members on the following issues without restriction or incrimination from Molina Healthcare.
- Health status, medical care or treatment options (including sufficient information to enable the member to decide among various treatment options, and information regarding alternative treatments that may be self-administered).
- Risks, benefits, and consequences of various treatment options.
- The opportunity to refuse treatment and/or express preferences for future treatment options.
To present a complaint, appeal or grievance: The right to file appeals or complaints on your own behalf or on the behalf of your patient within 60 days of receipt of the denial or limited approval, with your patient's consent, without fear of retaliation, and to have those complaints resolved. The right to obtain a written decision at the end of the appeal process explaining why Molina Healthcare’s prior decision is being upheld (if that is the case). The right to speak with the physician who, acting on behalf of Molina Healthcare, disapproves or limits approval of a request for covered services, and receive a written statement denying the approval upon request.
To communicate: The right to communicate openly with patients about all diagnostic testing and treatment options.
To timely claim payment: The right to expect that your claims will be processed accurately, timely and by industry standards.
To communication: The right to expect and receive respectful communication from knowledgeable staff and timely response to questions or concerns. The right to receive assistance with complex member issues.
To an appeal of revocation: If at any time, through the course of normal business, appeals/grievances or any quality review activities, Molina Healthcare becomes aware of a provider who is suspected or accused of improper conduct an investigation is initiated. The network associated with the provider is contacted and asked to conduct an investigation and report the findings. If Molina Healthcare is satisfied with the outcome and any corrective action necessary, no further action is taken. If Molina Healthcare is not satisfied, the case will be taken to the Quality Assessment/Performance Improvement (QAPI) Committee for a determination. If Molina Healthcare’s own review supports the action of the network no further action is taken. If Molina Healthcare’s own review indicates corrective action is necessary, it will impose this action on the provider and monitor compliance.
Molina Healthcare cannot require a provider network or physician employer to terminate their own agreement with one of their providers or employed providers or revoke credentialing. However, during the review process, if a provider network does not terminate a provider that it or Molina Healthcare has determined should not be providing services to Molina Healthcare members due to quality issues, Molina Healthcare will terminate that provider in our database and not allow services to be performed for Molina Healthcare members. The provider will be notified in writing of the decision and their rights associated with it.
If the decision is to terminate your participation, you have the right to at least 90-days prior written notice of termination of your status as an Molina Healthcare provider and the right to request a hearing within 10 business days of receipt of the notice of termination, and to have the hearing held within 30 days of the request for the hearing unless the termination is based on a belief that you have committed a fraud, breached the terms of your contract, or are an imminent danger to a patient or the public health, safety and welfare. The right to request a written reason for the termination, if one is not provided with the notice of termination. The right to have the hearing held before a panel of at least three people, one of whom is in the same or a substantially similar discipline and specialty as you, and to be present at the hearing with representation. The right to receive in writing the decision of the panel within 30 days following the close of the hearing (unless the panel requests an extension). The decision must specify the reasons for the panel's decision. If the panel recommends conditional reinstatement, the decision must include any conditions and time periods for conditional reinstatement, and the consequences for failing to meet the conditions.
To notify Molina Healthcare: Providers are responsible for notifying Molina Healthcare in writing of any of the following changes:
- Changes in practice ownership, name, address, phone or federal tax id numbers
- When adding a new physician to the practice or if a physician is leaving the practice
- Upon loss or suspension of your license to practice
- In the event of bankruptcy or insolvency
- In the event of any suspension, exclusion, debarment or other sanction from a State or Federally funded healthcare program
- In the event of any indictment, arrest or conviction for a felon or any criminal charge related to your practice
- If there are any material changes in cancellation or termination of liability insurance
- If or when you are closing your practice to new patients and vice versa
- At least 30 days before terminating affiliation with Molina Healthcare or one of its provider networks
Not to bill: Providers have a responsibility not to bill or balance bill Medicaid recipients for covered services except with respect to applicable copay, coinsurance and/or deductible amounts, regardless of whether you believe the amount of money you have been or will be paid by Molina Healthcare is appropriate or sufficient.
Provide coverage: Primary Care Providers and OB/GYNs have a responsibility to provide access to covered medical services 24 hours a day, 7 days a week. In practice, this means:
- Member telephone calls should be answered by a live answering service that is able to connect the member with his or her primary care provider or with a covering provider within 30 minutes.
- In the event that the member cannot receive a return phone call, the answering service must keep the member “on hold” until he or she can be connected directly with a physician.
- For physicians whose phone is answered after hours by an answering machine, the outgoing message must instruct members to call Molina Healthcare’s toll free after hours number 888-999-2404 in urgent situations. Otherwise, the message must refer the member to a phone number answered by a live person capable of offering the member information and referrals as necessary.
- On-call providers must return calls within 30 minutes.
Notification of Advance Directives: Providers have a responsibility to inform patients about their right to have an advance directive. To provide patients with written information on state law about patients’ rights to accept or refuse treatment, and the provider’s own policies regarding advance directives. Providers must document in the patients’ medical record any results of a discussion on advance directives. If a patient has, or completes an advance directive their patient file should include a copy of the advance directive.
Maintain medical records: Providers have a responsibility to have policies that address medical record protocol. Policies should include maintaining a single, permanent medical record for each patient that is available at each visit, protecting patient records from destruction, tampering, loss or unauthorized use, maintaining medical records in accordance with state and federal regulations and maintaining patient signature of consent for treatment. Medical records should be complete and legible and follow standard practices.
Provide care: Providers have a responsibility to provide care within their scope of practice, in accordance with Molina Healthcare’s access, quality and participation standards and in a culturally competent manner.
Participate in quality improvement: Providers have a responsibility to participate with Molina Healthcare in quality improvement initiatives and other activities associated with meeting regulatory requirements and upholding contractual obligations.
Non-discrimination: Providers have a responsibility to provide optimal care to members without regard to age, race, sex, religious background, national origin, disability, sexual orientation, source of payment, veteran status, claims experience, social status, health status, or marital status.
Give information: Providers have a responsibility to give members complete and accurate information concerning a diagnosis, treatment plan, or prognosis in terms they can understand (eliminating both language and cultural barriers), and without regard to plan coverage. To inform members of non-covered treatments or services and their cost prior to rendering them. To advise members of their right to contact Molina Healthcare’s Member Advocate if they have concerns about a non-covered service or wish to file a grievance or appeal.
Maintain confidentiality: Providers have a responsibility to maintain members’ Protected Health Information (PHI) strictly confidential, in compliance with Health Insurance Portability and Accountability Act (HIPAA) standards. To provide necessary member PHI to Molina Healthcare (in compliance with HIPAA standards), when required for payment, treatment, quality assurance, regulatory, data collection and reporting activities.
Submit claims: Providers have a responsibility to submit complete and accurate claims for their services that conform to Medicaid requirements within the time frames outlined in their contract. To provide Molina Healthcare with supporting documentation when required to support a claim.
Participate in utilization management: Providers have a responsibility to conform to Molina Healthcare’s referral and prior authorization policies and procedures as they relate to services provided. To cooperate with the utilization management nurses in providing necessary documentation or medical information.
Provide continuity of care: Providers who are terminating their affiliation with Molina Healthcare directly or through their network have a responsibility to continue caring for members for up to 90 days from the date of written member notification. Molina Healthcare will send a notice of the intended termination to all members on the provider’s panel with information on obtaining care and services during the 90 day transitional period and thereafter. For members who have entered the second trimester of pregnancy, the transitional period includes the delivery and 60 days of postpartum care related to the delivery. Providers offering transitional care must agree to:
- Continue to accept Molina Healthcare’s reimbursement rates in effect prior to the transitional period.
- Adhere to Molina Healthcare’s medical policies and procedures, including referrals, prior authorization requirements and treatment regimen(s) approved by the plan.
*Printed copies of information posted on our website are available upon request.